If one were writing about the improvement of gastronomy in America, one would probably not celebrate “over 300 billion hamburgers served.” But that’s very much the type of success Dr. Ashish Jha is celebrating in last week’s piece on recent US healthcare IT sales. Unfortunately, the proliferation of Big Macs does not reflect superior cuisine, and healthcare IT (HIT) sales do not equate with better healthcare or with better health. Quantity does not equal quality of care.
To be sure, Dr. Jha acknowledges the challenges of rolling out HIT throughout US hospitals. And he should be strongly commended for his admission that HIT doesn’t capture care by many specialists and doesn’t save money. In addition, Dr. Jha points to the general inability of hospitals, outpatient physicians and laboratories to transfer data among themselves as a reason for HIT’s meager results.
But this is a circular argument and not an excuse. It is the vendors’ insistence on isolated proprietary systems (and the government’s acquiescence to the vendors) that created this lack of communication (non-interoperability) which so limits one of HIT’s most valuable benefits.
In our opinion, the major concern is that the blog post fails to answer the question we ask our PhD students:
So what? What is the outcome?
This entire effort is fueled by $29 billion in government subsidies and incentives, and by trillions of dollars spent and to be spent by hospitals, doctors and others .
So where is the evidence to back up the government’s and industry’s promises of lower mortality, improved health and lower health care costs?
Single studies tell us little. Sadly, as many as 90% of health IT studies fail the minimal criteria of the respected international literature syntheses conducted by the Cochrane Collaboration.
In other words, studies with weak methodology or sweetheart evaluation arrangements just don’t count as evidence.
Nevertheless, we know that healthcare IT can improve some processes of care, like reducing duplications of tests, prescribing better drugs for the elderly, and decreasing dosage errors, especially in integrated settings, like certain Kaiser systems. But our and others’ research shows little or no evidence that such changes result in better health.
For example, all well-controlled studies in a recent Cochrane review show no effect of health IT on high blood pressure. The best data show no effects on healthcare costs although the administration and GAO promised us up to $100 billion. It turns out that the study promising those savings has now been debunked by the same group that made them, the Rand Corporation . It also emerged that the original research was supported by two of the largest vendors of HIT, a fact not previously acknowledged.
Another difficulty with this research literature is the proliferation of undisclosed financial ties to the industry or with HIT operations. Given the vast sums involved, US policy should be based on rigorous syntheses of the entire literature by unbiased researchers. We know financial and emotional ties are usually associated with finding more frequent and impressive HIT “successes [3, 4].”
It is essential that all researchers disclose their conflicts of interest to the readers of this and other blogs, editorials, original research articles and other publications. Unfortunately, we have witnessed major financial ties, such as patents, board memberships, consultancies and research funding go undisclosed in influential studies. Why should health IT researchers and companies be treated any differently from drug companies?
We also have indisputable evidence that health IT can harm health. Dr. Jha, in fact, was a member of the federal committee that produced that report on HIT safety (not noted in his piece)  . The industry and the government agencies charged with promoting HIT sales aggressively propagandize any study with positive findings and condemn studies documenting no or adverse effects of HIT on health .
The tension between the industry’s sales and patient safety concerns is reflected in the current efforts to prevent the FDA from exercising its regulatory authority over HIT. Both industry and its government promoters actively seek to avoid FDA oversight, citing the possible anti-innovative effects of regulation.
They’ve got a point, but so do those who worry about the innumerable errors enhanced by HIT’s clumsy, non-interoperable, and irrational user interfaces. We need a balance between regulation and freedom to innovate; there are valid concerns on both sides. Meanwhile, clinicians, scholars and the FDA itself have catalogued thousands of medication errors generated by these technologies .
We agree with Dr. Jha that HIT offers many and significant advantages over paper. But if it had to meet the criteria required of medications, it would never be approved for human use. Even the best studies fail to support the advertised claims of improved health and lower costs. More important, there is overwhelming evidence of patient safety dangers and failures.
We also agree with Dr. Jha that the software will undoubtedly improve over the next decades. HIT is only about 40 years old, and has rocketed to widespread use in the last few years via the government’s incentive and subsidy programs. This has been a mixed blessing. We’ve learned a lot about its abilities and extraordinary potential, but we’ve also observed many of its challenges and errors.
We sincerely hope that HIT will achieve its currently unfulfilled promises of improved health outcomes and efficiency. But this will require policies focused on evidence-based analyses and data standards that allow interoperability, rather than a rush to obtain subsides for questionably effective functionalities designed to encourage sales in a compressed timetable.
Software sales must be secondary to rigorous and unbiased research examining whether such software represents good value for the trillions being spent by US hospitals and clinicians.
Stephen Soumerai, Sc. D., is Professor of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute and Co-Chair of the Evaluative Sciences and Statistics concentration of the Harvard University-wide PhD Program in Health Policy.
Ross Koppel, PhD, FACMI, has taught sociology at the University of Pennsylvania for 21 years and is the PI on several studies at Penn’s Medical School.