Elizabeth A. Pector, MD

Family physician Randall Oates, MD, developer of SOAPware and an active participant in health IT matters, opined recently in a listserv discussion, "The gap between the vendor/academic/government policymakers and the real world continues to be beyond enormous. However, when I report these realities to the former, it is nearly always a 'deer-in-headlight' experience. I don't expect deer to know how much they don't know, but I have higher expectations for persons and organizations."

Consider Oates's comments in light of the top-down efforts of the Obama administration to promote health IT. The plan to reimburse doctors for adoption of electronic health records sounds great. There's only one catch: As written, the plan will pay only those doctors who implement an EHR that is used in an as yet undefined "meaningful" way. The administration's mandatory interoperable EHR today is nothing more than vague vaporware; true interoperability among systems may be many years away. (Oates characterizes the current road map to interoperability as "the equivalent of suggesting American families use 18-wheel rigs to go to the grocery store.")

Eventually, "meaningfully useful" technology will help doctors do a better job . . . as soon as software, hardware, and information exchange are more affordable and easily adaptable to the innumerable environments in which doctors work. We're not there yet.

Next, consider the top-down efforts of primary care organizations to sell an untested primary care medical home model to their member physicians and patients. In the opinion of family doc Douglas Iliff, MD, in his blog "Making It" (which can be found on the website of the American Academy of Family Physicians), the model as described by the National Committee for Quality Assurance is heavy on input (infrastructure) and light on outcomes (patient-care principles).

In a recent Annals of Internal Medicine article, Paul Nutting, MD, and colleagues report their initial lessons learned from participating in the AAFP's TransforMED medical home project. They indicate that the NCQA model needs revision so that it focuses more on patient-centered measures and recognizes the long, several-year process of transformation and development needed to create a technologically-enhanced medical home.

As reflected in Iliff's blog, many solo and small-group primary care practices feel that a wide variety of infrastructure—from micropractice to Mayo Clinic—can achieve effective patient outcomes. Inflexibly requiring staff huddles, patient portals, and meticulously documented practice procedures may divert doctors from patient care and lead to burnout and "change fatigue" as they strive to qualify for unspecified benefits of becoming a "certified medical home." My greatest fear is that the steamrolling force behind medical homes will run valuable small-practice primary care doctors off the track.

Meanwhile, consider what is a major priority of insurers and government: cost control. This overriding mandate, proclaimed from high atop skyscrapers in cushy boardrooms, drives the erection of innumerable obstacles to care—at doctors' expense. Insurers seek every excuse to deny coverage. Deductibles and premiums rise, and preauthorization hassles for radiology tests and medications are at an all-time high. The recent decree that physicians are creditors who must scramble to write analyses and procedures to identify red flags for identity theft is just one more ludicrous cost imposed on doctors, with many helpful leeches standing by to suck a few hundred dollars from our wallets to help us meet the red-flag deadlines. In effect, doctors spend their own money to save money for others.