Selling and Swelling a Bigger HITECH Bubble

Cherry picking has become essential for those who provide or insure health care. Choose the easiest route will capture more dollars with less cost of delivery - and this will earn more bonuses and assure no penalties. Changes since 2010 will reward those already doing well and will penalize those already behind. Cherry picking has apparently moved to top importance for those who promote digital solutions.

The digital leaders continue to present A Beautiful Day in the Neighborhood or Community as you will see. But which community, theirs or ours? 

Leaders are cherry picking the information to present, when they promote further digitalization and ignore the consequences such as:
  • The massive additional cost of digitalization is a factor contributing to a 1 percentage point increase in health care costs from July to August of this year alone. The clock is now ticking to determine future reimbursement based on the next 3 years of outcomes. Health care entities are trying to do everything possible to look good in the next few months. Quality matters little as what matters is the appearance as measured
  • Health care cost increases. They are not improving, as is constantly promoted. When you add massive cost of delivery in areas such as Health Information Technology and Care Micromanagement with non-delivery costs increasing by tens of billions a year more, you will raise costs, worsen delivery, or both.  EHR changes have been enough to help cause increased costs and overall inflation while not cutting costs or improving quality as was claimed years before. 
  • The distraction of team members from health care delivery and patient interactions as their payment support is cut, as their duties are devoted to appearance rather than patients, and as they are asked to do more with less.
  • The decreased productivity of team members resulting from EHR as indicated in studies that reveal two hours of EHR for every hour of patient care (Annals IM) 
  • The increasing power of corporations such as software corporations that are now taking their share of health care spending are the ones now playing a role in shaping designs their way. Leaders, associations, and the media promote their products and policies.
  • The tremendous opportunities that have been given for hacking, fraud, and abuse inside and outside of health care. Portals are indeed places of opportunity.
  • The shifting of dollars and jobs outside of the United States due to digitalization and support services. 
  • The diversion of dollars from 2621 counties with lowest concentrations of physicians and lowest concentrations of health spending by design have lost billions of much needed dollars and jobs as their revenues are forced to be sent to places in the United States with top concentrations of jobs and dollars. Disparities have been made worse than they already are.
  • The suppression of market forces due to rapid regulation - market forces that would have acted over time to improve the EHR software as it was applied
  • The lack of improvement in health outcomes or in the health of the population
  • The lower efficiency of health care delivery - essentially a move to lower value by those who claim to be focused on value.
  • The declining morale of team members dealing with countless EHR requirements that are meaningless and are not specific to patient care
  • The direct and indirect costs of updates, costs of changes in software, HIT personnel, maintenance, down time, hacking, reputation of the health system due to hacking, increased security ...
  • Forced sales of software resulting in lower productivity and the prevention of better software that would have taken more time and that would have cost more, but would have saved much more in terms of lost productivity. Suppression of market forces by regulation hurt nationwide health care productivity in many ways.

The Cost of Care Tipping Point Has Been Violated

America is at a tipping point in cost of health care. It has not been enough to spend more and more each year for drugs and immune technologies, highly specialized treatments and procedures, profits, insurance costs, and more. The workforce has been distorted to higher cost as well. Systems can generate so much more revenue via more subspecialized care that workforce and workforce costs have consumed more spending. Administrative cost acceleration has taken over where subspecialization left off. This brings us to the 2010 to 2016 time period.

The nation is just beginning to fall off the cliff into massive increases in health care demand due to demographic changes and the usual increases in technology by those who deliver health care - other than digital. 

A massive new influx in digital costs along with the administrative cost increases that accompany such changes is a most unwelcome development. The rise to 17% of GDP spent upon health care has not been stopped and is likely to continue as even more plan on profits from health care.

The complexities of population changes are a strain on team members, as are rapid changes in drugs, procedures, and care process. Team members have clearly been pushed over the tipping point with forced rapid adaption to poorly designed software and other massive regulatory changes. 

But we still see promotions of digitalization from the highest levels as seen in Health Affairs.

Progress in Digitizing Health Care by Karen DeSalvo and Vindell Washington

The two authors note "Over the past seven years, the United States has seen a historic health IT transformation, moving from a primarily paper-based health system to one where virtually everyone has a digital footprint of their care because of the dramatic uptake of electronic health records (EHRs). Recent data have helped quantify just how rapidly technology has transformed clinical settings."

My Comments - Proponents see transformation in terms of adoption of EHR.  The transformation of health care delivery is quite different from transformation to EHR. There are winners and losers in each new policy change. The recent post Time to Burst the HITECH Bubble indicates that the transformation has been the wrong direction - to higher cost, to strains on quality and to decreasing access. This is what happens when you are so immersed in innovation and what could be that you forget about what really is. The designers have lost touch with what is actually coming. 

Massive Data But at What Cost and What Benefit?

The authors note "Today, nearly all hospitals (96 percent) and nearly eight in 10 (78 percent) physicians use certified EHRs. This transformation is the result of 2009’s Health Information Technology for Economic and Clinical Health (HITECH) Act, when fewer than one in 10 hospitals and 17 percent of physicians used EHRs. This rapid uptake of technology reflects the unyielding effort by clinicians and health systems across the board who helped usher in this new era of medicine. The result of this effort is a vast amount of electronic health data now exists which simply did not seven years ago."

My Comments

Health Is About Home - Most health care issues happen at home, with a small proportion involving clinics, and a very small percentage involving hospitals. The data is an incomplete representation of health or health issues and has been demonstrated as limited for application to health care. The data missing could fill volumes for each patient. The missing data about situations, environments, behaviors, and social determinants shape outcomes better than those collected for health care delivery, especially billing or payment. Once again the focus on the micro prevents understanding of the macro and overall outcomes.

Distributions of Services Shape Data - Most data is collected on a relatively few people with chronic illnesses as well as people closest to dying. The information is least applicable to the general population. Half of Americans rarely use care and have little need for digital EHR. One per cent spends 100 times more than the bottom 50%. But they are paying for it - as are all Americans in one way or another. 

Misrepresentation of Motivation - The authors attempt to indicate that clinicians and health systems voluntarily acted. They had little choice except to do this. The new digital way is quite obviously the result of costly and burdensome regulation. 

Small Health Care Compromise - The rapid chaotic change has also caused problems especially to small health care. Given the rapid shrinkage of small health care with closures, mergers, and acquisitions, the digitization task has been made easier - in fact it was a major factor. The costs of digitization were so high that many providers had to close or be absorbed. Resistance is futile has been a clear message - a message with many consequences.  Physicians Question Value of Employed and Largest Practices with Merger Acceleration

None of our digital leaders talk about small health care and how it does a better job with local patient and community focus compared to a conglomerate or how it has improved prevention of hospitalizations compared to larger practices. 

Geniuses just legislated and regulated away involvement and engagement and yet consider their efforts a success.

Global Competitive Advantage - Not Hardly
The two authors note - "This transformation represents more than simply digitizing paper health records. It also puts us at a global competitive advantage and is leading to real-world impacts in the clinical setting. Systematic reviews of academic literature found that 84 percent of studies showed that certified EHRs had a positive or mixed positive effect on quality, safety, and efficiency of care. Other recent studies found that EHRs can reduce adverse events among cardiovascular, surgery, and pneumonia patients and that switching EHRs did not result in adverse safety events."
My comments 

For decades the incredibly high cost of American health care has been noted as a major reason for America to have a global competitive disadvantage in our economic engine. Health care cost allows other nations to steal our business. Digitization is a route to higher costs and outsourcing more health care dollars. 

Once again the designers are making a claim that is the exact opposite of the reality that they have brought about. 

A ten year 300 million dollar intervention by Robert Wood Johnson Foundation attempted to bring about transformation but had no significant impact upon population health and quality outcomes.

The US Health Care Ranks as Least Efficient

More Digital Distraction

Digital is one more distraction from interventions that could address cost, quality, and access. Population and health outcomes are about changes in the people, not health care.
The article goes on to promote interoperability, but fails to note serious and growing concerns about data security and privacy. What Americans need most is to be left alone by expensive and invasive health care. Real changes in health outcomes are about people changes and better support for people, parenting, early childhood development, early education. 

Real changes in health care delivery are about support of team members to deliver care, not greater administrative burdens and distractions from their care giving with fewer left to deliver care due to higher cost of care delivery from accelerating administrative and non-delivery costs. 

More Digital Diversions Compromising Primary Care

How much harder is it for primary care 
  • When billions more each year are subtracted from 150 billion in total operations, 
  • When shrinking the support for this 5% of spending to attempt to address 55% of encounters for 100% of the population. How much worse is it in 2621 lowest physician concentration counties with 40% of the population and only 25% of primary care spending - locations dominated by small practices and lowest paying Medicaid patients, and lower paid Medicare patients - who are paid even lower by a payment design that discriminates. And now these are settings that have 3 times the higher penalty rates from readmissions penalties. These are the truly underserved areas that will have additional penalties from MACRA as well.
Perhaps the leaders will want to comment regarding the lack of evidence basis in Pay for Performance and well as the inherent discrimination?
High Satisfaction - Not Hardly 

High satisfaction levels from providers that were previously not satisfied in just 2 years seems questionable. Since most did not change their software package and the changes have been minimal, what changed? The answer is not much. EHR Demands Leave Docs Burned Out, In Critical Condition.

Cherry picking the right studies or literature may get you the information that you want, but this is not the reality.  Physician morale is crashing due to EHR that was never ready for prime time and has not improved to meet these standards. Studies have demonstrated the tremendous distraction and lost productivity and high cost.

There was not even a hint of any of the limitations in this promotional piece. 

Digitizers assume people want to be digitized and that they want to have their information digitally shared. Many of them do not want this. The benefits are greatly exaggerated and the drawbacks are minimized. 

The HiTech Bubble is Swelling.
The digital leaders have not choice other than more selling.

Whose Community Do Health Care Leaders Support?
The authors note; "We received an overwhelming response from the community. Companies that provide electronic health records used by 90 percent of U.S. hospitals, health care systems with facilities in 47 states, and over two dozen professional associations and stakeholder groups have agreed to implement these three core commitments that will help ensure that health information flows."
My comments
  • Beware statements such as "We received an overwhelming response from the community" therefore please jump on our bandwagon. This is actually a sad reflection regarding the overall situation. Jump on the bandwagon should be a Red Flag that brakes are needed, not accelerators. It is time for thought and reflection rather than more rapid implementation.
  • Which community? It is obvious that the word "community" spoken by innovators is not the same word community as spoken by those who deliver care. Electronic communities or largest system communities or top concentration communities (or academic communities or the medical-industrial complex) are quite different from what Americans consider their community or what a physician considers my community. 
  • It is helpful to reflect on the words above and see who health care digital leaders want to please. Who has the top priority in their minds? Such is the degree of the obsession and the divisions between Digital Leaders and the American People.
If you cherry pick the right information
and ignore the information that indicates problems,
you can continue to
Sell and Swell a Bigger HITECH Bubble.

Recent Articles and Studies

Indicate 1 in 2 Physicians Demoralized

New technology must be better than what I already use; otherwise there is no reason to change.  In 2009, the Department of Health and Human Services led many to believe (incorrectly) “using electronic health records will reduce administrative burdens, cut costs, reduce medical errors and most importantly, improve the quality of care.”  Few, if any, of these goals have materialized.  IT experts are tinkering with the grand design of a documentation method that has satisfactorily served physicians for hundreds, if not thousands, of years.  It is no small undertaking; a certain degree of diligence is required for conversion to experience success... Non-physician health leaders are missing the forest for the trees as they search for innovative ways to enhance data collection while overlooking the accumulation of critical information to support proper medical decision making.

Today's advertising and headlines indicate worsening problems.

As healthcare providers arebeing asked to accomplish more with fewer resources, the American HeartAssociation offers a helping hand in filling the gaps. 

House Republicans Call tell CMS to stop mandatory involvement in payment reform in Modern Healthcare

Use your clinical expertise to effectively demonstrate how Epic’s software helps physicians and healthcare organizations focus on efficient, high-quality and personalized patient care. As a physician at Epic, you can make a far-reaching impact on healthcare and on practitioners around the world.

AAFP President Notes I don't want to treat a computer

Free Guide Helps Physicians Debug Bad EHR Contracts

Most physicians are unhappy with their EHRs and tech support, but more employed physicians are satisfied than are self-employed physicians. Only 40% of employed physicians and 31% of self-employed physicians were satisfied with their EHRs.

Providers are going through rapid change in how their business is conducted, delivered and paidfor. When you combine this change with industry consolidation and payer shifts,the uncertainty can be paralyzing. A few insights to help untangle the knot.

Advertising leads abound for Practice Management corporations that project ever larger systems with even higher levels of digital advancements. Patients and physicians will have vast data and search capabilities. Care will be better, safer, more coordinated, with less cost, and more patient focus. It appears to be open season upon the American people. It is hard to tell who is making more promises that will never be able to be kept. 

No one is asking why or how much or what the consequences will be.

The US Health Care Ranks as Least Efficient

Studies in 2005 indicated the tremendous cost of EHR - “To achieve an NHIN (national health information network) would cost $156 billion in capital investment over 5 years and $48 billion in annual operating costs. … $156 billion is equivalent to 2 percent of annual health care spending for 5 years.” (Rainu Kaushal et al., “The costs of a National Health Information Network,” Annals of Internal Medicine 2005;143:165-173, 165.) It is interesting that this was a Commonwealth Fund supported research project, but the ramifications of this huge cost on small practices and access never seems to register.

Recent Posts and References

Time to Burst the HITECH Bubble

Six Degrees of Discrimination By Health Care Payment Design

Assertions that Small Practices Can Prosper Are Not Helpful

Recovering General Surgery Is Impossible

Primary Care Must Rise from the Ashes of the Last 20 Years

Patients Should Be Changed, Not Physicians - Physician Behavior has been changed  -  the wrong way

Revisiting Basic Health Access in a Land of Smoke and Mirrors

Time Talent and Treasure to Measure Is Not Quality

The Mess that is MACRA - Kip Sullivan at The Health Care Blog

Value Failure By Those Who Promote Value

Bundling or Bungling, Once Again Into the Fray

Solving Mental Health Takes More than Race and Place

No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric

Primary care can be recovered and should be recovered, 
but cannot be recovered when moving the wrong directions

Robert C. Bowman, M.D.

The blogs represent the opinion of the blogger alone.
Copyright 2016


  1. Link for the Alignment for Koala Tea RWJF article

    Results: In total, 144 outcomes were analyzed, 27 were associated with improving population health, 87 were associated with improving care quality and experience, and 30 were associated with reducing the cost of care. Based on the estimated DD coefficients, there is no consistent evidence that AF4Q regions, over the life of the program, showed greater improvement in these measures compared with the rest of the United States. For less than 12% of outcomes (17/144), the AF4Q initiative was associated with a significant positive impact (P ≤.05), although the magnitude of the impact was often small. Among the remaining outcomes, with some exceptions, similarly improving trends were observed in both AF4Q and non-AF4Q areas over the period of intervention.

    Conclusion and Policy and Practice Implications: Our quantitative findings, which suggest that the AF4Q initiative had less impact than expected, are potentially due to the numerous other efforts to improve healthcare across the United States, including regions outside the AF4Q program over the same period of time. The limited overall impact may also be due to the variability in the “dose” of the interventions across AF4Q regions. However, these results should not be interpreted as a conclusive statement about the AF4Q initiative. More nuanced discussions of the implementation of interventions in the specific AF4Q programmatic areas and their potential success (or lack thereof) in the participating communities are included in other articles in this supplement.


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