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Believe it or not, EHRs and Los Angeles County's mental health problem have a lot in common.
It's bedlam in 'Los Angeles' Twin Towers Correctional Facility. Inmates in suicide-proof gowns scream and bang on their cell doors. Late last year, Bloomberg reported that Los Angeles County is looking for a new approach to dealing with the mentally ill and homeless, many of whom would have received care in mental health facilities had they not fallen victim to the Reagan era initiative that "returned" these individuals to the community, relying on medication to control them.
L.A. County's immediate problem is not new. It is a delayed consequence of wheels that were set in motion many years ago; coincidentally, the very time that the precursors of today's EHRs were under development. Looking back, one can see evidence of the same kind of flawed reasoning behind both initiatives. Some of it was detailed by The New York Times in 1984:
"One of the most influential groups in bringing about the new national policy was the Joint Commission on Mental Illness and Health, an independent body set up by Congress in 1955," according to the report.
The most influential groups in pushing EHR certification and widespread use were acting at the request of Congress such as Health Level Seven International, the American National Standards Institute, and The Health Information Technology Policy Committee created by the Office of the National Coordinator for Health IT.
"Extravagant claims were made for the benefits of shifting from state hospitals to community clinics ... The professional community made mistakes and was overly optimistic, but the political community wanted to save money," according to the Times. It is de rigueur for those who would like to build, buy, or mandate EHR systems to make extravagant claims regarding the ostensible benefits, cost savings, etc.
From the Times: "Tranquilizers became the panacea for the mentally ill... state programs were buying them by the carload, sending the drugged patients back to the community... but no one wanted to think it through." EHR has been touted as the panacea for what ails healthcare. "A team of RAND Corporation researchers projected in 2005 that rapid adoption of health information technology (IT) could save the United States more than $81 billion annually," according to a 2013 article in Health Affairs.
From the Times: "Dr. Brown, then an executive of the National Institute of Mental Health ... stated candidly ... Yes, the doctors were overpromising ... we did allow ourselves to be somewhat misrepresented."
Apparently EHR was overpromised as well: "Seven years later, the empirical data on the technology's impact on healthcare efficiency and safety are mixed, and annual healthcare expenditures in the United States have grown by $800 billion. In our view, the disappointing performance of health IT to date can be largely attributed to several factors," according to the Health Affairs report.
"They [mental health programs] ended up with everything but the kitchen sink without the issue of long-term funding being settled," says the Times. EHR certification requires that an EHR contain everything but the kitchen sink.
From the Times: "We knew that there were not enough resources ... to do the whole job ... [but] It happened [became apparent] much faster than we foresaw." Based on publicized reports about large-scale EHR implementations, actual costs often exceed initial projections by 200 percent to 500 percent. Medical Economics suggests that the average EHR implementation for a five-doctor practice averages $225,000 and totally consumes the time of one physician to two physicians and two to three other staff for the duration of the implementation. It further suggests that ongoing average annual expenses will be approximately $85,000.
"In retrospect it does seem clear that questions were not asked that might have been asked. In the thousands of pages of testimony before Congressional committees in the late 1950s and early 1960s, little doubt was expressed about the wisdom of deinstitutionalization," according to the Times.
For EHR, it likewise seems clear that questions were not asked that might have been asked and that little doubt was expressed about the wisdom of mandating the use of such antiquated products.
The solution for the mentally ill is becoming clear to L.A. County: Open its own mental health facilities or make it financially attractive for the private sector to do so. The solution for EHR is equally clear: Eliminate certification, link any mandates to performance, not to the purchase or use of products, scrap the existing penalties and fairly compensate practitioners for their time so they won't feel under pressure to skimp on documentation and rush through visits.