If we are to achieve the aims of health insurance reform/PPACA, let alone eventual health delivery reform, the US needs coherent, comprehensive federal health IT policy. In late December, PCAST, the President’s Council of Advisors on Science and Technology, issued its perspective on how HITECH has (and hasn’t) moved the needle and where we need to go from here. PCAST is an influential group. It is chaired by Eric Lander, President, Broad Institute of Harvard and MIT and John P. Holdren, Assistant to the President for Science and Technology and Director of the Office of Science and Technology Policy. The council includes heavy hitters from the technology and business worlds including Eric Schmidt, Chairman of Google, Craig Mundie, Chief Research and Strategy Officer of Microsoft, and Christine Cassel, President and CEO of the American Board of Internal Medicine. PCAST’s report, entitled “Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans: The Path Forward” makes several important additions to the health IT policy conversation, but fails to hit the mark in two critical areas.
On the positive side, we agree with PCAST that IT can contribute to lower costs and higher quality in health care, and that current national HCIT programs, while an enormous improvement over the last forty years of neglect and disincentives, are insufficiently radical to fully realize that value.
We agree that separation of data from applications, liberating the data from the proprietary databases and applications that typically imprison it today is core to unleashing the power of healthcare information (think: free-text patient note vs. reportable and trend-able lab results). Doing so creates value by allowing the right information to be delivered to the right individuals, at the right time, in the right format for the relevant context (e.g. trending of A1c values over time for population health management). Furthermore, freeing data from specific applications would enable greater innovation than is available today and is critical to certain types of data uses such as population-level research, comparative effectiveness research, and biosurveillance.
Finally, we agree that fully capturing the value IT can contribute to the healthcare system will require coordinated action and investment by both government agencies and private enterprise. Alone, neither has the capability to provide the combination of innovation, infrastructure, services, solutions, standards and regulatory frameworks that will be required to build and maintain such a complex system of solutions.
Based on our experience with health care systems around the world, we believe that the PCAST recommendations are lacking in two critical areas. First, technical policy, standards, and incentives are necessary but not sufficient to drive meaningful use. Target technical architectures must be placed in the context of actual practice and workflow at a minimum. If we want meaningful use by most providers, we can not ignore how data is currently transmitted in the practice of medicine.
For example, the clinical note is a critical component of medical care for historical record, coordination of care, and medical/legal protection. A clinical note, however, is more than the sum of its individual data. A note transmits additional information through:
- what data is explicitly excluded or included
- the sequencing and prioritization given to data elements
- and the additional context and language surrounding data
It is essential that these additional sources of information are not lost through movement to a ‘data-centric architecture’ which enables wholesale construction of datasets at the receiving end of an information exchange without providing this context.
We recommend that the ONC consider a hybrid approach which will enable documents to be transmitted intact (leveraging the substantial advances and investments that have been made in the existing standards and infrastructure such as IHE and CDA), and also will also enable data to be extracted and communicated independently when appropriate. Different uses of data, from point of care transactions to research, will then determine which structure is most appropriate for a particular situation.
Second, PCAST continues to focus the national health IT policy discussion on achieving meaningful use as an end in itself. Unfortunately, meaningful use does not equal meaningful outcomes. Certainly, meaningful use is better than adoption alone: simply having an EHR installed does not mean that a physician will use it for quality reporting, exchange of information between care settings, or to drive clinical alerts. ONC was right to avoid awarding incentives simply for adoption or to require EHRs for their own sake.
However, realizing value from health IT will not automatically result even from ‘meaningful use.’ Indeed behavior change is essential to unlocking the value of health IT. Leaders on this blog and elsewhere agree that EHR-enabled care coordination can have a demonstrable impact on the management of specific diseases thus improving outcomes. That being said, we know that many of the activities embedded within care coordination are not reimbursed in the current incentive system. Exchange of information across care settings, a core component of meaningful use criteria, does not necessarily mean that recipients of that information will use it to coordinate care if they are incentivized otherwise. Policy must focus on shaping the environment in which behavior occurs if it is to have impact. Only then can IT be an enabler.
Ideally, policy incentives are developed which actually shift practice towards desired objectives such that stakeholders naturally choose to leverage useful technology, rather than the other way around. Changing health care economics and organizations is critical to value realization through IT. Ultimately the business structure, not the technical architecture, of the industry will determine which cost, quality, and access objectives are feasible in health care.
As several on this blog have noted, the PCAST report is worth a read. It is a valuable addition to the national health IT conversation. We invite you to take a look as well at our full response to the ONC request for comments on the PCAST report. Our response is based on our recent experiences in Sweden, China, Australia, and Saudi Arabia, and our work with numerous clients in the US. We look forward to your thoughtful comments.
Benjamin Berk, MD, MS&E, is the coordinator of BCG’s health care information technology community and a project leader in the firm’s Chicago office. He can be reached at firstname.lastname@example.org. Simon Kennedy is BCG’s worldwide leader for health care information technology and a senior partner and managing director in the firm’s Boston office. He can be reached at email@example.com. Founded in 1963, the Boston Consulting Group (BCG) is a global management consulting fi rm and the world’s leading advisor on business strategy.