I’m well aware that a good fraction of the people in this country – let’s call them Rush fans – spend their lives furious at the New York Times. I am not one of them. I love the Grey Lady; it would be high on my list of things to bring to a desert island. But every now and then, the paper screws up, and it did so in a big way in its recent piece on the federal program to promote healthcare information technology (HIT).
Let’s stipulate that the Federal government’s $20 billion incentive program (called “HITECH”), designed to drive the adoption of electronic health records, is not perfect. Medicare’s “Meaningful Use” rules – the standards that hospitals’ and clinics’ EHRs must meet to qualify for bonus payments – have been criticized as both too soft and too restrictive. (You know the rules are probably about right when the critiques come from both directions.) Interoperability remains a Holy Grail. And everybody appreciates that today’s healthcare information technology (HIT) systems remain clunky and relatively user-unfriendly. Even Epic, the Golden Child among electronic medical record systems, has been characterized as the “Cream of the Crap.”
Moreover, in the last few years we’ve gained a deeper understanding of the hazards of HIT, including new kinds of errors created by the stormy marriage of imperfect computer systems and fallible humans. We’re also becoming familiar with subtler problems, such as the copy and paste phenomenon now plaguing progress notes and the degree to which computers can distance us from our patients (Abraham Verghese’s “iPatient”). These problems are all-the-more irritating since IT was hyped – overhyped – as the solution to so many of healthcare’s woes.
So it’s natural to be disappointed in the present state of HIT, and even to wonder whether HITECH is on target. But overall, I believe that we are on the right track, that there is no better way to get to an HIT Promised Land than the path we are taking, and that the Federal government should be commended for getting involved in a reasonable way.
In the February 19th issue of The New York Times, one of the most off-base, unbalanced articles in my recent memory paints a very different picture.The paper’s lead article – yes, Page 1, Column 1, above the fold, called, “A Digital Shift on Health Data Swells Profits in an Industry,” focuses particularly on the consequences of HITECH. The reporter, Julie Creswell, does raise some new and legitimate concerns, such as the degree to which HIT vendors have jumped into Washington’s toxic swamp of money and politics.
Yet the tone of the article is inordinately conspiratorial about HITECH, and downright dismissive regarding the overall value of HIT. Creswell’s sources are disproportionally slanted to HIT skeptics, including her choice to quote my UCSF colleague Mike Callaham, who pronounced our Epic system “lousy.” (I’d venture to say that most people at UCSF – including me – find the system imperfect but pretty good. Moreover, we switched to Epic, a company that Creswell paints as a Goliath, only after a dismal experience with a different system built by GE, a $240 billion behemoth of a company whose electronic health record product is foundering in the HITECH world.) After reading the Times piece, I found myself in full agreement with Mark Hagland, editor of Healthcare Informatics magazine, who wrote,
The opening one-sentence paragraph says it all. Creswell writes, of a presentation by the Chicago-based Allscripts to physicians in 2009, “It was a tantalizing pitch: come get a piece of a $19 billion government ‘giveaway.’” First of all, characterizing HITECH as a “giveaway,” without in any way mentioning the penalties embedded in the law for providers who haven’t implemented electronic records (EHRs) by the end of 2015, is simply irresponsible journalism….
Ms. Creswell could easily have noted that no other large industry in the United States remains even remotely as paper-based as healthcare… or that study after study has confirmed the benefits to patient safety, care coordination, and cost-effectiveness of the automation of patient records. [The story] will undoubtedly be read by many thousands of laypeople who may or may not have any sense of how misguided and distorted its core thesis is.
The Times article ends as skewed as it begins: with a backhanded reference to the “gold-rush mentality” of today’s HIT players.
Let’s pause to ask a few questions: Does anyone honestly believe that computerizing American healthcare is wrongheaded? Or that the correct strategy was to continue toe-tapping, waiting for “the market” to promote IT adoption when, in 2009, only 16 percent of both US hospitals and doctors’ offices had functioning clinical IT systems? Or that they would like to be a patient, or a clinician, in a paper-and-pencil hospital?
I didn’t think so.
In 2004, then-president George W. Bush asked David Brailer – a brilliant MD and PhD in economics – to direct a new federal office of healthcare information technology, whose primary goal was to promote IT adoption. Brailer and his staff realized that a top-down program that had Washington forcing computer purchases on doctors and hospitals would be a disaster. (In fact, such a strategy was adopted by the UK’s National Health Service – a centralized, command-and-control initiative that, in 2011, was deemed a fiasco and junked, at a cost to British taxpayers of $19 billion.)
Instead, Brailer began planning a program consistent with American values, one that would allow physicians and hospital leaders to choose their own vendors, and encourage market competition. The plan that he and subsequent heads of the Office of the National Coordinator for Health Information Technology (ONCHIT) developed was to fashion a set of standards – relatively easy to reach at first and progressively more ambitious over time – and then to find the cash to fuel a national incentive program. They found the booty (about $20 billion worth) in 2009 when Congress and the president were seeking “shovel-ready” projects to include in the $700 billion federal stimulus package.
That, my friends, is the crux of the story. The meaningful use standards were developed and disseminated after extensive public comment. The IT vendors, a sleepy industry of true survivors (many of them barely maintained their pulses for over a decade, just hoping that the day would come when HIT adoption finally tipped to their side), did what all U.S. businesses would do when the feds were considering tossing money in their direction: they hired lobbyists and made campaign contributions. I don’t love this (and there is a risk that the Epics of the world will succeed in thwarting competition by scrappy upstarts), but that is our system, and any responsible business would have done the same thing – in fact, they’d be stupid not to.
It’s not a conspiracy. It’s America.
And trumping everything, the program has worked. The HIT adoption curve, previously stuck on flat, is now extraordinarily brisk: by 2011, 35 percent of US hospitals had functioning electronic health records, more than double the percentage of 2009; a similar surge has been seen in outpatient practices. The literature continues to demonstrate that, overall, these systems do reduce medical errors and harm. The promise of easier data collection to fuel transparency, pay for performance, and quality improvement activities will soon be realized, and we will ultimately enter the long-awaited world of “Big Data” in healthcare – one in which we can aggregate patient-level data on millions of patients, paving the way for more efficient methods of determining best practices and risk factors.
There have been problems. The systems are not great, and the vendors – including Epic – are putting most of their energy into keeping up with the insatiable demand for installations, and relatively little into improvements. Studies have demonstrated that the promised productivity gains have been weak to nonexistent. We have the aforementioned problems with IT-based errors and new challenges to clinician-patient communication. But the history of IT innovation is one in which systems become optimized only after many cycles of user feedback and vendor improvements. That cycle is beginning to play out, and the result is sure to be better, more mature HIT over time. There is no shortcut.
The Times (full disclosure, my wife Katie Hafner, writes about healthcare and technology for the newspaper) has covered HIT, including its glacial pace of adoption, responsibly, up to now. The Creswell piece, by failing to acknowledge the value of healthcare IT, the absolute necessity of wiring our healthcare system, and the fact that a federal program to kick start this process was a perfectly reasonable policy approach, was unbalanced and unfair. While a cautionary note is welcome, one could come out of reading this article clamoring for a Congressional investigation of the HITECH program and of the activities of Epic, Cerner, and Allscripts. If our goal is to find ways to create an improved, and ultimately less expensive, healthcare system, such a response would be unwise, even counterproductive.
The HIT industry, and those who regulate it, don’t need any special favors, and the Fourth Estate should keep a close eye on things, particularly now that there is gold in them thar hills. But as journalists are drawn to the increasingly vibrant world of healthcare information technology, it will be important that they do their homework and strike a balanced tone. The Times piece, I’m afraid, was a HIT job.
Robert Wachter, MD, professor of medicine at UCSF, is widely regarded as a leading figure in the patient safety and quality movements. He edits the federal government’s two leading safety websites, and the second edition of his book, “Understanding Patient Safety,” was recently published by McGraw-Hill. In addition, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine and is chair of the American Board of Internal Medicine. His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.