Federal Agency Chief Rebuts Findings That Show EHR May Lead to Increased Diagnostic Imaging

Just one day after the Health Affairs article that showed an association between physicians' Electronic Health Record (EHR) use and increased ordering of diagnostic imaging the chief of the Office of the National Coordinator for Health Information Technology (ONC HIT), Dr. Farzad Mostashari has writen a scathing piece in the Health IT Buzz blog blasting the author's conclusions as "far beyond the scope of their research".

Dr. Mostashari points out the following:

• The Original Study Was Not About EHRs At All, Much Less Their “Meaningful Use”
• The Original Study Falls Prey to the Classic Fallacy of Using Association to Suggest Causality
• The Original Study Did Not Consider the Appropriateness of Imaging Tests
• Reducing Test Orders Is Not the Way that Health IT Is Meant to Reduce Costs

Essentially, Dr. Mostashari is serving as a government mouthpiece trying to poke holes in a study that questions the effectiveness of the 2009 American Recovery and Reinvestment Act (ARRA) that provides $25.8 billion in stimulus funding, much of to physicians and hospitals who purchase Electronic Health Records.

Dr. Ray, one of the commenters to Dr. Mostashari's blog post points out that the burden of proof is on the government to show that EHRs actually work to bring down costs.

And, quoting the original authors:

"History urges caution in assuming that advances in medical technology will result in cost savings. In fact, the opposite is more often the case."

Medical imaging costs will most likely rise as physicians gain increased access to image-viewing features of EHRs.

And, as I originally pointed out, critical pathways for high-cost conditions treated by physical therapists will become increasingly popular, driven by payers frustrated by soaring medical imaging costs.

What say you?

Physical Therapy Apps

The physical therapy application marketplace is growing.

The iPhone is just the first mobile platform where consumer apps really exploded.

But, the iPhone provides some lessons about where app developers and medical device innovators are heading within the physical therapy space.

According to Office of National Coordinator of Health Indormation Technology (ONC HIT) staff member Jacob Reider, MD all new medical apps need these features:

• Functional (it does what it is claimed to do)
• Reliable (it works consistently)
• Usable (it works in a way that is consistent with the user’s expectations)
• Meaningful (it does something important or valuable)
• Pleasurable (it is enjoyable to use)

The ONC HIT website takes Dr. Reider's message a step further:

"...the iPhone, for instance, uses a software platform with a published interface. This interface needs the ability to have both core components and applications (apps).

On the iPhone, core components include cameras, geolocation, networking capabilities, etc. The platform functionally separates the core components from the apps, and the apps are substitutable.

For instance, a consumer can download a calendar reminder system, reject it, and easily replace it with a new one.

Substitutability is the capability of a system to replace one application with another of similar functionality. As we define it, substitutability requires that the purchaser of an application can replace one application with another without being technically expert, without requiring re-engineering of other applications they are using, and without having to seek assistance from any of the vendors of previously or currently installed applications.

This allows developers to rapidly create a large marketplace of apps for consumers to choose from.
 
A HIT environment characterized by substitutable apps constructed around shared core components would drive down healthcare technology costs, support standards evolution, accommodate difference in care workflow, foster competition in the market, and accelerate innovation. 

Competition on quality, cost, and usability would become fierce. 

With the cost of switching kept low, a physician using an electronic health record (EHR), a CIO running a hospital system, or a patient using a personally controlled health record (PHR) would all be empowered to readily discard an under-performing app and install a better one."

British EMR Failure Invites Comparisons to USA HITECH Program

American physical therapists may breathe a sigh of relief that the Office of the National Coordinator of Health Information Technology (ONC HIT) will be less likely now to impose "top down" mandates for the purchase and use of interoperable health information technology now that Great Britain has decided to dismantle their failed system.

On September 22, 2011, the National Health Service (NHS) issued a Press Release announced that it was discontinuing its 10-year, $18.5 billion dollar effort to collect, computerize and centralize all of its electronic medical records. Existing electronic systems in hospitals and clinics would continue to operate but would not be interoperable across all of England.

The announcement essentially killed what had been hailed as “the world’s biggest civil information technology program” at that time.

The NHS program began in 2002 and was described as “top-down engineering” that met substantial resistance from physicians and other users of the system. The Press Release announcing the end of the program cited the lack of local control as the prime reason for the failure of its interoperable system:

“In a modernised NHS, which puts patients and clinicians in the driving seat for achieving health outcomes amongst the best in the world, it is no longer appropriate for a centralised authority to make decisions on behalf of local organisations.”

Authorities in the United States were quick to assure providers that a similar information technology (IT) effort stimulated by Title XIII of the American Recovery and Reinvestment Act of 2009, called the Health Information Technology for Economic and Clinical Health Act (HITECH) would not fail.

Faith in American electronic medical records is largely voiced by policymakers who say they are collaborating with providers, such as hospitals and physicians, rather than mandating a top-down structure.

Authorities claim that Electronic Medical Records strategy, standards and outcomes are set by HITECH Meaningful Use criteria but implementation is being set at the local level by any of the 900 certified IT vendors that the providers may choose to use. However, providers complains that 900 choices is NO better than no choice at all.

Why should private practice physical therapists care?

Used to be, we could just hang a shingle, treat your patients and expect to make a decent living. Now, if you want to work for yourself and your patients, you need to comply with all sorts of regulations that may or may not improve your patient care or add to your patient's outcomes.

For example, the Physican Quality Reporting System (PQRS) is a quality measure reporting program that has, since 2007, paid physical therapists up to 2% extra for treating and reporting Medicare claims data. In 2014, this little "extra" will turn into a discount and the program will turn into a top down mandate.

Can authorities in the USA learn from the British disaster?

I hope that authorities will learn that physical therapists, acting at the local level can determine what is quality and that some of these local measures can be used in place of centrally-determined, top down quality mandates.