|WHAT WE’RE READING
Stuff we read this week that made us think.
EHRs are deeply flawed—but what do we do about it?
Stories about electronic health records (EHRs) not living up to their promise are a dime a dozen, but we were intrigued by a well-researched piece from Fortune and Kaiser Health News which raises grave concerns about EHRs and the companies that make them, digging inside a “digital revolution” that has cost $36B and created a system that is an “unholy mess”. The article describes a new class of medical errors and patient safety risks that have been brought on by record-keeping software. Some relate to human mistakes that increase with EHR workflow: a doctor is more likely to place an order for the wrong patient in an EHR with multiple windows open on the screen than when writing on paper charts; hundreds of low-value alerts lead a provider to click past one critical flag. But more concerning are the defects in the systems themselves that have caused life-threatening errors, including generation of inaccurate medication lists or failure to deliver orders to labs, or record results of tests.
While the stories of patients harmed are heartbreaking, the larger issue raised by the article is the government subsidizing the rapid adoption of a flawed and underperforming technology. Large incentives were made available through the HITECH Act, passed in 2009, to encourage hospitals and doctors to adopt EHRs. That worked: 96 percent of hospitals have EHRs today, compared to just six percent in 2008, and over 86 percent of doctors’ offices have a digital records system. But the incentives have been less effective in creating a digital ecosystem in which patients can easily access and share their data, and doctor and nurse productivity can be increased. Some experts, including well-respected Chief Information Officer and Obama Administration advisor Dr. John Halamka, say the “meaningful use” incentives created pressure that was too intense for thoughtful technology development and adoption: “To go from a regulation to a highly-usable product that is in the hands of doctors in 18 months, that’s too fast,” Halamka said. “It’s like asking nine women to have a baby in a month.” Others felt the program enabled the “perverse business dynamics” of large EHR vendors, who developed closed systems that prioritized proprietary ownership of data over communication, provider workflow and patient access.
While the article doesn’t really suggest a way forward, it’s important to recognize that progress is messy. Our nation deserves credit for wiring its entire healthcare system in less than a decade, no matter how imperfectly, and there’s no going back to paper records. EHRs have enabled a number of large-scale data-gathering and quality initiatives, and played a pivotal role in rapidly changing prescribing practices to stem the opioid epidemic. And we should give EHRs full credit for killing an even more despised technology: the fax machine.
The skills gap behind healthcare’s labor shortage
Common industry wisdom predicts we’ll see a sharp rise in the need for low-skilled healthcare workers over the coming years, forecasting that we’ll need thousands of new caregivers, nursing assistants, and the like to manage the hands-on care needs of a growing population of elderly citizens, who often live hundreds of miles away from family support. An analysis out this week by economists at search firm Indeed.com shows that the industry may find itself more challenged than previously thought to fill higher-skilled healthcare roles. The authors evaluated the resumes of healthcare job seekers and compared them to employer job postings on Indeed between 2014 and 2018. They identified a healthcare skill gap between job seekers and the roles employers were looking to fill. The top ten categories of job seekers were largely low-wage, lower-skilled workers, including medical and nursing assistants, caregivers and home health aides. The top ten jobs in demand, however, included registered nurses (RNs), physical therapists, speech language pathologists, and occupational therapists, all requiring years of formal training and credentialing.
In contrast to other industries with labor force skill gaps, like the technology sector, it’s harder for healthcare to adjust. A tech company can hire from a more diverse pool, and train workers on the job. Healthcare providers are hampered by licensure requirements, and the years of formal training needed for most in-demand positions. Any efforts to “prime the pump” and increase supply have a long lag time and are limited by regulation of the number of training slots for doctors, nurses and other advanced professionals. Solving the skill gap problem is two-fold. Re-evaluating training requirements, expanding scope of practice, and creating more training slots for in-demand positions is critical, but won’t have an immediate effect. In addition to these structural changes, providers must actively “upskill” their lower-skilled workforces. Progress has been made toward “top-of-license” practice in which, for example, a medical assistant (MA) can perform some of the tasks delivered by a nurse today. Combining on-the-job training and technological assistance, like automation and artificial intelligence, could allow healthcare employers to more quickly build the workforce they need out of the one they have today.
The pernicious impact of noncompete agreements
A Kaiser Health News article that ran in this week’s New York Times caught our eye, concerning the use of noncompete agreements (NCAs) by health systems and physician groups to prevent their doctors from “stealing” patients when they leave employment and go to work somewhere else. The piece shares the stories of patients in the midst of ongoing treatment for urological disorders in Iowa whose doctors suddenly “ghosted” from their care—that is, disappeared without a trace. It turns out that the multispecialty group where the urologists worked had a covenant as part of their employment agreements restricting the doctors from taking patients with them if they left the group. Such agreements are common, according to the article: around 45 percent of doctors are bound by NCAs with their employers. As independent doctors are employed in greater numbers by large groups and health systems, that number is likely to increase. As highlighted by the article, however, prohibiting a doctor from continuing to care for a patient because of a change in employment can be very disruptive to care, leaving the patient struggling to find other sources of care. In some cases, the doctor’s previous employer may not be willing (or allowed) to provide information to patients on the doctor’s new whereabouts. Particularly in an environment in which growing importance is placed on delivering integrated, coordinated care, NCAs can jeopardize the continuity of care critical to good outcomes.
Noncompete agreements are a long-standing phenomenon not just in medicine but across industries in which skilled workers are employed. There’s a robust body of academic research on the topic, outlining the economic justification for such restrictive covenants, particularly where a firm feels the need to protect its investment in “human capital” and client relationships that could otherwise be stolen by competitors. But some states have built safeguards to protect continuity of care, requiring employers to notify patients when doctors switch jobs, and facilitating the transfer of their clinical information. And courts have grown reticent to enforce NCAs for doctors, especially when patient care might otherwise be jeopardized or a patient wishes to stay with their doctor. We’re not fans of NCAs in general—our view is that if you want to keep your employees, you should make employment attractive, not handcuff the people that work for you. And we’re particularly opposed to restricting patient choice as a result of enforcing NCAs. Rather than gatekeeping the doctor-patient relationship, groups and systems should build care offerings so compelling that patients want to stay regardless of the employment choice of any one doctor. If that’s not possible, then patients should be free to follow their physicians to a better solution.