In a rare show of bipartisan unity, Republicans and Democrats have embraced President Bush's Executive Order 13335 calling for the adoption of “interoperable” electronic medical records, (EMRs) or electronic health records (EHRs). In addition, the Medicare Modernization Act requires the establishment of similar records and the development of standards for electronic prescribing.
Veterans of the health-care wars may recall 1994 when Senator Clinton (D-NY), then First Lady, developed the “Clinton Health Plan.” The American Psychoanalytic Association and the Coalition for Patient Rights were among the first to recognize the primary premise behind the plan, namely the establishment of a healthcare network entirely controlled by the government and insurance companies, from which there was no escape, even through private practice. Private practice would have been illegal under the Clinton Plan. All patients and practitioners would have been contained in a system entirely controlled by managed care.
The use of EMRs is heavily supported by the insurance and information technology industries, both of which have a great deal to gain from such a transition.
The push for EMRs seems less radical at the moment. However, it does create the mechanism by which the goals of the Clinton Plan can ultimately be achieved. While the president's Executive Order pays lip service to privacy concerns, it comes down heavily on the need for “compiling the complete experience of a patient's care” as well as to permit the “cost-effective and timely data collection for bio-surveillance, quality measurements, and clinical research.” EMRs will certainly be required for those who file claims with insurance companies and Medicare.
The president appointed David Brailer to head the newly created Office of National Health Information Technology (ONHIT), which is charged with developing a system of interoperative EMRs over an allotted 10-year span.
The New York Times reported on February 17 that Brailer, a physician and economist, has delivered a warning to the health-care industry: If the industry cannot agree on standards by this summer, “then government will probably do what government does best—put out a mandate.” Proponents of EMRs maintain that lives and money will be saved by their use. Others disagree. CNN reports that 89 percent of savings generated by the use of an EMR system would accrue directly to the profit margin of insurance companies. Other studies show a high level of errors caused by computer glitches and incorrect data entry.
The use of EMRs is heavily supported by the insurance and information technology industries, both of which have a great deal to gain from such a transition. The problem here is the usual conflict of interest inherent in a health-care system operated for profit and by managed care companies (MCOs). EMRs are also heavily supported by Congress. In the 1990s, Congress was similarly supportive of managed care. In both cases, Congress passed legislation that enabled MCOs to profit by rationing health, while keeping their own hands clean. EMRs facilitate chart audits and overzealous utilization review, often resulting in payment denial and charges of fraud. By way of example, the Josie King Act of 2004, introduced by Patrick Kennedy (D-RI), states reimbursement will be withheld from physicians if chart notes do not reflect a predetermined “quality standard.”
Ironically, EMRs certainly could and should be a valuable contribution to the delivery of quality health care. The very technology which allows for the rapid transmission of information could theoretically also allow for the protection of patient privacy. Concern for patient privacy has been almost entirely missing from the discussion in Congress and the administration, nor does there seem to be any serious interest in the topic. By contrast, privacy protection has been central in the development of EMRs by the National Health Service in Britain. The key points about the British system are:
Patients are allowed to opt out of having an EMR.
Patients are allowed to make certain information inaccessible for routine purposes.
An audit trail is generated whenever an EMR is accessed or amended.
This is far better than the low standards set by HIPAA. The effect of HIPAA can be seen in the EMR system set up by PartnersHealth Care in Boston. This system has been lauded by the insurance industry and business interests as a model to be followed throughout the United States. Citing HIPAA, the group explains, there is no patient consent for release of information and there is no so-called black box where particularly sensitive information can be stored.
One might well ask why the focus on patient privacy in Britain is missing here. The answer
Robert Pyles, M.D., is chair of the Committee on Government Relations and Insurance, and a former president of APsaA.
can be found in the fact that there is no profit motive operating in the British system, in comparison to the managed care for profit system in the United States. Although the push for EMRs in the United States is couched in terms of quality of patient care, there is an enormous profit motive at work. The need for insurance companies to achieve control over patients and practitioners in the U.S. health system, I suspect, is a far more pressing motive than the altruism of developing a health-care system that delivers high quality care. EMRs create endless potential for denial of payment, and consequent limiting of patient care. The recent introduction of so-called Pay for Performance Initiatives combined with the use of EMRs will result in a system dominated by the dictates of managed care.
The American Psychoanalytic Association, long a leader in the fight to protect patient privacy, submitted comments to Brailer emphasizing the need to create a system of EMRs based on the British model and professional ethics, which will safeguard the ability of our members to deliver quality treatment to our patients. Jon Meyer, Jim Pyles (our counsel), and I plan to reiterate these points in an upcoming personal meeting with Brailer.