Can Hospital Systems – And Countries - Afford Healthcare IT in a Time of Economic Uncertainty?
A WSJ article on the financial condition of NY hospitals, and specifically a line by NY Mayor Bloomberg, caught my eye:
Wall Street Journal
Mar. 26, 2010
Under the Knife
New York City System Aims to Cut 2,600 More Jobs as State Funding Drops
By MICHAEL HOWARD SAUL and SUZANNE SATALINE
NEW YORK—The nation's largest public hospital system plans to slash its work force—including doctors and nurses—by about 10% over two years as government aid drops and the number of uninsured patients jumps.
With its budget deficit set to top $1 billion,
... Previous job cuts focused on trimming support staff, but the new measures will include physicians and nurses, Alan Aviles, the corporation's president, said in an interview.
"Early to adopt EMR's BUT the budget cuts were hitting the system hard?"
To the knowledgeable, this seems a non sequitur. Its message is clearly that yes, we spent tens or hundreds of millions of dollars on EMR's, but the adoption of EMR's should have saved us tens or hundreds of millions of dollars, helping insulate us from economic downturns.
Yet some very serious researchers say this is not the case.
For starters, there's, Ashish Jha’s research at the Harvard School of Public Health that compared 3,000 hospitals at various stages in the adoption of computerized health records and found little difference in the cost and quality of care. A New York Times story "Little Benefit Seen, So Far, in Electronic Patient Records" on those findings is here. Was anyone in the Governor's office or hospital governance reading their own newspaper?
Then, there's the Nov. 2009 “Hospital Computing and the Costs and Quality of Care: A National Study” (Amer J Med 123:1; 40-46) by Himmelstein and Wololhandler at
“As currently implemented, hospital computing might [very] modestly improve process measures of quality but not administrative or overall costs."
Technology could increase health care costs without markedly
improving quality, according
to experts at Wharton.
... "No one has done the careful research to indicate that if one health care system has information technology and the other doesn't, then the care is different. There are no controlled trials," says Mark Pauly, a health care management professor at Wharton. All that technology is no panacea, he warns. In fact, he believes IT could actually raise costs because of culture clashes, training, the implementation of the systems [I would say "the mayhem that often goes on during the implementation" - ed.] and the labor required to maintain the new technology.
"The best-case scenario is that information technology will improve quality but not lower costs. The worst case is that there's no difference at all."
... That opinion is echoed by other experts at Wharton and the
[Kevin Volpp, professor of medicine and health care management] agrees that tracking real cost savings from health care IT is a difficult task, but he expects there to be some benefits from spotting and eliminating redundant care. But those benefits aren't likely to add up to big savings, says Lawton R. Burns, director of the Wharton Center for Health Management and Economics. "I agree that information technology is important, but it's not the slam dunk it's portrayed to be," he says. The chase to reduce costs, improve quality and expand coverage is deemed the "iron triangle of health care. A lot of us wince [at that goal]," Burns notes. "It's arguable that we can't do any of those things well."
David A. Asch, a Wharton health care management and economics professor, agrees that technology is a big part of reform. "No one is arguing against it, but that doesn't mean that it's not oversold," he says. Gabriel likens the fascination over IT in health care to a shiny new object that's easier to focus on relative to more daunting issues.
... In addition, it's unclear what cultural issues [a big theme in my writings - ed.] will emerge as information technology is adopted. These cultural issues are in the forefront of primary care physician relationships. Experts at Wharton and Penn say physicians are generally skeptical of the technology movement. How much will a technology overhaul add to operating costs? How much will it cost to retrain workers? What's the electronic record learning curve? And what happens when a doctor has a laptop between him and the patient?
"Individual physicians just don't know where the money is going to come from," says Pauly. "If IT is tied to reimbursements it could work, but [many] are skeptical." Burns adds that the physician-patient relationship can also be altered. "Technology adoption changes the way you practice. What happens when your primary care physician is looking at his screen instead of you?"
There are the concerns of Abraham Verghese, Professor and Senior Associate Chair for the Theory and Practice of Medicine at Stanford, who wrote in the Wall Street Journal in a June 2009 article "The Myth of Prevention" that:
... I have similar problems with the way President Obama hopes to pay for the huge and costly health reform package he has in mind that will cover all Americans; he is counting on the “savings” that will come as a result of investing in preventive care and investing in the electronic medical record among other things. It’s a dangerous and probably an incorrect projection.
Finally, this is an experimental technology whose benefits and risks are not well known.
In the article "Electronic Health Record Use and the Quality of Ambulatory Care in the United States" (Arch Intern Med. 2007;167:1400-1405), the authors examined electronic medical records use throughout the U.S. and the association of EMR use with 17 basic quality indicators. They concluded that:
“As implemented, EMRs were not associated with better quality
the FDA recently testified that this technology can actually harm and kill
patients, but the extent is unknown. Existing FDA data is likely the "tip
of the iceberg", testified FDA official Jeffrey Shuren MD, JD at the
HIT Policy Committee, Adoption/Certification Workgroup, special meeting on
health IT safety on February 25, 2010.
I described Shuren's testimony in my essay "FDA on Health IT Adverse Consequences: 44 Reported Injuries And 6 Deaths, Probably Just 'Tip of Iceberg'." Considering FDA is nearly unknown as the go-to for such reports, and the low reporting of medical errors related to computing noted by Koppel at the same meeting, the actual rates of injury and death could be much, much larger.
In effect, NY hospital physicians, nurses and support staff will lose their jobs due to budget shortfalls, at the same time the NY hospitals have been spending many tens of millions of dollars or more on the extravagance of experimental clinical IT systems whose benefit is still an unknown.
Perhaps some of those millions could have been better spent on human beings, such as employees or better yet, patient care.
While I'm supportive of EMR experimentation when finances are stable (when performed with patient safety considerations as paramount, of course), this is not the time for such extravagance in NY, especially when jobs - both support and clinical - are threatened.
Irrational exuberance in technology is bad enough - it's far worse when you can't afford the objects of your affection.
One suggestion is that the healthcare IT experiments be put on hold as unaffordable under current conditions, and resumed when finances are more stable. The money could be diverted to keeping physicians, nurses and support staff employed. The risks could also be studied further. Computers are not more important than people, after all.
Since many of the layoffs will involve union members of District Council 37, the city's largest municipal employee union, perhaps the rallying cry "Computers for Union Busting" could apply.
(Some people would have no problems with that, but these are real, live hospital staff being put out of work, and the patients they care for being affected.)
Finally, these observations may apply to an entire country, the UK, that seems to have spent about £13 billion (about $19 billion U.S.) on health IT that doesn't.
Per the March 29, 2010 Telegraph.uk article "Hospital wards to shut in secret NHS cuts":
Tens of thousands of NHS workers would be sacked, hospital units closed and patients denied treatments under secret plans for £20 billion of health cuts.
... The proposals could lead to:
· 10 per cent of NHS staff being sacked in some areas.
· The loss of thousands of hospital beds.
· A reduction in the number of ambulance call-outs.
· Medical professionals being replaced by less qualified assistants.
At least the IT industry is alive and well.