Alberto Borges, MD

The use of EHRs has increased measurably in the past decade. After years of heavy lobbying, “enterprise” EHR vendors have convinced the White House and Congress that this technology has the capability to increase quality, decrease errors, and reduce costs (

). The federal government has responded by introducing intrusive legislative bills that are costly to physicians, Medicare and Medicaid patients, and the American taxpayer (

Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (H.R. 6331) empowers CMS to pay a bonus to physicians for successful e-prescribing, (

). It also mandates penalties for not e-prescribing beginning in 2012. One of the first bills signed by President Obama was the American Recovery and Reinvestment Act of 2009 (ARRA), which includes the HITECH Act, the cost to taxpayers for which has been estimated to be between $27 billion (

) over the next 8+ years, most of which is unallocated and could be repealed (

) if the Spending Reduction Act of 2011 (H.R. 408)becomes law.

I completely agree with the push to repeal the ARRA/HITECH Act; let me explain why:

		These laws, which will together eventually punish physicians who fail to meaningfully use an EHR and e-prescribe with a combined 7% in penalties, threaten to undermine the Medicare and Medicaid programs. They will force doctors who do not wish to own an expensive EHR system to abandon their participation in these programs. This will occur just when the number of elderly, sick, and poor patients in the United States is expected to soar (

		The only real winners are the EHR vendors themselves, along with consultants and lawyers (

), as doctors are being forced to purchase unwieldy technology estimated to cost as much as $40,000 (

) per year. These costs are due not only to the actual cost of the EHR software and hardware, but also to the cost of data reporting and the added cost of negative workflow caused by the use of the technology while seeing patients. The Congressional Budget Office reported that total implementation costs for office-based EHRs ranged from $25,000 to $45,000 per physician, with annual operating, licensing, and maintenance costs ranging between $3,000 and $9,000 per physician. These figures are conservative and most likely will increase due to market pressures and vendor workflow shortages (

		Small physician offices will continue to close as physicians join hospitals, which will decrease competition and increase costs to the consumer (

). There has been a flight of office-based internists to become hospitalists, from 6% of general internists in 1995 to 19% in 2006.These mandates may “possibly be the final nail in the coffin of the private U.S. medical practice” (

) due to a lack of well-controlled, unbiased, prospective, well-randomized studies showing that EHRs actually improve significant outcomes. Numerous citations show that EHRs don’t influence outcomes (

), introducing new types of errors, adding to the cost of doing business that will eventually be paid by the patient, and decreasing the quality of the physician-patient interview and examination.

		Few doctors will actually receive the meaningful use bonus.Billions are being spent on HITECH/meaningful use, yet according to a study published in 

, only 12% of physicians are eligible for incentives and already have a basic EHR (

). The CDC reported that as few as 2-4% of providers actually are capable of receiving the all-or-nothing payments, which is a very poor return on taxpayer dollars (

		The failed installation/deinstallation rate for EHRs is estimated to be about 50% (

		Lack of privacy is a major problem that continues to plague centralized HIT programs throughout the world. Both patients and physicians are wary of private medical information sharing, as such information can be stolen (

		The ability to universally interconnect doctors and hospitals (the central, most important mandate of the HITECH Act) continues to elude us, and will be a daunting task with more than 400 non-interoperable “certified” EHR systems in the marketplace (

Doctors and taxpayers are being asked to fund the expensive, unproven, and vendor-lobbied and —driven HITECT Act mandate that has failed to rapidly increase the adoption of EHR systems in health care. Congress needs to pull back the allocated, yet mostly unused, billions of dollars in funding. This money can better be used for either direct patient care or to pay down our country’s debt crisis.

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Too expensive; too unproven; and too burdensome. It's time to say goodbye to this unwanted legislation.

Congress Should Repeal the HITECH Act

One of the topics addressed at this year’s HIMSS conference was “the power of no,” a term coined by The New York Times that refers to the concept of limiting a patient’s right to treatment if those in power decide that the care is too expensive, the patient is too old, or the treatment is not likely to deliver enough value. At the heart of this debate is electronic health record (EHR) technology and the impact it may have on patient care (http://hcp.lv/aAHWgo; http://hcp.lv/93ysjw).

The problem that I have with all of this is that putting the concept of “best practices” to work can hinder or even eliminate the nuances involved in the art of treating patients that are learned through many years of medical training.

There are situations that unfortunately cannot be programmed into a computerized medical chart. You cannot supplant the learned experience of a physician with a computer system and subsequently call it “quality.” You cannot deny care to patients using a computer algorithm and call it “decreasing costs.” You cannot replace the mistakes that can occur with paper records with new mistakes using the EHR, and call it “reduction in errors.” This is not progress; in fact, some believe this increased bureaucracy is a form of “digital socialism.”

I agree with the points that David Blumenthal, MD, made during his speech at HIMSS, where he said the EHR can be a very powerful instrument that can help the physician see patients in a more organized manner, and can be a tool by which the physician can provide better care. Where I disagree with Dr. Blumenthal is that I believe the physician should have the freedom to choose the EHR that is most compatible with his style of documentation and is more in line with what he can afford. We should not have the government forcing physicians into choosing expensive, complicated EHR systems that can be used to track patient behavior—or worse yet, to mine patient data for the purpose of limiting care. In his speech, Dr. Blumenthal proudly stated that he was a friend of HIMSS. I feel that it is inappropriate for a powerful bureaucrat, a direct representative of the President of the United States, to align himself with one of the most powerful political lobbying organizations in the country, and to take part in crafting legislation that will benefit HIMSS members&mdash;possibly at the expense of physicians. Can we ensure that improving patient care is the top priority if there is a conflict of interest like the one Dr. Blumenthal appears to have (http://hcp.lv/bT35W7)?

President Obama and many in Congress want to take the failed concept of “managed care” and resurrect it with the use of expensive, powerful EHR systems and turn the US healthcare system into a European-style socialized medical system. Those in favor of this are ignoring the fact that 93% of physicians are not currently in the position to achieve “meaningful use” as outlined in the ARRA-HITECH legislation (http://hcp.lv/a7nt9a; http://hcp.lv/affsGB).

They are ignoring the will of the people, 55% of whom say they are against the new healthcare bill (http://hcp.lv/9tYeq3). They are ignoring the fact that in Massachusetts, the cost of healthcare centered around the use of powerful HIT systems has cost 15% more than the national average, and the fact that although 97% of the population has universal coverage, it does not mean universal access to a doctor, because of critical shortages of primary care physicians who since 2006 have opted to either leave the state or retire (http://hcp.lv/cWare4).

They are also ignoring the situation in Arizona, where in 2005, then-Governor Janet Napolitano passed a mandate that all physicians adopt HIT systems; four years later, EHRs were being uninstalled at a rate of more than 20% (http://hcp.lv/bL4LLN). They are hiding the fact that more than 50% of HER implementations failed in 2007, according to the Office of the National Coordinator for Health IT (http://hcp.lv/cYfbKs).

Worldwide, numerous countries that have pushed for high EHR adoption are experiencing difficulties, such as in the UK, where Cerner, a major subcontractor on parts of the National Health Service project, has faced a great deal of criticism suggesting that its systems are too difficult to use and implement. In Sweden, a country hailed for its progress with electronic records, a government panel issued a report in May 2009 linking computer malfunctions to “severe incidents” and even deaths (http://hcp.lv/b9xQ8g). Even Canada’s EHR initiative has stalled (http://hcp.lv/cGw20Z).

The history of EHR and its associated problems cannot be ignored. Statements attributed to the EHR such as “increased  quality, decreased errors, and decreased costs” should not be taken at face value, but instead proven in large, scientific prospective trials. Big government and the insurance industry need to let physicians do what they do best—provide care for patients in an unfettered, less bureaucratic environment.

Alberto Borges, MD, is in private practice and is an associate clinical professor of medicine at the George Washington University in Washington, DC. Check out his website at http://msofficeemrproject.com.

The opinions expressed in this column do not necessarily reflect those of MDNG.

One of the topics addressed at this year's HIMSS conference was "the power of no," a term coined by The New York Times that refers to the concept of limiting a patient's right to treatment if those in power decide that the care is too expensive, the patient is too old, or the treatment is not likely to deliver enough value.

The HIT Realist: Digital Socialism and the Power of No

The HIT Realist: Digital Socialism and the Power of "No"

One of the topics addressed at this year’s HIMSS conference was “the power of no,” a term coined by 

that refers to the concept of limiting a patient’s right to treatment if those in power decide that the care is too expensive, the patient is too old, or the treatment is not likely to deliver enough value. At the heart of this debate is electronic health record (EHR) technology and the impact it may have on patient care (

The problem that I have with all of this is that putting the concept of “best practices” to work can hinder or even eliminate the nuances involved in the art of treating patients that are learned through many years of medical training. There are situations that unfortunately cannot be programmed into a computerized medical chart.

You cannot supplant the learned experience of a physician with a computer system and subsequently call it “quality.” You cannot deny care to patients using a computer algorithm and call it “decreasing costs.” You cannot replace the mistakes that can occur with paper records with new mistakes using the EHR, and call it “reduction in errors.” This is not progress; in fact, some believe this increased bureaucracy is a form of “digital socialism.”

I agree with the points that David Blumenthal, MD, made during his speech at HIMSS, where he said the EHR can be a very powerful instrument that can help the physician see patients in a more organized manner, and can be a tool by which the physician can provide better care.

Where I disagree with Dr. Blumenthal is that I believe the physician should have the freedom to choose the EHR that is most compatible with his style of documentation and is more in line with what he can afford. We should not have the government forcing physicians into choosing expensive, complicated EHR systems that can be used to track patient behavior—or worse yet, to mine patient data for the purpose of limiting care.

In his speech, Dr. Blumenthal proudly stated that he was a friend of HIMSS. I feel that it is inappropriate for a powerful bureaucrat, a direct representative of the President of the United States, to align himself with one of the most powerful political lobbying organizations in the country, and to take part in crafting legislation that will benefit HIMSS members—possibly at the expense of physicians. Can we ensure that improving patient care is the top priority if there is a conflict of interest like the one Dr. Blumenthal appears to have (

President Obama and many in Congress want to take the failed concept of “managed care” and resurrect it with the use of expensive, powerful EHR systems and turn the US healthcare system into a European-style socialized medical system. Those in favor of this are ignoring the fact that 93% of physicians are not currently in the position to achieve “meaningful use” as outlined in the ARRA-HITECH legislation (

They are ignoring the will of the people, 55% of whom say they are against the new healthcare bill (

). They are ignoring the fact that in Massachusetts, the cost of healthcare centered around the use of powerful HIT systems has cost 15% more than the national average, and the fact that although 97% of the population has universal coverage, it does not mean universal access to a doctor, because of critical shortages of primary care physicians who since 2006 have opted to either leave the state or retire (

They are also ignoring the situation in Arizona, where in 2005, then-Governor Janet Napolitano passed a mandate that all physicians adopt HIT systems; four years later, EHRs were being uninstalled at a rate of more than 20% (

). They are hiding the fact that more than 50% of EHR implementations failed in 2007, according to the Office of the National Coordinator for Health IT (

Worldwide, numerous countries that have pushed for high EHR adoption are experiencing difficulties, such as in the UK, where Cerner, a major subcontractor on parts of the National Health Service project, has faced a great deal of criticism suggesting that its systems are too difficult to use and implement. In Sweden, a country hailed for its progress with electronic records, a government panel issued a report in May 2009 linking computer malfunctions to “severe incidents” and even deaths (

). Even Canada’s EHR initiative has stalled (

The history of EHR and its associated problems cannot be ignored. Statements attributed to the EHR such as “increased quality, decreased errors, and decreased costs” should not be taken at face value, but instead proven in large, scientific prospective trials. Big government and the insurance industry need to let physicians do what they do best—provide care for patients in an unfettered, less bureaucratic environment.

Alberto Borges, MD, is in private practice and is an associate clinical professor of medicine at the George Washington University in Washington, DC. Check out his website at 

. The opinions expressed in this column do not necessarily reflect those of 

Alberto Borges, MD

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