In the fourth scene of the first act of Hamlet, Marcellus remarks that something is rotten in the state of Denmark. In examining the context, scholars feel Shakespeare didn’t mean “state” in the sense of Danish geography. Instead he was referring to the rulers inhabiting Elsinore, the royal castle where the bulk of the familial and political chicanery went down in the play.
Something’s rotten in the District of Columbia as well, putting physicians investing in EHR implementation on edge. Last week, four princes of the U.S. House — Ways and Means Committee Chair Dave Camp (R-MI), Energy and Commerce Committee Chair Fred Upton (R-MI), Ways and Means Health Subcommittee Chair Wally Herger (R-CA), and Energy and Commerce Health Subcommittee Chair Joe Pitts (R-PA) — fired off a letter demanding a halt to electronic health record (EHR) incentive payments. The letter was sent to CMS Acting Administrator Marilyn Tavenner, National HIT Coordinator Farzad Mostashari, M.D., and HHS Secretary Kathleen Sebelius.
Why do they want to stop EHR incentives? These Republicans, all of them — who have been historically opposed to regulation and minimalist when it comes to governmental oversight of private enterprise — claim that meaningful use stage 2 rules don’t go far enough. To wit: “We believe that the Stage 2 rules are, in some respects, weaker than the proposed Stage 1 regulations released in 2009,” they wrote in the letter.
Of course the final rules are weaker than the proposed ones. That’s how it works. As Beth Israel Deaconess Medical Center CIO John Halamka, M.D., pointed out in the first Boston HIT conference SearchHealthIT attended in early 2010, those proposed stage 1 rules required neonatal units to report the smoking status of newborns — a peculiarity fixed in the final version. Halamka and other health IT standards authorities have worked diligently with the Office of the National Coordinator for Health IT (ONC) to make the regulations fit the national health care map. Not an easy task when that landscape includes primary care physicians, large and small hospitals, and specialists catering to many different age groups and with extreme variance in health issues.
Several HIT leaders have remarked to us over the last 30 months that proposed versions of many regulations, meaningful use included, include “kitchen sink” wish lists — because, as they put it, it’s easier to remove something in a proposed regulation than add it to a final edition.
The representatives’ letter is hardwired with other logical fallacies. For example, they bemoan stage 2’s revision to stage 1 requirements in which meaningful users no longer need to test their ability to exchange information with other providers in order to qualify for incentive checks. As SearchHealthIT reporter Ed Burns notes in casual conversation over the cube windows here in the office, however, Camp and his colleagues are ignoring the fact that the test requirement is made redundant in stage 2 because meeting the new criteria — such as incorporating patient lab tests into EHRs and sending/receiving standard summary of care documents — proves interoperability. Either that, or the letter’s signees perhaps haven’t bothered to actually read the rule or our cheat-sheet guides on it.
The representatives do make one salient point, although again it seems to point toward a desire for more regulation. They urge Sebelius to “take steps to eliminate [subsidizing] business practices that block the exchange of information between providers.” That would seem to require what some of the more liberal-minded folks have been suggesting to us all along: ONC mandating vendors use more specific data and exchange standards and excluding others, instead of letting the free market crowd-source and merge its choices.
Considering the politically conservative source of this apparent call for new regulations, it makes us wonder whether this letter was vetted by someone who understands how health IT works or was quickly dashed off by policy wonks who wouldn’t know a blade server if it smacked them upside the head. Or if they even believe half the rhetoric in it. It reads like saber-rattling in order to get a poll boost a few weeks from election day.
Building a national network of EHR systems that can pass information from provider to provider is difficult, expensive, and completely essential work. It’s a messy job, because health care somehow, as Camp and his colleagues rightfully point out, has built a system where patient data is “trapped in information silos.” Congressional watchdogs on both sides of the aisle are well within their rights and principles to monitor costs and progress of the project. They — we, too — need to see that our tax dollars will eventually pay off in lower-cost, better-quality health care. After all, every single one of us is a patient.
Suspending the construction of that partially constructed national network of interoperable health care data would be disastrous. Patient safety would be put in jeopardy as half-implemented EHRs would suspend clinical data in hybrid paper-electronic workflows some facilities use now as a workaround.
While the “haves” among health care providers probably will continue on their HIT implementations — meaningful use is fairly rudimentary to these big fish, who have moved on to analytics and complex clinical decision support systems to maximize quality and minimize costs — the “have nots” would be left behind, marooned in paper, effectively frozen out of accountable care organizations and other quality-based care initiatives that are sweeping through the health care system.
See how Camp’s expansive, mostly rural Michigan 4th District constituency likes seeing their local hospitals go bankrupt and driving 80 miles to the nearest emergency department when that happens. It’s a long haul to Saginaw or Traverse City from the middle of his territory, especially when the roads are covered with that scenic lake-effect snow Michiganders enjoy each year from November to April.
There are other arguments. Our own Reda Chouffani reminds Congress that the stage 2 rules weren’t created by ONC fiat, but instead with thoughtful consideration of thousands of public comments, and this letter seems to undermine that standard, mandated rulemaking process. Modern Healthcare’s Joe Conn penned a story citing two Bipartisan Policy Center reports released on the same day as Camp’s letter. Researchers concluded that yes, lack of interoperability between health data systems is still an issue, but stage 2 will help ameliorate it. The Health Information Management Systems Society (HIMSS) published five more reasons stopping EHR incentives at this point is a bad idea.
Furthermore, the representatives don’t get into what they plan to do with incentive money that isn’t spent, but here’s guessing it won’t be set aside for tax refund checks.
The main point? The Bush administration got the ball rolling on HIT initiatives, and the Obama administration agreed it was an idea that would benefit all U.S. citizen-patients. Now that the bipartisan-endorsed paper-to-digital transition of our health care system is underway, disrupting it would be disastrous. Congress voted to allocate the funds for building HIT infrastructure in 2009, and agreed to turn over its administration to HIT pros. There’s no turning back without brutal consequences to patients and a health care system that’s already ailing. Camp and his crew seem to be reneging on their end of the deal for political gain.
It’s time these Hamlets sheath their sabers and let us all get back to work. If they had such reservations about EHR incentives, they shouldn’t have voted for it in the first place.