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.

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.

20 replies »

  1. 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 we have already paid for.
    Lastly, we do not need trade associations like HIMSS staffed by non-clinical people making proposals that will cost enormous sums of money but of course payable to vendors of the EHR Vendors Association- HIMSS’ spawned offspring.

  2. 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 the patient.

  3. 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 1980’s. People no longer know when it is OK to die, when it is time to die, when one is supposed to die. Now no one can die if there is anything they have not had that might give them that miracle, for it is not one more day they want, but a miracle. Mostly patients and families think healthcare is broken because it ultamately fails, causing shock and disbelief and anger and litigation. EHR only provides attornies, both plantiff and defense, with grist for their mills. No amount of documentation changes bad care into good care. Having the same doctor for a long time is better than having your complete record available all the time. The military have always kept a single record on their people from start to finish. Each member physically carries it from station to station. Someone still has to read it! Electronically I probable could tell quicker when the last tetanus shot was given without reading the entire record. I do not see record continuity being a big deal, unless one wishes to deprive the patient of freedom to get different and untainted opinions about their care.

  4. 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 by high-tech (you know, lasers and robotic surgery!). I was a systems and software engineer for a decade before I went to medical school and I’m pretty under-impressed by what I’ve seen in the field. In fact, 15 years ago when I was still a software engineer(I’m over 45!), my colleagues would have been pretty embarrassed to have produced the software that I’m currently using. It’s amateurish at best. It certainly doesn’t meet any kind of standards for good user interface design. It does a remarkably poor job of data aggregation. It doesn’t have a search function or even allow easy access to older data, much less provide “decision support”. It has made my job harder rather than easier.

  5. 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 communities that appropriately aggregate data for quality improvement
    • Continued education and training; and
    • Interdisciplinary research
    However, in spite of this clear support for funding and continued development of HIT, some media headlines have painted this report as harshly critical of the potential of HIT in general, and EHRs in particular. This media misinterpretation resulted primarily from two faults inherent to the report : (1) the NRC’s mislabeling of their recommendations as a change from what health IT leaders are advocating for; and (2) the NRC’s inappropriate assignment of blame to EHRs as being the cause of dysfunction, rather than their understanding that EHR functionality and implementation deficits are a result of a dysfunctional reimbursement system, which is based on volume of episodic care and verbosity of documentation.
    While it is true many early adopter systems believed (at the time) that merely switching off paper medical records to EHRs would lead to improved and safer care – nobody has believed that, or has advocated that position in years. The current conventional wisdom is that HIT is quality and safety agnostic, and that its role is to serve as enabling infrastructure (toward whatever ends it is pushed to support). And as long as providers are incented primarily for procedures and volume, it is a surprise to no one (including the health systems studied), that their implementations have resulted thus far in only modest care improvements. That said, there is a much clearer understanding in 2009 of where potential value lies in HIT implementations, and most health systems implement very differently now than even a few years ago – focusing on custom clinical content and targeted decision support – which can lead to further care improvements even within a dysfunctional health care system.
    The NRC faults current EHR build as not supporting the cognitive support necessary to optimize care. This deficiency is obvious, and abundantly clear to veteran EHR and HIT users – many of whom work on their own or with vendors on new and better functioning clinical decision support. However, let’s be fair as to the root cause of this deficiency. It is neither lack of vendor vision nor limitation of IT technology; it is lack of a market. EHR vendors must build applications that will sell, and the advanced clinical decision support that the NRC appropriately calls for does not and will not have a market – until health care is less fragmented, efficiency goals are aligned, and payment policy moves away from procedures and volume to information and quality outcomes. In our current fragmented and dysfunctional system, EHR purchasers are looking for a toolset that helps their practice to function more efficiently (and pay off the HIT investment) – which equals coding and documentation support. This is not the fault of EHRs – but squarely the fault of our healthcare system.
    The NRC also makes the point that EHR technology needs to change, because many providers find that they spend more of their time on using the EHR to document care, rather than spending sufficient time on providing care. While it is certainly true that EHRs could make documentation easier, let’s not forget that providers using paper records voice the same complaints. Documentation changed from a medical art to a burdensome chore, not with the advent of the EHR, but with the Evaluation and Management (E/M) payment system changes of the mid 1990s. This payment schema effectively eliminated the possibility of concise and relevant documentation, replacing it with a “pay-for-verbosity” system. These payment requirements (along with the very real threat of fines and prosecution for billing fraud) have unfortunately also served as the basis for many EHR sales to physician practices; as there was and still is a clear market for documentation and coding support. Again, the fix is not technologic; it is health system and payment reform.
    In spite of these criticisms, the NRC offers good advice on improving HIT and EHRs, and sound recommendations for federal support. However, the key to getting it right is combining support for HIT with health system process and payment reform. Without alignment of efficiencies and defragmenting healthcare and healthcare delivery processes, even better HIT will not be consistently and optimally used. And without a concomitant commitment to a sustainable business case for health information management and quality, even universal adoption of optimized HIT will be a disappointment. The time for change coupled with wise investments is now.

  6. “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 generic EMR/PM offerings will work well in an emergency room setting, but I do not see why not. The needs are the same as for primary care roughly speaking.
    Dictation can be done directly into any system, but shouldn’t be a significant factor in decision-making regarding acquisition of a product. Voice to text software is very good and there are inexpensive products that are specialized for medical terminology.
    Take a look at PracticeFusion a “free” web-based system, AmazingCharts, an inexpensive locally-installed product, eClinicalWorks’ product. There are many other good products. If you want more concrete information, contact me. I can provide more detail gratis. I am findable.

  7. 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

  8. 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 find something better, you can export your data and go elsewhere.
    Regardless of other’s opinions, a server that can monitor hundreds of thousands of medical cases will alert you of similar cases and outcomes before you have even considered them. That my friend is not just an electronic file cabinet but a smart assistive file cabinet. It’s not a fantasy. This just requires networked computing. Multiple doctors, agences, and practices sharing case information (not personal information).
    If you belong to a large HIT network like this you can get test results back faster from a diognostic center that also belongs to the same network. You send your patient to other doctors within your HIT network and speed up the process. Your patient does not have to fill out the same forms over and over. The next doctor will enter the data into the network. You get results with the patient record. Seamless.
    This should not cost billions or millions if developed by private investors.
    Stop complaining and join me.

  9. 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 fantastic task. Requiring that such software be as simplistic as “office software” is phantasmagorical. The complexity of the tool is usually directly proportional to the magnitude of its purpose. There are numerous software products out there, used by professionals of all trades that are not being constantly compared to word processors. Adobe Illustrator\Photoshop, SAP, Siebel, CAD and flight simulators are a different breed of tools than Word and PowerPoint.
    I do agree that today’s EHRs are too rigid and, by choice, relegate themselves to an observer\recorder role in the clinical process. I’m not sure how welcome technology is in the clinical decision process. I am pretty sure that most EHRs are not making a whole hearted attempt at participating and adding value to this process. That most likely needs to change and maybe this is the anticipated “disruptive change”. In the meantime I’d rather stick with the one recommendation that makes the most sense “Seek incremental gain from incremental effort”. Sounds much better to me than the unproven process of throwing millions of dollars at government sponsored software development, whether it is, or it is not, open source. We still have a free market in this country and the biggest improvements to quality are always derived from free competition. The customer will make the ultimate decision regarding both incremental and disruptive changes, and this is how it should be.

  10. 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 and knowledge within workflow – whether a paper or electornic office.
    Congrats to the NRC team for a terrific report highlighting the emperor’s clothes in the HIT world. Hopefully application of the economic stimulus funds from the federal government will follow the path illuminated by the NRC report.
    John Haughton MD, MS

  11. 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 procedures. However, not much of the software is great, or affordable, and not enough docs have the right attitude. EHRs won’t improve healthcare, but physicians must, and may want to use one.

  12. 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 practice or my patients, I will be all over it. Don’t delude yourself over the value of EHR, except to intrude into the doctor-patient relationship to find new ways to decrease reimbursement. Bullying practitioners will only drive more of them away from participating. And how about all the other parties, like worker’s comp companies. Ther is no standardization anywhere in that arena. Whe don’t we see the VA and the DoD get their respective acts together with a workable system before it is inflicted on the rest of the unsuspecting public.

  13. 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 unwillingness of many physicians to adapt this tool is attitudinal (aka emotional), there is little hope for adaption and effective use of computer technology any time soon. Any time soon defined as until the current generation of physicians retires.
    That is one of several factors that underlie my staunch opposition to any material expenditure of federal funds on subsidizing EMR adaption by physicians.
    To encourage adaption of computer technology that permits universal digitization of clinical data – something I agree should happen as soon as possible – the federal government can do a number of things:
    1. Require all providers who are reimbursed by Medicare to provide an electronic record of any medical service funded by Medicare that is requested by a patient or not receive payment for the service.
    2. Provide initial funding to an entity such as the Apache Software Foundation to launch a top-level project to create (likely refactor an existing) EMR/PM software product available to all for free, the same as all other similar software development projects. Funding for something like this would be ample in the tens of millions not billions of dollars.
    3. Set a mandate that all Medicare-reimbursed medical service providers have a functioning EMR system within 5 years without any corresponding funding aside from launching the project in point 2.

  14. 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, for example, ONCHIT’s decision to take the promised 2/5 set aside for small companies and give all the money to big corporations that that produced unimpressive “me-too” commodities.
    I’ve been writing about these issues for years and often felt like a lone voice in the wilderness. I invite you to read, for example, Health Information Technology: Past Predictions, Current Reality, and Future Potential at this link.
    I truly hope things are going to change!

  15. Wow. Great summary of what I agree looks like a seminal work, even if it is limited by an IT slant on the healthcare universe. Having been a provider and worked on improvement with many medical practices and hospitals nationally, these issues are front and center.
    Relying on human/physician memory for decision making regarding many diagnoses as well as planning care is like pilots making maps and plotting routes every time they take off. Much of decision making is rules based-automation and decentralizing SOME of it to patients and other non-physicians who can apply the rules would improve clinical outcomes and reduce costs. Oprah recently saw 4 physicians regarding symptoms before her thyroid problem was diagnosed and she can afford the “best” care. Why not provide patients with more robust cognitive support and tools to check and take action about health status? A friend recently complained that she hadn’t heard back from her primary care physician about a latest blood test to check her high cholesterol was shocked and delighted that she could buy a kit for under $15 at Target to check it herself. An additional trip to a lab and processing by her health plan cost her time and about $55 in addition to the office visit.
    The lack of user friendly EHR and IT is epidemic. We need an EHR with the user friendliness of an I-Pod. Granted that’s an over-simplification, but a year after implementing their EHR one group with whom I’ve worked still had a 19% drop in MD productivity (i.e. visit volumes. A key reason? The software is complicated to maneuver. An academic group on the east coast uses their EHR as a glorified word processor so little data can be extracted. Many groups don’t implement their EHR’s coding module which is a key factor in achieving a positive return on investment, via more accurate documentation of visit activities.
    Amen to the comment that today’s systems don’t support clinical decision making, but I think that function is also under utilized, often due to inefficiency. Patient interactions often get stuck in the rut of information gathering, leaving little time. At a routine medical appointment last week, I was asked for some demographic information three times and my physician spent 10 minutes of our 20 minute visit reading information form the history form that I’d just completed back to me as he entered it into the EHR-couldn’t that task have been delegated to a nurse or medical assistant or better yet entered by me into an easy to use touch screen or other hardware?! Time spent on joint decision making about my health and prevention would have made for a much more satisfying visit.

  16. Group,
    The “customer” is the doctor and records are overhead. Make me massage a computer with every patient and the overhead goes up. IT making healthcare better or cheaper or faster is fantasy, with the exception of record storage and digital radiolgy. Now that has been a homerun. But records are about changing the filing cabinet, not revolutionizing a specialty.
    “Cognitive support” sounds like an elitist term to impress the gullable and deceive the naive. Government really wants the Emergency Medical Hologram from “Voyager”. Short of that, I don’t hink “cognitive suport” is a term that should catch on.

  17. David & Michael,
    David, you have been espousing this for sometime and I agree this is of seminal importance. Michael, I couldn’t agree more with your suggestion that the gap in HIT implementation is partially due to the fact that consumers have not been delivered what HIT promises.
    I would suggest that many IT companies employ very impressive technology wizards but are not strong in medical or health care knowledge (most have less than 1% of their staff as medical professionals), have not considered the employment or use of a sociologist, do not know why people err, do not have ‘ patients or consumers’ on their advisory boards, and rarely consider the patient/consumer integral to the basic process of health care. To state it simply, cognition has not been top-of-mind for the vast majority of IT companies, nor has true patient (as a customer) participation.

  18. Dear Michael: Many thanks for your comment. I think the spirit and substance of this report is very much in line with your point that it’s the quality improvement and cost savings that count, not the IT per se. To have this point made so emphatically by the National Academies and NRC is quite remarkable, don’t you think?
    The era of “cognitive support” tools for BOTH physicians and patients is really in its infancy, but I believe the demand for decision support will grow. And as it does, it may create demand by consumers and clinicians alike that is akin to what your describe happening with respect to cell phone technology. Not all physicians care only about the money. But it’s still very early.
    I think that there is a generation of physicians and other health care professionals who believed that our journey to employ “computational science” to make medical care more rational, safer, and – most importantly — based on evidence of what works and what doesn’t, who are very disappointed with progress to date. This is deeply felt, and sincere, and ought to be acknowledged as a gift.
    Perhaps it was hubris for doctors and computer scientists living mostly in large academic medical centers, along with a handful of IT vendors, to think that they could do this on their own. It may even have been arrogant and self-serving.
    So, let’s focus on the customers, as you suggest, in the next round! We can do this. Regards, dCK

  19. David:
    Thanks for an excellent overview of an important report. The tunnel vision of the IT community is unintentionally shown by the comparison of the IT gap to the “quality chasm.” That demonstrates a fundamental misunderstanding. The quality chasm is a gap between the care we have and the care we should have. Health IT, by contrast, is a critical tool in closing that gap — but it is only that, a tool. Just like telephones or, for that matter, file folders.
    Better use of information technology lies at the core of achieving a number of goals that will make health care more cost-effective, safe and of better quality. But the reason we have a gap in IT implementation is that potential customers either do not believe the problems are as severe as the health IT folks say, do not believe it is worth spending the time and money on health IT needed to solve them or don’t believe health IT can deliver on its promises.
    Contrast that attitude to the incessant demands of smartphone customers, for example, that drive competition among BlackBerry, Apple, Palm and others for a growing “personal IT” market.
    Unfortunately, the “disruptive” and “radical” change that the report notes is needed in health care is mostly sought by thoughtful leaders such as yourself. The average hospital administrator or practicing physician wants disruptive change, all right, but would define it as having to do with higher reimbursement.
    Yes, health IT vendors have overpromised consistently and customers are right to be wary. However, the disconnect between what health IT leaders know is needed and what most customers truly want to spend money to buy is, in my view, why the health IT rollout has taken so long.
    On the other hand, the rate of progress is speeding up. The Wall Street Journal first ran a story about health IT that was entitled,”Electronic Medicine: Scientists Press Work on Advanced Machines to Aid Medical Care.” That was in 1959.