Wednesday, October 17, 2012

The Stockholm Syndrome and EMRs

First the definition:

Stockholm syndrome, or capture-bonding, is a psychological phenomenon in which hostages express empathy and have positive feelings towards their captors, sometimes to the point of defending them. These feelings are generally considered irrational in light of the danger or risk endured by the victims, who essentially mistake a lack of abuse from their captors for an act of kindness.

Now, the health care connection.  As a result of the billions of dollars allocated by Congress to health information systems as part of the stimulus program, those companies who had a head start in implementing electronic medical records quickly found themselves in demand.  Of all those companies, Epic is the most successful. Forbes notes, "By next year 40% of the U.S. population--127 million patients--will have their medical information stored in an Epic digital record."  (Here in Massachusetts, the biggest convert was Partners Healthcare System:  "System development and implementation will occur over a 10-year period and represent a capital investment of approximately $600 - 700 million."  Elsewhere, notes Forbes: "The biggest win: a $4 billion project to digitize medical records for health care giant Kaiser Permanente."

What is striking about this company is the degree to which the CEO has made it clear that she is not interested in providing the capability for her system to be integrated into other medical record systems.  The company also "owns" its clients in that it determines when system upgrades are necessary and when changes in functionality will be introduced.  And yet, large hospitals sign up for the system, rationalizing that it is the best.  For example, Partners said, “The new health care landscape will challenge us to engage in population health management, improve the coordination of health care, and accept financial risk for the care of our patients. This new system will enable us to meet those challenges.”

But it can hurt to go down this path.  In another article, Forbes notes:

Customers, such as New Hampshire’s Dartmouth-Hitchcock Medical Center are feeling the pinch. DHMC which implemented Epic last year at a cost of $80 million, expects a weak operating performance in 2012, partly because of expenses related to Epic.

Now, re-read the definition of the Stockholm syndrome and see if it isn't apt.  But it doesn't have to be this way, as I have noted in quoting an article by Kenneth Mandl and Zak Kohane in the New England Journal of Medicine:

It is a widely accepted myth that medicine requires complex, highly specialized information-technology (IT) systems. This myth continues to justify soaring IT costs, burdensome physician workloads, and stagnation in innovation — while doctors become increasingly bound to documentation and communication products that are functionally decades behind those they use in their “civilian” life.

We believe that EHR vendors propagate the myth that health IT is qualitatively different from industrial and consumer products in order to protect their prices and market share and block new entrants. In reality, diverse functionality needn't reside within single EHR systems, and there's a clear path toward better, safer, cheaper, and nimbler tools for managing health care's complex tasks.

Here's the ultimate corporate risk for Epic.  Now that it controls this big a piece of the American market--paid for by federal appropriations--if something ever goes wrong (e.g., a coding or decision support error that results in harm to patients), you can expect a bunch of Congressional committees to come down on the firm like a ton of bricks.  It doesn't matter which political party is in the majority.  People will ask:  "Isn't an EMR as much of a medical device as the ones regulated by the FDA?  Isn't the handling of prescription drugs by EMRs as much a part of drug dispensing as the drugs themselves?  Shouldn't EMRs be regulated by the federal government for that reason, too?  How did this firm get such a big share of such a critical market with no government review?"


Anonymous said...

Mandl and Kohane's analysis is right on target. Literally billions of dollars have been wasted on inadequate EMR systems, starting well before Meaningful Use was even a gleam in the government's eye. The industry is truly unaccountable.
From your description, it sounds to me like Epic pursued a deliberate strategy of market dominance to ensure its place in the conversation when the inevitable impetus toward interoperability increases. Not a bad business strategy if you can execute it.
As for EMR's being a medical device, I and many other physicians have felt that is the case for some time, and have even written the FDA about it. They replied that they are studying it. In their defense, it is like trying to close the barn door after the horse is out, like so much else in the money-driven modern health care 'system'.

nonlocal MD

Linda said...

Great article, very funny and appropriate considering Epic's lack of Interoperability and inability to play nice with others in the EMR sandbox...

wrinkledman said...

As for Partners and Epic, birds of a feather...controlling the marketplace.

Anonymous said...

This is just unresearched and incorrect.

Epic is in fact a national leader in interoperability and connected to DoD, VA, NwHIN, other EMRs and has connected its sites using national standards pushing over 2,000,000 CCDs per month.

This whole blog post is silly.

Paul Levy said...

Maybe you should talk to the users and listen to what they say about the company's attitude. In any event, please re-read the last paragraph. You--assuming you are at Epic--face a huge corporate risk that you don't acknowledge.

Paul Levy said...

On the risk of error front, check out this article about Contra Costa:

Last week, a nurse for a Contra Costa correctional inmate prevented the facility’s electronic health record (EHR) from recommending a fatal dose of heart medication. As Mathias Gafni of the Contra Costa Times reported yesterday, the nurse’s knowledge of her patient’s history enabled her recognize the incorrect dosage of Digoxin and correct the electronic gaffe.

According to the report, this isn’t the first error caused by the Epic system, which went live on July 1 as a means of connecting the correctional facilities with the rest of the Contra Costa health system.

Dan Haley said...

This post is spot-on. Of course, as in any industry there is a wide variety of approaches - philosophical as well as technological - on the EHR spectrum. At athenahealth, where I work, we believe to our core in information liquidity and true interoperability. That is the entire foundation of our cloud-based model, and it couldn't be more different from the Epic approach, which - as the author points out - limits "interoperability" to a deliberately closed (and locked!) ecosystem, and thereby undermines the public policy imperative of open and free health information sharing. Some related thoughts here:

Jeremy said...

From LinkedIN:

Your latest post on EMRs and Stockholm syndrome was brilliant, brave, and the right thing to do. I gave a HIStalk interview about a year ago that attempted to articulate some of what you recently wrote and caught some hell for it.

Kudos Paul!

Anonymous said...

I am an analyst, not a doctor, but I have a project I am working on sharing CCD and PDQ files back and forth between Epic and Next Gen. I have found the Epic team to be helpful and encouraging. I understand from them I am the third account to tackle this. It is true the information is not as robust as it would be if I were sharing with another Epic client, but it is evolving fast and there is more meat with every upgrade. (and every vendor has upgrades)

In addition, as for Epic being "locked down", if an Epic client so desires, they can enroll a in a programmer class at Epic, and if they pass thru the hoops, they can write programming points to do whatever they want the system to do.This is dangerous because, again, as with any vendor, once you customize you are on your own for support of that application.
Epic clients have gotten lazy with what they call model hospital, which is a prebuilt system. I installed Epic when you had to build everything yourself. Many things can be changed in model if one has the fortitude.

Again, as with any vendor, customizations are risky because

Anonymous said...

Dr. Levy,

This gets the prize for one of the insightful presentations you have done. Epic is not unique. The question is: how did any of the vendors get their devices into hospitals to manage the care of patients and workflows of doctors without any oversight? Is that not what the FDA is supposed to do?

Thank you for seeing the light as espoused at the the health Care Renewal Blog.

Tonya Simpson, RN

Jon P said...

There is a further dimension to the EMR question for all large vendors and that is the software engineering model that requires changes to the system functionality by programming. As one commentator says, you send a programmer to Epic for training courses so that they can do programming changes in house.
At iCIMS we believe that level of technology is antiquated and contributes exactly to the lock-in described in the blog. Our approach is to provide functionality that enables the clinical team to build the design of the system themselves with the support of our clinical analysts if desired and then create the application automatically from the design. In that way the design is no longer under vendor control and the clinical designers at the client's premises can change the system at any time in real-time. This has the interesting effect of making clinical workflow of the EMR the responsibility of the clinical community and the computational processing the responsibility of the vendor, a fair and just distribution of obligations.

InformaticsMD said...

I've used the "Stockholm syndrome" at Healthcare Renewal to refer to why physicians give in to bad health IT, instead of refusing to use it, or, as might have happened in older days, simply cut the network cables and/or smashed the workstations.

InformaticsMD said...

Re: "People will ask: "Isn't an EMR as much of a medical device as the ones regulated by the FDA?"

Jeff Shuren MD JD at CDRH thinks so. He stated this explicitly on Feb. 25, 2010 (see testimony to the HHS Health Information Technology HIT Policy Committee:

... Under the Federal, Food, Drug, and Cosmetic Act, HIT software is a medical device. Currently, the FDA mandates that manufacturers of other types of software devices comply with the laws and regulations that apply to more traditional medical device firms. These products include devices that contain one or more software components, parts, or accessories (such as electrocardiographic (ECG) systems used to monitor patient activity), as well as devices that are composed solely of software (such as laboratory information management systems).

... To date, FDA has largely refrained from enforcing our regulatory requirements with respect to HIT devices.

See this link.

Further, it won't be just the government who comes down like a ton of bricks. It will also be the Plaintiff's Bar - who I have begun to assist, also to make aware of the issues and to whom I am recommending pursuit of the sellers of the technology when patients are injured or killed -- as was a relative of mine and others of whom I know about. My pre-informatics role of Medical Programs Manager for a regional transit authority, in which I interacted with many attorneys in worker's comp, substance abuse, fitness for duty etc. was good prep.

Let's see how the IT personnel in this industry in their arrogance do on the witness stand as defendants, against attorneys prepared with the expertise people in my field, Medical Informatics, provide.

-- SS

Anonymous said...

Jon P, I think you are absolutely on the right track. As a former hospital clinical laboratory director, I would have given my left arm (being left handed) for that sort of control, instead of endless wrangling with uninformed and heedless EMR vendor reps to get the changes we desperately needed - which often never came at all, or weren't done right anyway.

nonlocal MD

Timothy Cook said...

From Google+:

Excellent article by +Paul Levy Many of us in the trenches have been advocating away from the lock-in approach by these big companies, for years. It is so obvious that these large companies only care about the bottom line and not about real improvement in how health information is managed. Tiny, fundamental changes is all that is needed for all healthcare information to be made semantically interoperable. But, those changes are counter to the desires of monopoly seeking organizations like +Epic, +Cerner, etc. So, openly available academic projects like #mlhim will wait. We will wait until the pain and frustration and expense is greater than the desire to change. Maybe then an organization like #W3c will take notice. Organizations like #ANSI and #CEN and #ISO are so tangled in 20th century thinking and bureaucratic processes that the are virtually immune to making any drastic changes.

Scot Silverstein said...

From Facebook:

Good post. I've used the Stockholm Syndrome myself for the passive attitudes of captive physicians relative to bad health IT.

As to the government "coming down like a ton of bricks", I'd be more worried about the Plaintiff's Bar. I am advising and educating members of AAJ and its subchapters on health IT risks, the poor quality in the industry, and the need to call the sellers to account in the courtroom when patients are injured (and I am helping the attorneys in cases where that occurred).

This is not a joke. My mother's injuries and death were the last straw.

I also offer help to the Defendant's Bar in helping their clients avoid HIT-related med mal in the first place, and by my writings am attempting to put myself out of business, but the Defendant's Bar seems disinterested in what I have to say.

It would not be hard to conceive they are looking at the $$$ they gain from post-injury or post-death litigation defense.

Anonymous said...

So this is a good piece, but I do want to clear up some misconceptions.

FULL DISCLOSURE: I used to work at Epic as a Project Manager, and currently my every day work still involves Epic.

Of all the EMR vendors available, I still believe, even having worked with others, that Epic is the best. Now, that might be something like "The best of the worst situation", but still the best, nonetheless. Of all the companies out there, I think it's the one that's the least concerned with the bottom line.

That said, the company is exceedingly arrogant--both from an internal perspective and an external perspective. What Epic is trying to force on the healthcare industry right now is it's version of what's best for healthcare. Hospitals are consistently and constantly advised that the "Epic Way" is the appropriate way of doing things, and that they should change their way of doing things to match what Epic is saying.

This is a fine line to walk - on one hand, Epic has the experiences from several thousand implementations to share, but on the other hand, what's best for some is not best for all. There's a fine balance to walk there as the hospital to say "this is what works best for us, regardless of what Epic says." A lot of organizations have trouble telling Epic, "No," and end up with workflows and processes that at best are confusing and outlandish, and at worst outright don't work.

Make no mistake, while Epic might be making strides towards interoperability (Judy is on the advising committee, any road), it's Epic's hope to crush all the other competition and be the only EMR on the market.

@Scot Silverstein -

While I appreciate your sentiment, your post to hold "sellers accountable" shows a little bit of naivete, at least where Epic is concerned. Epic, as an EMR, is more of a scaffolding for you to model your system. The system is mind-bogglingly configurable. The client (hospital) is the one who configures all of the system, helped out by their Epic project team. In Epic, there's NOTHING care-related that is hardcoded. In the example above of the incorrect dosage -- that's the result of a data-entry error by a staff member of the hospital, not in Epic. Epic doesn't hold or control that information; it can only take what was entered into it during the "Build" phase of the install. If it was shoddily configured with incorrect information, that's data entry, not the EMR itself.

The other EMR's that I've worked with have been similar, but I'm sure there are some that are much more rigid, and thus much more culpable for mistakes.

Physician Technologist said...

I applaud Levy for his article, and to you, for referencing it. Epic's business practices of "strong arming" their clients to use only Epic products is unconscionable.

With their purchases being driven by government mandates and funding for meaningful use, I can't understand why the Feds haven't made it MANDATORY for all EHR vendors to fully integrate with other systems, or lose the ability to be a qualifier for meaningful use dollars.

Under those circumstances, competition would thrive. The large vendors would be forced to innovate and provide better service to compete against small and medium sized businesses. At a minimum, healthcare providers could purchase best-of-breed solutions to complement the EMR, improving the entire environment.

Right now, the Epic's of the world are scoffing at their clients' needs, laughing in the federal government's face, and taking their money as well.

Anonymous said...

Anonymous states
The war is on between Epic and Cerner. Cerner is joining forces with McKesson to beat Epic. I amazed at KLAS comments with regards to Epic and Cerner. They don't mention nickle & diming customers but they absolutely do this with every service is at a cost. However the smaller vendors like GE, McKesson and Allscripts get nailed for nickle and diming. And while we are that front, hospitals nickle and dime their patients for everything used for their care. Lets face it folks, to stay in business you have to increase your revenue and cut your costs.

Anonymous said...

Stockholm Syndrome and healthcare, Stockholm Syndrome and capitalism. There are many aspects of healthcare that imprison patients. Healthcare is worried because they will no longer have the ultimate say in control. EMRs controlling some aspects of healthcare doesn't seem like the end of the world. Furthermore, the largest obstacle to interoperability is healthcare organizations themselves, seeking to keep patients in their own networks. Interoperabilty between different EMRs? how about allowing full interoperability between different implementations of a single EMR? Epic has a team of 300 people working solely on interfacing Epic with non-Epic systems (allowing for best of breed suits to exist with Epic). It is up to other EMRs to do the same to connect with Epic (Epic supports open standards) and other competitors. Complete interoperability is not one EMRs responsibility. Holding Epic responsible for complete interoperability would allow small vendors to piggyback off of Epic claiming greater functionality when the functionality was paid for by Epic and their customers. This is a much more complex issue than the article and comments are making it out to be.

Anonymous said...

Epic has some well paid trolls here to execute ad hominem attacks. Epic was a giant turd. I cant believe im saying this, but I prefer CPRS out at the VA and that thing is a horrible monstrosity.