A few thoughts as we head into the holiday season and look to end 2009
1. Efficiency. One of the great hopes for health care IT must be efficiency, not merely cost savings, but increased efficiency. Efficiency will be needed if patient volumes increase as more patients have insurance. And another important factor will be a largely unreported physician shortage, the result of bad public policy, since Medicare reduced funding of GME in 1977 and the result of miserably inaccurate manpower studies over many decades.
It is true that a primary care physician is now spoken of, but that shortage will inevitably be back-filled with nurse practitioners, moving family docs upstream. The projected shortage by 2025 of 124,000 physicians will include even more critical shortages of specialists more difficult to replace since their training cycles are longer. Already the U.S. is short over 1000 Neurosurgeons, and the shortage of General Surgeons is perhaps greater. Even today, there are not enough physicians in Neuro and General Surgery to cover emergency rooms. Should anyone believe that rationing of health care will produce a benefit, watch carefully and, for yourself, invest in a stable patient-physician relationship.
2. Paying for Healthcare Reform. One cannot avoid noting that many reform proposals include cuts in Medicare and cuts in physician fees. These are usually accompanied by assurances that physicians should not or do not want to run businesses---only care for patients. And, if that is true, using the model of K-12 public education may provide insight into a system in which students are assigned a room and a teacher for whom books are prescribed along with approved tests. The loss of discretion parallels a loss of professionalism. But, there is and will be a physician shortage, and if market forces prevail, physicians will have options that make difficult a planned policy of yearly salary cuts. Healthcare IT cannot overcome poor public policy.
3. Productivity. Given attention by Erik Brynjolfsson,'s article, "Productivity Paradox in Information Technology" in 1993, the discrepancy between investment in computers and greater output was noted and studied. Over time, and with investment in training, retasking and machinery, productivity did increase, but there was a time lag, a lag that will be repeated in healthcare following the stimulus of ARRA. It can be a lag made worse by falling outputs if the wrong EMRs and PHRs are chosen. Without carefully designed templates and algorithms chosen or understood by physicians, a "point and click" EMR can add minutes to each visit. It is all about work flow, and speed. If bandwidth is inadequate or connection to a hospital encumbered by a series of "go-to-my-PC" interfaces, physicians will abandon the EMR regardless of promised cash payments. The workable model that can be learned in a few months without changes in personal work flow will be similar to MIE's "minimally invasive" SaaS download, and it will be natively web-based. There does not need be a train wreck, but there might be. Physicians should insist on a trial period with no penalties for exiting a contract.
4. Meaningful Use. My guess is that the MU bar will be set low, initially. I'd also guess that many physicians, those who select software based on manufacturer promises of certification, will abandon attempts to meet MU standards if the software requires additional steps, and time, to verify and record the required reports. All products will not be equally friendly, but I am optimistic that better-designed programs will profit physicians and reach government goals.
5. Health Information Exchanges, HIE. States like Indiana should prove a laboratory for EMR adoption and success for MU. Indiana should have connected its 5 HIEs sometime in 2010. In those regions served by HIEs, large areas of Indiana have over 50% EMR use by physicians. Comparisons of MU success in regions with HIEs vs. those without functioning digital data exchange should prove the synergistic value of EMR and HIE in achieving Meaningful Use. Biocrossroads, a consortium of the State of Indiana, Universities, Medical products companies and Pharma companies, should be funded by the ARRA stimulus in early 2010 to cover all of Indiana.
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