Effort to Make Health Insurance Reimbursement Fairer Lead by Director of Insurance Company Accused of Unfair Practices

We previously discussed a legal settlement of charges that UnitedHealth's Ingenix subsidiary manipulated its database of payments to physicians so as to reduce its and other insurers' payments to "out-of-network" physicians. 

One aspect of the settlement was a new initiative to better determine such payments.  Now that effort has been caught up in the web of conflicts of interests that has ensnared health care.  As reported by the Syracuse (NY) Post-Standard,

[New York state Attorney General Andrew] Cuomo obtained $100 million in settlements from 13 insurers, including Excellus, that used the defective reimbursement data supplied by Ingenix, a subsidiary of United Health, the nation’s second biggest insurer. Cuomo’s investigation showed insurers such as Excellus used that data to shortchange New York consumers by as much as 28 percent.

Also, the settlement included

money ... to create FAIR Health Inc., a New York City-based nonprofit that is supposed to come up with a new, fair reimbursement system that will be used by insurers nationwide. FAIR Health has contracted with SU [Syracuse University] to help create that database.

The effort was lead by SU Professor Deborah Freund, "a distinguished professor of public administration and economics. She also is an adjunct professor of orthopedics and pediatrics at Upstate Medical University."

However,

Freund also happens to be listed on the health insurance company’s payroll.


Excellus paid Freund $61,378 last year for serving on its board of directors, according to a financial report Excellus filed with the state last week.

After The Post-Standard spent several days investigating her ties to the insurance company, Freund quit the Excellus board Friday afternoon.

The Post-Standard noted,

But some consumer advocates said it was odd that a paid director of Excellus, one of the companies targeted in Cuomo’s investigation, was playing such an important role.

[Art] Levin, of the Center for Medical Consumers, said it was ironic that one of the people helping to fix a payment system riddled with industry conflicts of interest may have had a conflict of her own.

'This makes no sense whatsoever given that Excellus is part of the settlement,' Levin said.

Chuck Bell, programs director of Consumers Union, publisher of Consumer Reports and an outspoken supporter of the payment reform project, was unaware of Freund’s ties to Excellus.

'I think it’s a concern because consumers do want this to be an entity that is independent of the insurance industry,' Bell said.

Among Freund's defenders was

Dr. Nancy Nielsen, immediate past president of the American Medical Association and a board member of FAIR Health, [who] said the AMA looked closely at Freund’s qualifications and her Excellus affiliation. She said the doctors’ group concluded her expertise is important to the project and was comfortable that there were enough safeguards in place to avoid any conflicts. Nielsen said FAIR Health would have independent experts not tied to the insurance industry review any recommendations from Freund’s research team.

But to add another level of irony, and perhaps conflict of interest, the Minneapolis - St Paul Business Journal just announced

The American Medical Association will use an electronic health records system from Ingenix, the company said Monday.

The Eden Prairie health care information technology said its Web-based CareTracker software will run on an AMA platform currently in beta testing with the Michigan State Medical Society and will launch nationwide later this year.

The platform is touted as a way to improve patient care, clinical efficiency and make administration simpler. CareTracker is the first such system that the AMA will provide to physicians online.

'Ingenix and the AMA will help doctors adopt health IT systems that reduce time spent on administrative tasks and enable them to devote more of their time to patient care,' said Bill Miller, Ingenix executive vice president of health care delivery systems, in a news release. 'Ingenix CareTracker integrates patient medical records and e-prescribing tools into the physician’s workflow. By selecting CareTracker for its platform, the AMA is helping physicians make smarter, more practical decisions about technologies to support their practice.'

Although we often discuss conflicts of interests involving physicians or health care academics who moonlight for drug and device companies, and the effects of these relationships on clinical research and medical education, it seems like the pervasive web of conflicts of interest in health care has entangled just about every kind of health care organization, health care decision-maker, and health care opinion leader.

Thus, we need to be extremely skeptical of just about everyone and every organization claiming to provide health care related goods and services, or whose goal is to improve any aspect of health care. The danger is that such skepticism will lead to cynicism and distrust.

At the least, comprehensive, detailed disclosure of all even indirectly relevant financial and other relationships by all health care decision-makers and opinion leaders at any level, whether they be individuals or organizations, would make it somewhat easier to assess their decisions and opinions.

Post Title → Effort to Make Health Insurance Reimbursement Fairer Lead by Director of Insurance Company Accused of Unfair Practices

How "Independent" a Source of Health Care Reform Data?

This week, a Washington Post article discussed who provides the data being cited in the ongoing US debate about health care reform.

The political battle over health-care reform is waged largely with numbers, and few number-crunchers have shaped the debate as much as the Lewin Group, a consulting firm whose research has been widely cited by opponents of a public insurance option.

To Rep. Eric Cantor (Va.), the House Republican whip, it is 'the nonpartisan Lewin Group.' To Republicans on the House Ways and Means Committee, it is an 'independent research firm.' To Sen. Orrin G. Hatch (Utah), the second-ranking Republican on the pivotal Finance Committee, it is 'well known as one of the most nonpartisan groups in the country.'

But how independent is the Lewin group?

Generally left unsaid amid all the citations is that the Lewin Group is wholly owned by UnitedHealth Group, one of the nation's largest insurers.

More specifically, the Lewin Group is part of Ingenix, a UnitedHealth subsidiary that was accused by the New York attorney general and the American Medical Association of helping insurers shift medical expenses to consumers by distributing skewed data. Ingenix supplied UnitedHealth and other insurers with data that allegedly understated the 'reasonable and customary' doctor fees that insurers use to determine how much they will reimburse consumers for out-of-network care.

In January, UnitedHealth agreed to a $50 million settlement with the New York attorney general and a $350 million settlement with the AMA, covering conduct going back as far as 1994.

Ingenix's chief executive, Andrew Slavitt, said the company's data was never biased, but Ingenix nonetheless agreed to exit that particular line of business. 'The data didn't have the appearance of independence that's necessary for it to be useful,' Slavitt said.

Lewin Group Vice President John Sheils said his firm had nothing to do with the Ingenix reimbursement data. Lewin has gone through 'a terribly difficult adjustment' since it was bought by UnitedHealth in 2007, he said, because the corporate ownership 'does create the appearance of a conflict of interest.'

'It hasn't affected . . . the work we do, and I think people who know me know that I am not a good liar,' Sheils said.

Is it only an appearance of conflict, and how objective is the Lewin Group's work?

Lewin's clients include the government and groups with a variety of perspectives, including the Commonwealth Fund and the Heritage Foundation. A February report by the firm contained information that could be used to argue for a national system known as single-payer, the approach most threatening to insurers, Sheils noted.

But not all of Lewin's reports see the light of day. 'Let's just say, sometimes studies come out that don't show exactly what the client wants to see. And in those instances, they have [the] option to bury the study,' Sheils said.

So, in summary, a group providing ostensibly "independent" data and opinions about an important health care policy debate is actually a subsidiary of a commercial managed care organization/ health care insurance company which clearly has vested interests in certain policy options. While the consulting group apparently struggles to be objective, its top leader reported that is fashions its reports at the behest of its clients, and that clients can "bury" reports that offend them, possibly because they do not serve their vested interests.

It is not surprising that participants in the current, noisy debate about health care reform, like many other health policy debates, have vested interests, and that their positions are likely to promote these interests. However, what should at least be disturbing is how often those with vested interests try to appear to be disinterested and independent. Should we trust "independent" voices that actually are conflicted, or those who cite "independent" views that actually come from interested parties?

By the way, we first posted about the Lewin Group's actual status as an Ingenix, and hence UnitedHealth subsidiary here in January, 2009, and first posted about how its contribution to the current health care reform debate was being touted as independent here in April, 2009. That a news organization with the status of the Washington Post is now picking up this story suggests a little optimism that the anechoic effect might be weakening.

Post Title → How "Independent" a Source of Health Care Reform Data?

Who Is Warning Us About the Perils of a Government-Run Public Health Insurance Plan?

There has been considerable discussion lately about whether the US government should offer a publicly run health insurance plan similar to the current Medicare program for the elderly and disabled. A recent report has thrown a bit of cold water on the idea, as noted in this AP article:

A public health insurance option for middle class families could help cover the uninsured but it may well put private insurers out of business, a respected consulting firm concluded in a study released Monday.

The report by the Lewin Group, a numbers-crunching firm that serves government and private clients, said it all depends on details that lawmakers are far from deciding. Nonetheless, the report could provide ammunition for critics who say a public plan would move in the direction of government-run medicine.

President Barack Obama and many Democrats want to create a government insurance plan to compete with private plans that now cover about 170 million Americans. The issue is major sticking point for Republicans and the insurance industry.

The Lewin study found that if such a plan were open to all employers and individuals, and if it paid doctors and hospitals the same as Medicare, the government plan would quickly grow to 131 million members, while enrollment in private insurance plans would plummet.

'The private insurance industry might just fizzle out altogether,' said John Sheils, a Lewin vice president and leading author of the study.

By paying Medicare rates the government plan would be able to set premiums well below what private plans charge. Monthly premiums for family coverage would be $761 in the government plan, compared with an average of $970 in private plans, the study estimated. Employers and individuals would flock to the public plan to cut costs.

This new report by the Lewin group also provided more ammunition to politically conservative commentators opposed to a public health insurance plan, e.g., see this link.

I am not going to comment on the substance of the report, or the argument over the merits of a public health insurance plan, save to note that in my humble opinion, the biggest danger of such a plan would be to further exaggerate differences in payments made to primary care and other "cognitive" physicians and to physicians who mainly do procedures. We have posted before (e.g., here) on how Medicare has come to fix payments to favor procedures and disfavor primary care and other cognitive services. Increasing the number of patients covered by Medicare or a Medicare-like plan, without changing the current Medicare payment system, would only make these discrepancies worse. Note that this potential problem with the public health insurance plan was not mentioned in the Lewin Group report.

Perhaps the nature of the Lewin Group influenced what this report did and did not emphasize. The group was described above as an independent consulting firm. Its web-site says it is "a premier national health care and human services consulting firm." It also claims:

The Lewin Group is committed to independence and integrity in our work. We combine professional expertise with extensive knowledge and a rigorous approach to analyzing and solving problems to deliver value to each of our clients and to the larger community as well.

That's a somewhat self-contradictory assertion. It seems that delivering "value" to specific clients might be hard to do while maintaining "independence."

Perhaps considering the nature of the Lewin Group's clients would clarify things. The group says its clients include "hospitals, health systems and providers;" "payers / insurers;" and "pharma/bio/device." The middle group seems most germane to a debate about The services provided to them include:

The Lewin Group helps payers and insurers succeed in complex government, commercial, and long-term care markets.

Based on our more than 20 years of experience, The Lewin Group offers our clients detailed understanding of the competitive marketplace and the expectations of purchasers. Based on rigorous, data-driven research, we provide our clients with actionable information grounded in practical, real-world advice.

Our understanding of public policy through our work with government entities, including Medicaid and SCHIP, helps us understand how policies are shaped and how they impact our clients. With this insight, we help our clients strategize and succeed in public programs and new product offerings.

So, the Lewin Group specifically offers to help insurers succeed in a complex market partially controlled by government. Maybe this orientation had some influence on the report they published now being used to support arguments for private, commercial health insurance.

Finally, who owns the Lewin Group? The description provided in the news story above suggests it is independent, and perhaps is even not-for-profit. Per Lewing Group web-site, it is neither:

The Lewin Group is an Ingenix company. Ingenix, a wholly-owned subsidiary of UnitedHealth Group, was founded in 1996 to develop, acquire and integrate the world's best-in-class health care information technology capabilities.

Ingenix has been in the news lately. See our posts here, here, and here about legal settlements of charges that large health care insurance companies used a database created and allegedly manipulated by Ingenix to underpay out of network claims. So, the Lewin Group is a part of Ingenix, an organization that just settled claims that it manipulated data about insurance payments.

Furthermore, Ingenix is in turn part of UnitedHealth. It is amazing how often UnitedHealth's antics have provided grist for the Health Care Renewal mill. See this post for a summary of the company's more recent escapades.

For balance, I must note that the Lewin Group web-page asserts:

The Lewin Group operates with editorial independence and provides its clients with the very best expert and impartial health care and human services policy research and consulting services.

But again, note that the focus is on making clients happy, not providing the public with unbiased knowledge.

So a report being used to support arguments against government-run health insurance was published by a subsidiary of one of the largest commercial health care insurance companies and managed care organizations, a subsidiary that just settled charges that it manipulated data to increase insurance company profits.

With a new administration in the White House, there is new interest in health care reform. It is not surprising that this has inspired some vigorous discussion. Nor is it surprising that some of the discussion comes from those with vested interests to protect. They have, of course, every right to make their views known. But it would be a more honest discussion if everyone were willing to put their vested interests on the table.

Post Title → Who Is Warning Us About the Perils of a Government-Run Public Health Insurance Plan?

WellPoint Settles

As reported by the Indianapolis Star (among others), the large health insurance company/ managed care organization WellPoint is the latest company to settle charges related to its use of a questionable data-base to determine payments for out of network care:

WellPoint has agreed to pay $10 million to settle an investigation by New York Attorney General Andrew Cuomo into questionable insurance reimbursements in that state.

The Indianapolis-based insurer becomes the seventh major health benefits company to settle in what authorities called an industrywide scheme to defraud consumers.

Cuomo charged the insurers with setting artificially low reimbursement rates to doctors who weren't in their health networks.

At the heart of the investigation is Ingenix, a unit of insurance giant UnitedHealth Group, which operated a database commonly used by health insurers to determine payment for out-of-network care.

Cuomo said Ingenix operated a'defective and manipulated database' and that insurers underpaid members for their out-of-network care.

Because it was owned by UnitedHealth, the database company had a vested interest in helping set rates low, so companies could underpay patients for out-of- network services, Cuomo said Wednesday in a statement.

WellPoint said it acknowledged the conflicts of interest in the database that Cuomo's investigation brought to light.

'We support his efforts to increase the transparency of health care costs,' said Ken Goulet, executive vice president and chief executive of WellPoint's commercial business, in a statement.

This is hardly the first time we have discussed questionable actions by WellPoint on Health Care Renewal. Our most recent post on this company was here. Yet despite the many transgressions made by this company, nobody seems to have taken responsibility for any of them, none of its leaders have apparently suffered any negative consequences for them, and the company's general reputation seems not to have suffered.

We have posted before about the Ingenix database here. To repeat, the most curious thing about this case is how so many major health care insurance companies/ managed care organizations used the same data-base, created by one of their competitors. Why are ostensible competitors collaborating so? If we are supposed to be basing our health care system on free markets and competition, why is this apparent cooperation among supposed competitors not raising at least eyebrows?

Post Title → WellPoint Settles

UnitedHealth (and Ingenix) Settles

UnitedHealth just settled yet another lawsuit. As reported by the New York Times,

In a settlement with one of the nation’s biggest insurers, New York’s attorney general, Andrew M. Cuomo, has ordered an overhaul of the databases the industry uses to determine how much of a medical bill is paid when a patient uses an out-of-network doctor.

A statement from Mr. Cuomo’s office said the industry had engaged in 'a scheme to defraud consumers' by systematically underpaying the nation’s patients by hundreds of millions of dollars over the last decade.

The move, to be announced Tuesday, is part of a settlement with the insurance giant UnitedHealth Group, which operates the industry databases. It results from a yearlong investigation by Mr. Cuomo’s office that concluded the data had understated the true market rates of medical care by up to 28 percent.

The settlement will have a nationwide impact because UnitedHealth, the biggest health insurer in New York, operates the databases used by the entire industry, through its Ingenix business unit. The deal calls for creation of a new independent database, to be run by a university that is still to be selected.

Because insurers typically reimburse patients for only 70 to 80 percent of the 'reasonable and customary' cost of medical services when they visit doctors outside the insurer’s designated network of physicians, the patient can get shortchanged if the insurer understates the prevailing local fees.

According to Mr. Cuomo, the databases consistently understated the local 'reasonable and customary' rates, which Ingenix collects from insurers. The report of the investigation’s findings described the industry calculations as 'created in a well of conflicts' that produced information that was 'unreliable, inadequate and wrong.'

In an interview Monday, Mr. Cuomo said: 'For years this database was treated as credible and authoritative, and consumers were left to accept its rates without question. This is like pulling back the curtain on the wizard of Oz. We have now shown that for years consumers were consistently low-balled to the tune of hundreds of millions of dollars.'

It is amazing how often the antics of UnitedHealth leadership have been grist for the Health Care Renewal mill. As we noted in September...

We have posted quite a bit about leadership problems at one of the US biggest for-profit managed care organizations/ health care insurers, the UnitedHealth Group (UHG), most recently here.

UHG has not always been known for being particularly patient-, employer-, or physician-friendly. For example, as reported by the Hartford Courant, "UnitedHealth Group Inc., the largest U.S. health insurer, will refund $50 million to small businesses that New York state officials said were overcharged in 2006." We have previously discussed how UHG promised its investors it would continue to raise premiums, even if that priced increasing numbers of people out of its policies (see post here); allegations that the UHG acquisition of Pacificare in California lead to a "meltdown" of its claims paying mechanisms (see post here); charges that the UHG acquisition of Sierra Health Services would give it a monopoly in Utah, and that UHG was transferring much of its revenue out of the state of Rhode Island, rather than using it to pay claims (see post here); and numerous violations of Nebraska insurance laws by UHG (see post here).

Such anecdotes conflict with the UHG mission statement, as recently revised. The company pledged to:
* Enhance the performance of the health care system, and improve the overall health and well-being of the people we serve and their communities.
* Work with health care professionals to expand access to high-quality health care so people get the care they need at an affordable price.
* Support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.

One hypothesis is that UHG has trouble adhering to its idealistic mission because of the shortcomings of its leadership.The story of the fall of its recent CEO, Dr William McGuire, was strikingly instructive. As we have previously discussed, (see these posts here, here, and here from 2006 with links backward) Dr McGuire received outrageously lavish remuneration, which stood in stark contrast to the previous UHG mission's pledge to "make health care more affordable."Controversy has swirled over the timing of huge stock option grants given to Dr McGuire (see post here), leading to his resignation in October, 2006 (see post here). More recently, McGuire agreed to pay back some of those options, although that would reportedly leave him with more than $800 million worth of options (see post here).

Note that the latest settlement seems to make a mockery of the last point in the UnitedHealth mission statement as listed above. It would appear that information as it appeared in UnitedHealth subsidiary's Ingenix's data-base disempowered people, that is, people other than UnitedHealth leadership.

Nonetheless, despite all this bad behavior, UnitedHealth is still one of the US' largest managed care organizations/ health insurers. That suggests how fundamental problems in leadership of health care organizations are to the ongoing health care crisis.

By the way, note that this recent settlement is about dodgy practices at UnitedHealth's Ingenix subsidiary. Just yesterday, we discussed a report that made the rather bizarre assertion that the US would soon face a shortage of gastroenterologists, members of a quite well recompensed procedurally oriented sub-specialty. But we noted that not only was the report sponsored by a company that manufactures the endoscopes and related equipment used by gastroenterologists, but that it was authored by the Lewin Group, often portrayed as independent and authoritative, but in fact another part of Ingenix. The just announced settlement should suggest even more skepticism about the independence and authoritativeness of this report.

Just as the prevalence of conflicts of interest affecting medical researchers and academic medicine should make patients and physicians skeptical of the clinical research they do, the prevalence of conflicts of interest affecting health services and policy researchers and pundits should make people, physicians, and policy makers skeptical of the policy research they do, and the policy recommendations they make.

Post Title → UnitedHealth (and Ingenix) Settles

On a Clinical IT Abomination and a Health IT Leadership Gap

... If there ever was a reason for physicians, other clinicians and patients to oppose the use of Electronic Medical Records forced upon them by third parties, here it is. Assuming this story is accurate, it reflects what I believe will be an increasing trend towards control of the medical profession via computer:

Association of American Physicians and Surgeons (AAPS)

August 2008 News

Innocent Caught in Dragnet

With a 19.7% increase in budget, and a 64-person increase in staff to a total of 1,495, the Office of Inspector General (OIG) is aggressively looking for fraud. The anti-fraud cash cow brings in $20 for $1 spent. To "find" fraud, the government gets creative, elevating ordinary billing disputes to fraud.

"The government overkills. It ruins their life. Doctors lose their career. They overbill Medicare, and it may have been sloppy," states attorney Patric Hooper. "But rather than pay back $100,000, they owe millions" (MCA 6/30/08).

One Pinellas County, Fla., physician was hauled off in handcuffs because of an ongoing dispute with UnitedHealth Care over E&M coding. What preceded the indictment was a refusal by the physician to use [healthcare IT] products sold by Ingenix, a United subsidiary. "It's clear from the documents that United filed the claim in retaliation," said the doctor's attorney. "I've never before encountered such a blatant attempt at coercion by a payer public or private" (ibid.).

Note that electronic medical record software, such as Amazing Charts, could make you liable for false claims, as through unintentional misuse of cut-and-paste functions or templates that automatically fill in blanks (ibid.).

Enforcement is being enhanced through use of anti-fraud "strike forces." The investigators are often retired policemen, and they do not treat physicians as "white collar" (MCA 6/30/08).

Some suggestions from Medicare Compliance Alert: Guard your NPI. Screen staff carefully, and watch out for "rogue employees" who might be identity thieves. Report business partners to the government; it can protect your own business. Have procedures in place to deal with search warrants. Be sure the information on your Medicare enrollment form is accurate; wrong information from a form filled in 20 years ago could result in a false claim (ibid.).

AAPS advice: consider opting out.

I believe a much more aggressive response is needed from the medical profession, including organized medicine, besides "opting out" of abusive third party payer arrangements.

In a former role of Manager of Medical Programs for a regional transit authority, I've seen labor unions that were representing bus drivers and janitors act far more aggressively and wisely in representing their members against management whims than organized medicine represents physicians against payer and government whims.

If organized medicine were performing its role in representing the profession aggressively, considering the evidence that paper charts can perform as well as electronic records in many circumstances and that most clinical IT benefits accrue to payers and other third parties, then major concessions would have been demanded of the primary beneficiaries for physicians to adopt electronic medical records.

"Musn't be too aggressive or appear disgruntled" is one of the reasons I've heard from academic colleagues that this does not occur. Physicians must be "gentlemen" and "team players." ("Team player" in today's context often means "co-conspirator to mediocrity" or to even worse).

I ask "why?" [should physicians avoid appearing angry]. The directness and actual aggressiveness of the labor union representatives I saw in action was quite effective in improving the conditions for their members. Interestingly, the union people were aggressive when "in role" yet polite when I encountered them in other settings, such as the daily commute to work. The public would likely respond to legions of angry doctors like few other means of communication could muster.

In a similar vein, I have heard from numerous circles that it's best to advocate for informatics leadership of Health IT (such as EMR, CPOE etc.) without demonstrating emotion or 'disgruntledness.' That raises several questions:

• Are physicians finding themselves marginalized and at the whim of IT managers, payers and other non clinical third parties because they have been just too angry and aggressive in demanding what was best for medicine and for themselves?

• Has there ever been any disagreement or conflict of such major proportions (and profitability) as healthcare that has been resolved purely through gentleman's dialog?

• Finally, are there lessons to be learned from these gentlemen who "petitioned for redress of grievances in the most humble of terms", only to be answered by even worse treatment?

On leadership of Health IT efforts: the sudden push by government towards universal HIT in recent years has often puzzled me. HIT rapidly moved from "experimental" status to godsend and panacea, although ample evidence was available that this was not the case. Enterprise EHR's seem to cost as much as entire new hospital wings. Yet ONC, AHRQ and other agencies seemed to start operating from the panacea assumption, largely since the internet hype that began at the end of the last decade.

The Office of the National Coordinator for Health IT (ONC) was established in 2004 to promote electronic health records in the United States. Regarding ONC, I've recently had some conversation with persons instrumental in the evolution of VistA, the Veteran Administration's EHR, and listened to presentations on VistA at a number of conferences.

It seems VistA is a very different universe from commercial HIT, one of strong collaboration and pride and creativity. This is likely due to its unique and relatively constrained purpose (care of veterans and family) and the non-profit nature of its history. You can get a good sense of this from the new book "Medical Informatics 20/20: Quality and Electronic Health Records through Collaboration, Open Solutions, and Innovation" (Amazon link here) written by key VistA personnel from that perspective. (Note: I use the book for teaching graduate students about the best ways to create and implement HIT and am cited in it for my views on social issues in HIT as at my website).

Commercial HIT is, on the other hand, highly corporatized, in the worst 2008 sense of the word. It is a highly competitive (need I say cutthroat) business, highly fragmented, proprietary, and anything but open. Commerical HIT is characterized by many stakeholders with widely varying agendas, forming an often dysfunctional "HIT ecosystem" (link) that largely excludes clinicians from meaningful decision making. The ecosystem is primarily centered on profit. It is an entirely different world than VistA.

In addition, hospital IS departments are usually woefully unprepared and incapable of meeting the challenges of clinical IT. IT is not a hospital core competence. Quite frankly, many of the IT leaders I've met in hospitals have been barely competent and in some cases downright abysmal where the needs and culture of practicing clinicians -- and sick patients -- are involved.

Physicians have been "resisting" health IT for 30+ years now. The diffusion of healthcare information technology after 30-plus years of effort and billions of dollars spent remains limited. As per the 2008 statistics in the NEJM article "Electronic Health Records in Ambulatory Care - A National Survey of Physicians", NEJM 359:50-60, just four percent of physicians in the U.S. reported having an extensive, fully functional electronic-records system, and just thirteen percent reported having a basic system. Most hospitals are also lacking the technology to any meaningful extent.

Yet those same physicians have to be restrained from using new therapeutic modalities and drugs where the benefit to patients is reasonably clear cut, even procedures and devices that are complex to perform or utilize.

Perhaps our society should take the 'resistance' to clinical IT as a phenomenon for serious consideration. One should perhaps ask themselves if they'd happily volunteer to receive a new therapy or drug that physicians have been 'resisting' for several decades.

Clinical IT is a world further characterized by issues such as these (thanks to Al Borges, MD and Health IT discussion site EMRUpdate.com for some of these links):

• "Oh no! Half of all current EMRs fail!", from 1/2007 Technology for Doctors (link to PDF)
  

• "Avoiding EMR meltdown: How to get your money's worth. About a third of practices that buy electronic medical records systems stop using them within a year. A little homework can help ensure you buy one that will work for you.", from 12/2006 AMNews (link)
  

• Quote: "The failure rates of EMR implementations are also consistently high at close to 50%", from Proceedings of the 11th International Symposium on Health Information Management Research – iSHIMR 2006 (link to PDF)
  

• Quote: "Industry experts estimate that failure rates of Electronic Medical Record (EMR) implementations range from 50–80%.", from 7/2006 A Commonsense Approach to EMRs (link to PDF)

• Kaiser Permanante HIT Meltdown (link)

• UK: Milton Keyne's Care Records System caused 'near meltdown' (link)
  

and many others of a similar nature.

This raises several questions:

• ONC was founded by our government. Where, exactly, was the government receiving its inputs on HIT pros and cons, drawbacks and challenges? The drawbacks have been known for a long time. Was the primary source of information from the pro-HIT optimists, opportunists and Pollyannas (per my HIT Ecosystem essay), lobbyists, and those whose experiences were largely positive in development of non commercial, large scale HIT (e.g., VA?) Could a term to describe what the administration has been told by the "HIT Ecosystem" members be this word?
  

• Was ONC founded on the premise that the commercial HIT 'ecosystem' operates like the VA, i.e., a world of collaboration and creativity? Could it be seeing commercial HIT through 'rose-colored glasses?'
  

• ONC seems to have focused on "technical" issues - standards, interoperability, etc. - at the expense of the social impediments and drawbacks to HIT. It seems the working assumption is that all that stands in the way of universal HIT, much like in the VA, is fine details of the technology and 'physician resistance.' Is ONC positioned to understand the commercial HIT sector and its issues, and in fact produce a candid and realistic "lessons learned" report as being called for in proposed House Energy and Commerce legislation?

These are very important questions. I do not know the answers. However, the decision makers in our government should ensure that they do.

-- SS

Post Title → On a Clinical IT Abomination and a Health IT Leadership Gap