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New NRC Report Finds “Health Care IT Chasm,” Seeks New Course Toward Quality Improvement and Cost Savings

Like the Institute of Medicine’s (IOM) 2001 counterpart report, “Crossing the Quality Chasm,” a new report from the National Research Council of the National Academies is complex, full of new ideas assembled from multiple disciplines, and is likely to have seminal importance in framing public policy from now on. “Computational Technology for Effective Health Care:  Immediate Steps and Strategic Directions” was released last Friday, January 9, 2009 in draft, but there is so much to comment on that I think it’s wise to begin with a quote from the committee that sums up the central conclusion:

In short, the nation faces a health care IT chasm that is analogous to the quality chasm highlighted by the IOM over the past decade. In the quality domain, various improvement efforts have failed to improve health care outcomes, and sometimes even done more harm than good. Similarly, based on an examination of the multiple sources of evidence described above and viewing them through the lens of the committee’s judgment, the committee believes that the nation faces the same risk with health care IT—that current efforts aimed at the nationwide deployment of health care IT will not be sufficient to achieve the vision of 21st century health care, and may even set back the cause if these efforts continue wholly without change from their present course. Success in this regard will require greater emphasis on the goal of improving health care by providing cognitive support for health care providers and even for patients and family caregivers on the part of computer science and health/biomedical informatics researchers. Vendors, health care organizations, and government, too, will also have to pay greater attention to cognitive support. This point is the central conclusion articulated in this report. (emphasis added)

It would be difficult to find a more sober indictment of US health care IT policy and implementation over the past decade than what is contained here.

The report is the result of many meetings and site visits beginning in April 2007. It was written by a committee chaired by William W. Stead, MD, Director of the prestigious Informatics Center at Vanderbilt University Medical Center, and includes not only some of the nation’s top academic computer scientists and health IT engineers, but representatives from the private sector (Google and Intel) as well.

The report recommends that governmental institutions – especially the federal government – should explicitly embrace measurable health care quality improvement as the driving rationale for its health care IT adoption efforts, and should shun programs that promote specific clinical applications or products.

Although the report’s language is sometimes almost impenetrable, the Committee’s major criticism of today’s health IT is that the systems in use do not support the clinical decision making processes that are foundational to the practice of quality medicine, lacking what the authors refer to as “cognitive support.” Nor do they adequately support the data collection and aggregation necessary to analyze, report, and improve care.  Again, in the words of the report:

The committee also saw little cognitive support for data interpretation, planning, or collaboration. For example, even in situations where different members of the care team were physically gathered at the entrance to a patient’s room and looking at different aspects of a patient’s case on their individual computers, collaborative interactions took place via verbal discussion, not directly supported in any way by the computer systems, and the discussions were not captured back into the system or record (i.e., the valuable high-level abstractions and integration were neither supported nor retained for future use).
Instead, committee members repeatedly observed health care IT focused on individual transactions (e.g., medication X is given to the patient at 9:42 p.m., laboratory result Y is returned to the physician, and so
on) and virtually no attention being paid to helping the clinician understand how the voluminous data collected could relate to the overall health care status of any individual patient. Care providers spent a great deal of time in electronically documenting what they did for patients, but these providers often said that they were entering the information to comply with regulations or to defend against lawsuits, rather than because they expected someone to use it to improve clinical care.

And I found it refreshingly honest that the report compares the human interfacing of health care software with software used in other information-intense environments, and not favorably:

A reviewer of this report in draft form noted the non-intuitive behavior of most health care IT systems and the training requirements that result from that behavior. Hospitals often require 3- or 4-hour training sessions for physicians before they can get the user names and passwords for access to new clinical systems. Yet much of the computing software that these people use in other settings (e.g., office software) adopts a consistent interface metaphor across applications and adheres to prevailing design/interface norms. As a result, there is much less need for training, and the user manual need only be consulted when special questions arise. In contrast, health care IT lacks these characteristics of conventional software packages—a fact that reflects the failure of these systems to address some basic human interface considerations.

Not all criticism

But the new “Health Care IT Chasm” report is not just criticism.  It suggests a number of ways to think about the challenges going forward, posits principles that can achieve a vision of patient-centered decision support, and makes clear cut recommendations aimed at the government, health care provider organizations, the IT vendor community, and researchers.  Here are a few highlights that caught my immediate attention:

  • Motivated by a presentation from Intermountain Healthcare’s Marc Probst, the Committee found it useful to categorize health care information technology (IT) into four domains: automation; connectivity; decision support; and data-mining. The report comments that there is currently an “imbalance” in which most IT efforts have been focused on automation, and not enough on the other three domains.
  • The report suggests two sets of principles to guide governmental policy on health care IT, one for making progress in the near term, and one for the longer term
    • Making progress in the near term, “Principles for evolutionary change”:
      •    Focus on improvements in care – technology is secondary.
      •    Seek incremental gain from incremental effort.
      •    Record available data so that today’s biomedical knowledge can be used to interpret the data to drive care, process improvement, and research.
      •    Design for human and organizational factors so that social and institutional processes will not pose barriers to appropriately taking advantage of technology.
      •    Support the cognitive functions of all caregivers, including health professionals, patients, and their families.
    • While preparing for the long term, “Principles for radical change”:
      •    Architect information and workflow systems to accommodate disruptive change.
      •    Archive data for subsequent re-interpretation, that is, in anticipation of future advances in biomedical knowledge that may change today’s interpretation of data and advances in computer science that may provide new ways extracting meaningful and useful knowledge from existing data stores.
      •    Seek and develop technologies that identify and eliminate ineffective work processes.
      •    Seek and develop technologies that clarify the context of data.
  • The report calls for increasing the development of IT tools for patients and consumers, not just doctors and nurses:

A final and significant benefit for the committee’s vision of patient-centered cognitive support is that patients themselves should be able to make use of tools designed with such support in mind. That is, entirely apart from being useful for clinicians, tools and technologies for patient-centered cognitive support should also be able to provide value for patients who wish to understand their own medical conditions more completely and thoroughly. Obviously, different interfaces would be required (e.g., interfaces that translate medical jargon into lay language)—but the underlying tools for medical data integration, modeling, and abstraction designed for patient-centered cognitive support are likely to be the same in any system for lay end users (i.e., patients).

  • The report recommends that health care organizations and their leaders:

Insist that vendors supply IT that permits the separation of data from applications and facilitates data transfers to and from other non-vendor applications in shareable and generally useful formats.

Notice the wording here doesn’t mention standards, but only shareable and generally useful formats. To discuss the separation of data from software applications de-mystifies that awful term interoperability, and gets more directly at the heart of the matter of sharing data.

  • The section of the report on Research Challenges provides readers with a high level diagram of what the committee calls the “virtual patient” — which they define as “a conceptual model of the patient reflecting
    their [the clinician’s] understanding of interacting physiological, psychological, societal, and other dimensions.”  The diagram illustrates where they believe health IT is currently, and where it needs to go in the future.

Ebm_practice
Bound to spark controversy

As readers of this review will certainly know, there is currently an on-going debate occasioned by President-elect Obama’s pledge to spend $50 billion on health IT as part of the economic recovery package, about how the new administration should parse these investments in health IT over the next few years.  One group favors massive
expenditure on existing products and services, such as EHRs, and the other recommends an approach that would also support incremental and less disruptive IT adoption while re-designing clinical software and communications technology to be more affordable and directly contributory to better care outcomes.  The timing of the Health Care IT Chasm report, therefore, could not be, well, more timely.

There is probably something in this report to help reinforce the arguments of both the “EHRs are good enough” camp as well as the “don’t spend bad money after good” group. But I find it predominantly a cautionary tale, told by a group of scientists who have carefully considered the present course of IT investment and have found it needing a re-direction.  Because many of the committee members are or have been leaders of the present course, the report is by definition courageously self-critical. It is also commendable that this committee took the time and effort to actually survey health care institutions, talk with doctors, nurses, and patients, and examine first hand the social, organizational, and technical interactions of the IT systems they criticize in this report.  This is not just a report by the experts.  It is a report by experts who are also stewards and witnesses.

David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on health care professional and consumer technologies.

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Harry StevensThomas SuttonJ BeanPeter Basch, MDRoderick Silva Recent comment authors
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Harry Stevens
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Harry Stevens

Why reinvent the wheel? An electronic health record system is already available in the VA healthcare system which after the billions of taxpayer dollars spent to debugg works just fine handling millions of patient records across state lines. There are no commercial equivalents to this. Why should the taxpayers have to underwrite the cost of this all over again? And lets face it, they worked out the bugs on interfacing services like radiology and machine readable technologies too so lets just cut to the chase- a single payer system with a uniform EHR for every citizen and all the benefits… Read more »

Thomas Sutton
Guest

As a designer active in developing healthcare solutions (hardware and software), I think it is worthwhile to consider the role of the design process used to develop medical IT, as a key contributor to its evident failure. Driven largely by a nightmarish regulatory environment, medical design projects tend to follow a dysfunctional process where much more attention is given to creating a paper trail than actually discovering and meeting the needs of end-users. Which is a fascinating parallel to what some of the doctors in this thread say about the record-keeping burden and how it distracts from the needs of… Read more »

MD as HELL
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MD as HELL

J Bean has said it quite well in regards to the quality of software. However I do not think there is “tremendous potential for improved patient care” in EHR. The lack of EHR is not what is wrong with healthcare today. What is really wrong is the consumerist movement has overpowered the doctor in terms of what care the patient receives. Bolstered by the John Edwards Effect (my name for defensive medicine), patients and families demand and receive scans, PEG tubes, dialysis, hospitalizations, home health, ED care, CPR, and life support that would never have been done prior to the… Read more »

J Bean
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J Bean

I don’t have much to add to what Peter gave us. Although I’ve wanted to contribute to this thread, I spend most of my evenings entering data into our new, multi-million dollar EMR and no longer have much free time except on Wednesdays. I’ve stopped seeing patients one day per week so that I can have more time to wrestle with the computerized input of useless dreck. EHR has tremendous potential for improved patient care, however at this point, there are apparently no implementations available that provide all of these marvels. Despite what Wendell believes, most physicians are pretty enchanted… Read more »

David C. Kibbe, MD MBA
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Great comments, Peter. Very Thoughtful. DCK

Peter Basch, MD
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Peter Basch, MD

Kudos to the National Research Council for their comprehensive and sober analysis of the state of health information technology as it exists today, and for their thoughtful recommendations. These recommendations reflect not just their research and editorial advice, but the current conventional wisdom and implementation approach of nearly all clinical informatics leaders. These recommendations call for continued federal financial support for: • Improved care enabled by HIT (and not for HIT adoption per se); • Innovation on workflow and process improvement; • Development of enhanced and highly functional clinical decision support for providers and patients • Health care institutions and… Read more »

Wendell Murray
Guest

“the best available software can still be expensive, intimidating, and in some cases, counterproductive.” True, but there is still a wide range of good to excellent software available. Not only that but “expensive” software can be negotiated downwards in price given the fortunate fact that the marketplace is highly competitive. Equally helpful is the fact that the incremental product cost of software is essentially zero, so the purchase price has a lot of room for downward negotiation. To MD mad Hell (I prefer to refer to you as MD mad as Hell), I do not know whether any of the… Read more »

David C. Kibbe, MD MBA
Guest

Wow! Terrific comments, all valuable. The new terminology here blows me away:
“smart assistive file cabinet”
“incremental gain from incremental effort”
“communication and knowledge within workflow”
“When positive attitudes converge with decent software, the results can be great”
“a system that is…not a brick”
“unimpressive ‘me-too’ commodities”
“epidemic of user-unfriendly IT”
“cognition has not been top-of-mind for the vast majority of IT companies” (pun intended? 😉
Kind regards, DCK

Roderick Silva
Guest

At the risk of making some readers angry, if you own software that is inflexible, complicated, and closed, you made a bad purchase. Don’t blame HIT. Today’s technology allows us to create intuitive, elegant, and flexible solutions that are simple to learn. Yes, your data is yours and you should have the ability to export it in multiple formats. This will allow it to fit inside any other solution that should come your way. No, it should not cost you thousands of dollars. You should pay monthly for it and not be binded to a contract. This way, if you… Read more »

Margalit Gur-Arie
Guest

I believe the HIT discussion suffers from a lack of precise definition of terms. On one hand there are expectations that EHRs will provide “cognitive support” , on the other hand EHRs are supposed to be as easy to learn as word processors. I really don’t know what “cognitive support” is, but I submit that the two expectations are incompatible. Creating software that has the ability to capture the essence of collaborative interactions between care givers gathered at the entrance of a patient room, and has the ability to digitize that collaboration and analyze it in proper context, is a… Read more »

John Haughton MD, MS
Guest

Great report. Looks as if it might explain alot – for example, have physicians been reluctant purchasers or Saavy consumers – Looks like Physicians are Saavy consumers holding on buying expensive EMR systems with little proof of efficacy. Simple programs, designed to improve care work. It’s possible to spend less than $100 / month / physician and improve metrics of care from 40% to 80% within a three or four month period. The secret is the right information in the point of care workflow; performance monitoring and safety-net lists of patients falling through the cracks – in other words, communication… Read more »

botetourt
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botetourt

Unfortunately, MD and Wendell are both right. After all these years, the best available software can still be expensive, intimidating, and in some cases, counterproductive. In the best of cases, the physician must approach EHR usage with a positive attitude, and a basic understanding that there is a learning curve. And I would agree that resistance varies directly with age. When positive attitudes converge with decent software, the results can be great–even the stragglers look back and wonder how they got along without computers, and heaven forbid that the system go down and everyone has to go back to manual… Read more »

MD as HELL
Guest
MD as HELL

Wendell, My attitude is practical, not emotional. My group has searched for a system that is intutive and flexible and not a brick. We have yet to see one. I can dictate faster than I can type and I am worth more seeing patients than my transcriptionist costs. Mandating an EHR for payment makes me wonder to what end will this help the patient. It will only slow down patient care. After 26 years of ED practice I am not young, but neither am I impractical. I am also pretty good. When something is good for my hospital or my… Read more »

Wendell Murray
Guest

MD mad as Hell’s response reflects the reality of the attitude of a majority of physicians, at least those over say the age of 45 to take an arbitrary number. Computer technology – hardware and software combined – is a tool like a stethescope to be used as a means of better performing the task at hand of delivering medical services. Delivering them better presumably. For whatever reason, many physicians are hostile to its use, as reflect by MD mad as Hell’s comment. Counterproductive to MD mad as Hell, but reality nonetheless. It seems clear to me that since this… Read more »

Steve Beller, PhD
Guest

This is most encouraging! We certainly need disruptive innovation! That includes radical alternatives to the extremely complex interoperability and technology standards, the inefficiencies of XML, and the costly centralized systems that dominate the HIT landscape. In addition, we need radical alternatives to the inflexible software programs that do little to support providers’ clinical decisions, to aid consumers/patients in their self-care, to coordinate care across healthcare disciplines, and to enable researchers to generate and disseminate evidence-based guidelines. Our government has been spending tons of money on large IT companies, and have spent little on IT small companies with disruptive innovations. Take,… Read more »