Let’s Reboot America’s HIT Conversation Part 1: Putting EHRs in Context

On December 19th, we published an Open Letter to the Obama Health Team,

cautioning the incoming Administration against limiting its Health
Information Technology (IT) investments to Electronic Health Records
(EHRs). Instead, we recommended that their health IT plan be rethought
to favor a large array of innovative applications that can be easily
adopted to result in more effective, less expensive care.

The
response to that post was vigorous – we received many comments and
inquiries from the health care vendor,  professional and policy
communities – urging us to provide more clarity. One prominent
commentator called to ask whether we, in fact, supported the use of
EHRs. We both have been active EMR and health IT supporters for many
years. Dr. Kibbe was a developer of the Continuity of Care Record
(CCR), a de facto standard format for Electronic Medical Records
(EMRs), and has assisted hundreds of medical practices to adopt EHRs.
Dr. Klepper has been involved in EMR projects for the last 15 years,
and the onsite clinic firm he works with provides every clinician with
a range of health IT tools, including EMRs.

That said, we are
realistic about the problems that exist with health information
technologies as they are currently constituted. As we described in our
previous post (and contrary to some recent claims), most products are
NOT interoperable, meaning licensees of different commercial systems –
each using different proprietary formats – often find it difficult to
exchange even basic health care information.

Most EHRs are
bloated with functions that often are turned off by practitioners, that
are promoted politically through the current CCHIT certification
process, and that drive up costs of purchase, implementation and
maintenance. Despite moving toward Web-based delivery models that have
MUCH lower transactional costs than old-fashioned client/server
approaches, most commercial offerings are still extremely expensive,
especially compared to the revenue flows of the relatively small
operations they support. (John Halamka MD’s recent recommendation that the Fed invest $50,000 per clinician for rapid implementation of “interoperable CCHIT certified electronic records with built in decision
support, clinical data exchange, and quality reporting

provides an idea of the resource allocations that are on the table.)
The very wide range of choices in the market currently raises the
question of whether the implementation of a national EHR infrastructure
MUST be so costly.

Many health care professionals still think of
health IT as a compartmentalized function within health care
organizations. But health IT has increasingly become the glue between
and across all health care supply chain, care delivery and financing
enterprises. In the past, it was enough for health IT to facilitate
information exchange inside organizations – in which case a proprietary
system would do – but we now expect information to be sent and received
seamlessly, independent of platform, including over the Internet. Most
of the currently dominant EHR technologies don’t even begin to get us
there.

Nor, despite the rampant optimism about its potential,
can a focus on health IT alone – or even more emphatically, EHRs –
resolve health care’s deeper problems. As the noted health care
economist Alain Enthoven wrote in a December 28 New York Times
editorial:

[President-elect Obama]… has suggested, for example, that electronic medical records could
save Americans nearly $80 billion per year. But information technology
cannot bring meaningful savings if it is used in a health care system
that regularly rewards waste and punishes efficiency, as ours does.

In other words, as the recent reports from the Congressional Budget Office and the Dartmouth Atlas
point out (yet again), real reforms will require an array of
significant changes, many of which will face withering opposition from
entrenched interests. One of those interests is the established health
care information technology sector, which stands to finally win
handsomely from huge Federal investment in their current products.

The
good news is that this is the position held by Peter Orszag, the
incoming Director of the Office of Management and Budget, the current
Director of the Congressional Budget Office, an astute student of
health care dynamics, and a key member of the Obama health team.  In
July 18, 2008 testimony before the Senate Finance Committee, he said:

The
bottom line is that research does indicate that, in certain settings,
health IT appears to facilitate reductions in health spending if other
steps in the broader healthcare system are also taken to alter
incentives to promote savings.
By itself, however, the adoption of more health IT is generally not sufficient to produce significant cost savings.

In
other words, it is fair to be skeptical about how we should proceed
with a national health IT build-out effort. The health IT industry’s
current product/service offerings are analogous to the auto industry’s
obsession with SUVs, as much the problem as the solution. Just as the
auto industry can be re-purposed to build lower-energy, less wasteful
vehicles, so too should the health IT industry be encouraged to offer
smarter products that serve the interests of an affordable, convenient,
and evidence-based health care system.

A smorgasbord of Health
Information Technologies is available to help us build a far better
health system. Part 2 will describe some functions that a national
health IT infrastructure renewal effort might consider.

David C. Kibbe MD MBA
is a Family Physician and Senior Advisor to the American Academy of
Family Physicians who consults on healthcare professional and consumer
technologies. Brian Klepper PhD is a health care market analyst and a Founding Principal of Health 2.0 Advisors, Inc.

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