Obama and Newt Gingrich Both Want to Spend $19 Billion on Electronic Medical Records: What’s That About?

As I finish writing this, a gathering is taking place at the White House to begin an important national discussion on a way forward for health care in the U.S. The Obama administration should be congratulated for moving this discussion forward.

But the first major health care initiative of the new administration is already in process, and Newt Gingrich thinks it’s great. Part of the federal stimulus package, the HITECH Act (Health Information Technology for Economic and Clinical Health Act) includes a $19 billion outlay to promote health information technology (HIT) and in particular the use of Electronic Medical Records (EMR). On the website of Gingrich’s Center for Health Transformation, he says that the $19 billion for HIT is one of only two good things in the stimulus package.

And the HIT vendors are raring to go, ready to make a profit. Already their websites are replete with offers to help health care organizations cash in on this windfall. It is almost certain that the pace of technological change in health care, and in particular the implementation of EMR’s, will accelerate significantly as a result. All this without a well-developed and organic mechanism of oversight, without collective workforce input and without a real plan for reforming health care. It is taken for granted that this technological infusion will cut costs and improve quality, without any conversation about the impact on the healthcare workforce.

As a friend once said: “If technology is the answer, you are probably asking the wrong question.” And focusing on the wrong problem.

If Newt Gingrich and Barack Obama are giving the same answer, we know that something is wrong.

Powerful interests, with an eye on markets and dollars, have been successfully pushing technology as the answer for health care for a long time. George Bush mentioned Electronic Medical Records and Health Information Technology in several of his State of the Union Addresses. President Obama included them in his first address to Congress and now there is $19 billion to back this up. Many politicians and policy makers seem to fall prey to the allure of simplistic technical solutions to a complex, social problem. We need to recognize that:

Technological fixes built on failed organizational structures are often wasted and can in fact exacerbate the problems of the existing systems. In the 90’s, consultants warned manufacturers about automating a dysfunctional manufacturing process. And what is more dysfunctional than the health care “system” in the US? After the voting catastrophe of 2000, many localities tried to throw technology at the problem. Where are those Diebold electronic voting machines now, and where is the money taxpayers spent on them? The fact is that once monies are spent on core technologies, taking on the real systemic issues can become more, not less, difficult.

The sharks are already in the water. IT vendors and consultants have been pushing their way into health care for a long time in their search for new markets. Now they, along with insurance companies, hospitals and other health care organizations, are all looking to get their piece of the public pie, and not looking out for health care. This funding will help to solve their problem of profitability, but what will it do for health care and health care workers? They will be hard at work pushing design and implementation of EMR and HIT in directions that meet their needs, and using taxpayer dollars to do it.

The health care workforce stands to lose out.  Workplace technologies are almost inevitably applied, in our capitalist system, in ways that work to the detriment of the workforce – undermining skills, eliminating jobs, increasing top-down control and regimentation/standardization (a particular problem in a care setting), monitoring the workforce, and in general undercutting the voice of the workforce in their own futures and in the systems they operate. Nurses complain that computer systems are poorly designed and difficult to use (both hardware and software), and lament that they spend valuable time looking at the computer screen when they should be looking at their patients. The workforce is, in general, kept out of technology decision-making, and therefore consideration of workforce needs and application of workforce skills, knowledge and understanding of the actual work process is absent

The fact that public monies, large sums of public monies, are being spent represents both a threat and an opportunity. The threat, simply put, is that with so much money being poured in, worker (and health care) unfriendly technological change will be massively accelerated. This is almost inevitable. Electronic Medical Record systems are so much more than a digital file. They are the digital backbone for a technological transformation of health care delivery, driven by profit rather than care. The HITECH Act mentions, for example, remote patient monitoring, telemedicine (web-based health care) and self-service applications (ATM’s for health care) among other technologies.

The opportunity is that, with a labor-sensitive administration overseeing the distribution of the funds and the development of connected policies, the workforce should be able to create a collective seat at the table and have a voice in the use of funds, in the policies and in the implementations that will soon be taking place. This will not happen without concerted and rapid action in several areas: 

Workers need a place at the table. HIT Policy and Standards Committees are established by the HITECH Act. Only 1 member of the Policy Committee is required to be “from a labor organization representing health care workers.” “From”, not even a representative as is required for IT vendors and insurers. Unions need more representation if the interests of the workforce are going to be a real part of the discussion. Demanding more of a place at the table is critical.

Unions need to be ready, and they aren’t. Unions are, in general, ill-prepared, both ideologically and practically, for playing a significant role in a technology policy and implementation process, especially one of this magnitude. They are handcuffed by the ideology and practice of management rights and hampered by a lack of practical experience in inserting worker voice into technological decision-making. Unions need to work quickly to develop their capacity to have policy input but also to bargain, and bargain expansively, over technological change at enterprise and workplace level.

Funding is needed for training and collective and independent worker involvement. Workers at every level of the organization need to be able to have collective input into the development, implementation and evaluation of HIT. But in order for this to happen in any real way, training will have to take place through unions representing health care workers, and funds need to be available to support the independent development of union-based input mechanisms. Portions of the $19 billion should be specifically and immediately set aside for these purposes.

Analysis of impact on the workforce must a part of all implementation. The Health Information Technology Research Center which is established under the Act currently has no mandate to look at the impact of HIT on the health care workforce, or for that matter to listen to input from the health care workforce. There should be an evaluation component that is specifically directed at the workforce and that is designed to gather the voices of workers being affected. This research must be done through and/or in conjunction with unions representing health care workers.

Technologies should serve health care reform. The context cannot be forgotten. At a time when “real” reform of the health care “system” is presumably on the table, rapid technological change that is not undertaken in the broader context could very well be a conservative force. Unions need to link the HIT discussion to the discussion of health care reform. This cannot wait.

There are models for the use of funds to deal with social impacts of new technologies as they are introduced. Over the last several years, funding for Nanotechnology has been provided by the federal government to the tune of about $1.5 billion per year. Tens of millions of dollars have been set aside to examine the social impacts and societal implications of nanotechnology. While the workforce and the work process are glaringly absent from this discussion, they could certainly be included. It certainly seems reasonable, when 19 billion in tax dollars is being spent to promote a technological change in an industry, that some funding is set aside to examine social impacts (including impacts on the workforce), and to support collective workforce voice in technology decision-making.

In closing, I have to return to the irony of Newt Gingrich’s involvement. The Center for Health Transformation has two “Hot Topics!!” on its website. The first is the stimulus package and specifically enthusiastic support for the HITECH Act’s $19 billion for health care technology. The second is an attack on the Employee Free Choice Act.

Do we get the point?

Charley Richardson
UMass Lowell Labor Extension Program
Charles_Richardson@uml.edu