Monday, January 5, 2009

Good Enough? The Debate Over Investments in Healthcare Technology

Are today's healthcare IT systems "good enough"?

David Blumenthal (Harvard Medical School and Institute for Health Policy) said "the debate over whether existing technology is good enough has only emerged recently, with the prospect of a huge national investment in electronic health records. What seems to be happening ... is that passionate health technology advocates fear the country could get locked into an imperfect system."

Healthcare technology interoperability is considered a key component to reduction of administrative costs and improved coordination and continuity of care. Mike Leavitt, Secretary of HHS, contends that "we're already on the road to a system that is universally accessible and secure. Health information experts ... have been working on foundational health IT standards and have made substantial progress."

In Next Steps for Interoperability, John Halamka (Chair of HITSP and CIO for Harvard Medical School and Beth Israel Deaconess) believes that "we can achieve a substantial improvement in care quality and coordination by implementing the systems available now." He posits that the definition of healthcare technology interoperability that is "good enough" includes:
  • "Support for medication interoperability such as e-prescribing linking providers, payers, and pharmacies
  • Support for laboratory and radiology interoperability such as orders and results integration among providers, hospitals and commercial labs
  • Support for seamless electronic interchange between providers and payers for administrative data flows.
In 2009, several EHR vendors will support clinical summary exchange."

Transition into product, and incentive systems for EHR adoption, has been accelerated through certifications including interoperability standards. Mark Leavitt, Chair of the Certification Commission for Healthcare Technology (CCHIT), recently reported on the existing certification programs, which started with an ambulatory EHR certification program launched in 2006.

According to Mark Leavitt, CCHIT certified product are now required for a number of EHR incentive systems which have developed over the last two years, with total investments exceeding $700 million, including 44 distinct public and private EHR programs and "54 new EHR rollouts, representing 147 hospitals under Stark safe harbor rule." Around 46,000 physicians are eligible for, or have received assistance under these programs.

Take time to parse the following from Mark Leavitt: "That there are no good products is absolutely not the problem".

Secretary Mike Leavitt argues that that Obama's Recovery and Reinvestment Plan should require that investments in health IT systems be certified interoperable. This "could spur a critical mass of the nation's doctors to finally enter the information age... If we're going to build a 21st-century health infrastructure, we need to do it strategically, continuing the careful work on harmonized standards that will create one nationwide, interoperable system. That's the only way to make an investment in health IT produce value for providers and patients and improve the quality of health care overall."

Not everyone is convinced that these investments will pay off. David Kibbe (Senior Advisor to the American Academy of Family Physicians) and Brian Klepper argue that "the easy solution would be to spend most of the health IT funds on EHRs. The EHR industry has made it easy by establishing a mechanism to 'certify' EHR products if they incorporate certain features and functions." Kibbe and Klepper contend that EHRs are expensive, disruptive to implement, with no clear patient safety benefits and are not yet interoperable. "These barriers to adoption are well documented; they form the wall that has kept physician EHR adoption overall to less than 25 percent in this country. Even if a hefty federal subsidy reduced the exorbitant cost of the EHRs, many practices would suffer severe negative business impacts, and primary care access could temporarily be reduced on a national scale."

In the meantime, some healthcare organizations are waiting on the sidelines for the federal Recovery and Reinvestment Plan to be enacted before making new health IT investments.

Link here for more on the "Good Enough" debate in Healthcare Technology.


Hunscher said...

Excellent and insightful post. I tend to agree with the argument that pushing EHRs on PCPs is a bad move. Many such systems are abominable from a usability perspective, and would likely interfere with care quality rather than improving it.

Personally I think the focus should be on lightweight EHRs to aid in clinical decision support. A good prompt and reminder system (e.g. Cielo Clinic) doesn't need a full-blown EHR back-end to provide significant gains in quality.

P&R systems are a boon to primary care in another way: They help the PCP to avoid missed opportunities for billable procedures. This provides an incentive for PCPs to overcome their resistance to practice automation.

The next biggest bang-for-buck would be e-prescribing on top of a lightweight EHR. If tied in with third-party payer formularies and databases of drug interactions and contraindications, e-prescribing improves patient safety and ensures maximum reimbursement for prescribed medications.

Anonymous said...

With DEEP respect for Dr. Halamka, I find his observations regarding EHR's ONLY applicable when the HIT industry provides products that are SIMPLE, EFFECTIVE (today not years from now) and AFFORDABLE.

It is EASY for Harvard to put hundreds (or even TENS) of MILLIONS of dollars into an HIT program but for the VAST majority of hospitals/Groups/Doctors doing their best to provide the highest level of care with the resources at hand, creating the PERFECT solution is not realistic.

What they need is something that is good enough, supports guideline-driven care and costs less than their cell phone bill.

The pursuit of perfection in replicating PAPER-based processes in a digital world RETARDS the development and growth of new "low-tech" innovative ideas that provide IMMEDIATE improvements in care and cost little. Online patient registries like DocSite, I2I or Cielo are examples. Creating a purely digital practice isn't the point. Improving patient care by whatever means is...or have we forgotten that?

An EMR is NO solution for an ambulatory physician providing the best care they can with continuously reducing compensation. EMRs generally destroy productivity, add headcount purely for IT support and provide NO clinical/financial benefit for years to come. Despite the marketing hype, it makes NO sense for most physicians to invest in an EMR today. We will come to a better solution, but those physicians who have STAYED AWAY from buying EMRs are acting rationally and appropriately.

Thanks for your informative blog. I've been a big fan for a while, but this is the first time I've ever stepped forward to comment.

EMR Medical said...

An informative article.. Thanks for the post.