Will Unrecognized EHR Incentives Lead To Unintended Consequences?

Every day that I see patients, I am struck by the fact that, at least at my institution, the physician's work flow is no more efficient than it was 38 years ago when I was a medical student. In many cases it's worse. Things that used to get written in three separate places are now recorded four or five times. The patients' charts used to be either available or missing, now the information is scattered in a half-dozen systems, none of which have good indexing or retrieval functions. It is not unusual to find that the information is functionally unavailable (i.e. missing) and it's hard to differentiate between the missing and the non-existent. My colleagues at institutions that use "certified" EHRs spend extra, often unpaid, hours every day charting and coding.

What was it that induced healthcare institutions to accept and implement products that actually impair efficiency? This is, or should be, a recurring question. It has many facets, but an important one is whether government regulation can result in "meaningful use" of EHR. I'm not referring to meaningful as defined by some arbitrary administrative criteria, but meaningful in the sense that patient care is safer, more timely, efficient, humane and cost-effective.

There are always those who are unhappy with the status quo and envision a different - and they would say improved - world. This is the stuff of everyday conversation and debate among friends and family. Some (like me) respond by writing about it. Others get politically active and attempt to develop, and then impose, policies and procedures (laws and regulations) to encourage, induce, or coerce the public to participate in making the change du jour. Obviously, those few who become political have some incentive to do so. Just as obviously, the rest of us lack that incentive.

So, life is all about incentives. Being hungry gives you an incentive to eat. It may also provide an incentive to find a job, go on welfare, or rob a bank. Since people differ, what incentivizes them will differ. Whether through evolution or by design, humans are wired to evaluate things in terms of benefit to ourselves, our family, business, etc. Specific decisions may turn out to be correct, or not, but decisions about incentives tend to be made easily and with confidence.

Self-interest and perceived incentives affect how each individual reacts to every new law or regulation. Some take the new rules as dictates and follow them without question, some search for ways to avoid complying, and others try to profit even if it means violating the spirit and/or the specifics of the rules. One imagines various internal dialogs: "How can I get the most out of this new situation or minimize any negative impact?" "What kind of loophole is there that can be exploited to my advantage?" "If I violate the rules, will I get caught?" This happens whether the situation is a traffic jam and the task is to choose an alternate route or financial deregulation, and there appears to be an opportunity to make a profit by giving loans to unqualified borrowers.

Superficially, the recent financial mess appears a case of unanticipated consequences. But is it? If more thought had been given to the incentives that were created by the deregulation of the 1990's, many of the consequences could have been predicted. What was called "deregulation" was in reality an intended mechanism for producing consequences - good for a few, bad for the rest and therefore called "unintended."

With that as background, consider the recent news that four-fifths of the nation's hospitals, and 41 percent of office-based physicians, currently intend to take advantage of EHR incentive payments. The value of the incentive really depends on the qualities of the product that must be acquired to receive the payment. If the product is technologically and conceptually advanced and has been proven to enhance productivity and patient care, then the real value is in adopting the product; the small payment is just what it claims to be - an inducement. If the product is technologically and conceptually obsolete and is rooted in the paper-based, charge-capture mentality of the past, then the small cash payment and the avoidance of the small penalty are forms of coercion. Remember, certification does not insure that a product will help you practice better or more efficiently, only that it will allow you access, perhaps in incredibly inefficient ways, to a laundry list of functions that some regulator decided were probably important to someone.

The bottom line: healthcare reform as it currently stands is loaded with incentives, some overt, some hidden, some intended, and some unintended. Acting too soon, and without careful consideration, increases the risk of falling victim to one of those "unintended" consequences.