EHRs: Weighing Incentives and What's Best for Patients

It is fair to say that in order for an EHR to be of value, it's must influence how, when, and in what way patients are treated and results must be beneficial. It would certainly be difficult to justify using an EHR that had a net negative impact on patient care, although some EHRs do. Fortunately for EHRs, questions of efficacy are rarely asked by organizations that are contemplating or have recently committed millions to a purchase.

EHRs should be considered to be a therapeutic modality, just as a drug or a surgical procedure is a therapeutic modality, since it can impact patients in both beneficial and detrimental ways. As with drugs and surgical procedures, it is reasonable to expect that decisions about if and when to apply EHR to a patient are made on the basis of objective evidence, not anecdotal accounts, personal biases or external pressures, be they political or economic. This suggests that whatever approach we adopt to judge the efficacy of drugs and surgery be applied to EHR, or conversely, whatever approach is used to judge the efficacy of EHR should be good enough for selecting the best drugs and surgical procedures. A thought experiment can help to clarify the implications.

Let's imagine a world in which the FDA didn't license drugs but certified them. Drug manufacturers would be free to market any drug.

Let's further imagine that the government decided that physicians were prescribing certified drugs less often than they should. Such a decision is ultimately political, not scientific or clinical. Manufacturers of certified drugs would have an interest in motivating their legislators to "do something" about the "problem" of low sales volume, prompting them to make strategically placed political contributions. An organized group of medical pundits might have an interest in making themselves important in the eyes of the government so that they could secure funding and a mandate to control some aspect of national healthcare policy. Perhaps a group of influential parents believe that uncertified drugs or vaccines pose a risk to their children. In this scenario the legislators, under pressure from the various interest groups, eventually "do something" - they decide that they will offer incentive payments to those physicians who prescribe only certified drugs.

An incentive program such as this is a very good thing for the manufacturers of certified drugs because it provides a way to influence physicians' decision making in a way that will appear to be above reproach. In the "old days," manufacturers were able to provide direct incentives to physicians by means of samples, meals, trips, and gifts of various sorts. This was eventually declared to be unethical. Medical schools, medical societies declared that they would no longer countenance these incentives. The new program of government incentives provides a mechanism to accomplish essentially the same "unethical" goal but in an "ethical" manner. Medical ethicists have yet to object that the wolf is back dressed in sheep's clothing.

This fictional scenario leaves me with a nagging question: What is it about the EHR incentive program that makes it appropriate and ethical to influence physicians, through emoluments, to make decisions about what EHR they use to treat patients when, in the absence of that payment, they might have thought were not in the patient's best interest?

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