THCB

Missive from the DMZ

Not everything about improving health care is breathlessly hanging on one high stakes decision.

The Supreme Court will rule soon enough on the constitutional challenges to the Affordable Care Act. Meanwhile, even amid the drama and bitter struggles, progress can occur in health care improvement—like the ever increasing adoption of health information technology. Believe it or not, there is broad agreement about using this technology in health care. Scott Gottlieb and J.D. Kleinke in a recent Wall Street Journal opinion said it well, “. . . promotion of health information technology is one of the only demilitarized zones in Washington—consistently attracting bipartisan support . . . .”

So, this rare consensus seems real and durable, but what is actually happening in the hallowed HIT ground where both sides have somewhat oddly come to a policy truce?

Since May of 2004 when President George W. Bush established the Office of the National Coordinator for Health Information Technology (ONC) we’ve witnessed a slow but relentless upturn in adoption. That progress dramatically accelerated with attention and funding in the American Reinvestment and Recovery Act in 2009. Since 2006, the Robert Wood Johnson Foundation (RWJF) in collaboration with ONC has supported an ongoing, independent effort to monitor the national adoption of the electronic health record.

RWJF recently released the latest edition of that report, “Health Information in the United States: Driving Toward Delivery System Change 2012”. Both Health Affairs and JAMAalso simultaneously published articles based on chapters in that report, and Health Affairs hosted a briefing at the National Press Club regarding that release. Much of the information in this report comes from two important national surveys—one on ambulatory care conducted by the CDC/NCHS and the other on inpatient care by the American Hospital Association. The RWJF project in collaboration with ONC developed the key definitions for both the “basic” and the “advanced” electronic health record. All of the legitimate assessments of the national rate of electronic health record adoption in the U.S. since 2006 have used these gold standard definitions.

From the most recent NCHS and AHA surveys included in the 2012 report—there is both good and sobering news. First the good—the rates of adoption at both the physician and hospital level are increasing significantly. For example, the rate of physician adoption of at least a “basic” electronic record rose from 12 percent in 2007 to 34 percent in 2011. Similarly, for hospitals—the adoption of at least a “basic” system has risen from about 9 percent in 2008 to about 26 percent in 2011. The sobering news comes with the next step.

Unfortunately, these same surveys highlight both increasing physician intention to apply for meaningful use incentives but also an extremely limited ability to use the technology meaningfully. For example, a little over one half of physicians reported an intention to apply for incentive payments while only 10.5 percent of those actually had an electronic record with functionalities to support meaningful use. For hospitals, over 80 percent at the time of this survey could not meet meaningful use standards.

What about exchanging the information? That step remains a major challenge. In this year’s report immediate past national coordinator, David Blumenthal notes, “The exchange of information is going to be one of the most ambitious health care social projects that we have ever undertaken. The mapping of the human genome will look simple in comparison. The reason is that it’s a human-ware problem, not a software problem.”

RWJF has had its own experience with health information exchange challenges. Central Indiana Alliance for Health started as one of 17 communities in RWJF’s long term effort to help communities improve care, Aligning Forces for Quality. In Aligning Forces, regional leaders work together on a variety of activities—including publicly reporting quality and cost information, engaging consumers, changing payment and supporting clinical improvement. Central Indiana with its nation leading Indiana Health Information Exchange (IHIE) should have been ideal for such an effort. Unfortunately, they weren’t. As noted in this report, these leaders were simply not able to use the information exchange resource for Aligning Forces—especially for public reporting of quality measures for their community. IHIE’s problems were not technical ones—but cultural—or human-ware problems. The community leaders could not overcome longstanding resistance to using their information exchange for publicly available information.

We have many tough health and health care challenges facing our nation—and we have just a few areas of consensus where we’re working together. As this RWJF report shows, we are making some progress in the HIT sweet spot—but just having consensus is not going to be enough. If we are to meet our massive challenges, we will need all hands and minds working together to meet them—and even then, there are no guarantees. Time is ticking, friends—let’s stay focused—and look hard for more DMZs. We’re going to need them.

Michael W. Painter, JD, MD is the senior program officer at the Robert Wood Johnson Foundation.

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Michael MillensonAbdhul Khan, PhDJonathan HMargalit Gur-ArieR Davis Recent comment authors
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Michael Millenson
Guest

Bravo, Mike, for being reality based and focusing on the important goals health IT is designed to help us reach. Even if it’s not going to be as magically easy as some proponents promised.

Mike Painter
Guest
Mike Painter

Thanks, Michael. Agree with you completely-the country is making progress getting this technology into health care. That alone, though, will not transform care. That seems to be the very wise consensus in this discussion.

Abdhul Khan, PhD
Guest
Abdhul Khan, PhD

That NEJM perspective above was defective in its failure to consider the human rights violations of the patients serving as subjects in this experiment, that so far, has only enriched the vendors, while doing nothing for outcomes or cost reductions.

Mike Painter
Guest
Mike Painter

New NEJM Perspectives piece that directly pertains to this discussion: “Unraveling the IT Productivity Paradox”

http://www.nejm.org/doi/full/10.1056/NEJMp1204980?query=TOC

southern doc
Guest
southern doc

The authors conclude:

“invest in creating new measures of productivity that can reveal the quality and cost gains that arise from health IT”

I.E., start with your pre-determined result, and try to design some sort of measure that leads to it. Love it.

Curly Harrison, MD
Guest
Curly Harrison, MD

Let’s get back to the issue. Both sides of the aisle have been deceived by the HIT vendors and their trade group to hand out boatloads of cash for meaningfully useless workflow altering devices and billing machines.

RN Russel
Guest
RN Russel

I do not see paper money disappearing in outlr lifetime. I do see more sophisticated forms of paper money being developed. On the other hand the metal forms of money are endangered. If the civilized world were to opt out of paper money, describe for us this brave new world of transactions at the street level . Perhaps you have the currency model of the future all mapped out… I doubt that. Not with all your Bernackies, Volkers, Greenspans together with the basket of EHR PhDs from ONC will you be able to do this. If you have it ,… Read more »

BobbyG
Guest

Read David Graeber’s “Debt: The First 5,000 Years.”

Mike Painter
Guest
Mike Painter

Rob-very thoughtful post-agree with you that there is a big difference between regulatory meaningful use–and meaningfully using the technology-nice.

Rob
Guest

I just wrote a post about my mixed emotions on this and feelings on meaningful use from the perspective of a doc using EHR for 16 years.
http://more-distractible.org/2012/06/11/a-funny-thing-happened-on-the-way-to-meaningful-use/

Rob
Guest

I just want to know who would go to a bank that didn’t use a computer to keep track of their financial transactions, instead using paper ledgers. Again, the problem with EMR is its use and implementation. When it is used poorly, it makes care worse. When used well, care is much, much better. Doing a study of paper charts vs. EMR is like doing a study to see if cars are faster than walking. The problem with many implementations of EMR is that they are akin to giving the doc a car but telling them they have to push… Read more »

southern doc
Guest
southern doc

Don’t deny that EHRs have the potential to be a great improvement, and have demonstrated that in other countries. However, here they’re being implemented in a system that is so dysfunctional from top to bottom that they tend to make things worse rather than better. They’re just a bandaid being applied to a gaping wound, and they are diverting resources and attention from addressing the really serious problems we have. To continue with your analogy, using EMRs in our health care system is like being given a car to drive up 90 degree rock wall. I’d rather have a good… Read more »

Mike Painter
Guest
Mike Painter

southern doc-Your observations about care dysfunction are spot on. You’re also right to say that if folks are just using EHRs within the dysfunction to optimize within that dysfunction rather than as part of efforts to correct it, then EHRs will likely just be another part of the problem. I agree with that.

BobbyG
Guest

Change.The.Payment.Paradigm

southern doc
Guest
southern doc

“Change.The.Payment. Paradigm”

And THEN design a functional EHR system. Rather than building one now that reinforces the current paradigm.

southern doc
Guest
southern doc

It would be SO EASY to design and use an EHR that was solely about better patient care. Sadly, that’s not what we’re getting and not what we’re being forced to us.

Many of us are becoming increasingly hostile to EHRs because we see that they are ALREADY being aggressively used to preserve, not fix, the dysfunctions in the system: corporatization, obsession with profits, unequal access to care, and so on.

Thanks for the replies. We probably agree on much of this (though I still think that NEJM article was really lousy).

Mike Painter
Guest
Mike Painter

southern doc-on your point about payment…Exactly. You’re singing my song now. I also think I’m understanding you now-and that we probably do agree. Very interesting. And ditto on your replies–thank you.

Fran Stevens, MD
Guest
Fran Stevens, MD

Speaking of $ee$hit and lightbulbs at its Chi office on So Wackers (lights are on but no one is ever home), perhaps the WSJ authors will retract their statement in their op-ed about how certification equates to assurance of safety?

Mike Painter
Guest
Mike Painter

NEJM editors and reviewers disagree.

southern doc
Guest
southern doc

“If a physician in 2012 tells you that his or her memory and handwriting are better for you than an EMR, you should run, not walk, to a physician who practices in the current century.”

Even though the studies show again and again that standards of care are met at a greater rate by docs using paper charts than those using EHRs (most recently in last month’s Family Practice Journal)?

Interesting.

Mike Painter
Guest
Mike Painter
southern doc
Guest
southern doc

That study is a disaster. The demographic differences between the practices involved are so enormous that it is impossible to adjust for them.

RN Russel
Guest
RN Russel

How many CCHIT guys does it take to change the light bulb?
Answer: TOO many & they will have to hire some that will fit in their shoe box office on Wacker Dr.

BobbyG
Guest

Open mic night.

Margalit Gur-Arie
Guest

The quality of the ride notwithstanding, riding from darkness to a well lit inferno may not constitute an improvement.

southern doc
Guest
southern doc

Zing!

Curly Harrison, MD
Guest
Curly Harrison, MD

It behooves JD MD Painter and JD Kreinky to read the editorials in the current issue of the NEJM about the crappy tools being put out there without any accountability to transform medical care in a sham on the American people.

BobbyG
Guest

Links?

J.D. Kleinke
Guest

My “crappy doctors” comment obviously hit a nerve. The real issue with EMRs and their celebrated imperfections is a displacement of resentment over accountability and transparency. Such “intrusions” of technology into the realm of a previously impervious guild always infuriates some of its members, usually the more economically vulnerable and/or technically incompetent. If a physician in 2012 tells you that his or her memory and handwriting are better for you than an EMR, you should run, not walk, to a physician who practices in the current century. In the meanwhile, I’ll continue to indulge in my “Jobsian fantasy” – right… Read more »

BobbyG
Guest

Ouch.

🙂