Tech

As the Debate Over Obamacare Implementation Rages, a Success on the IT Front

Just a little over four years ago, President Obama, in his inaugural address, challenged us as a nation to “wield technology’s wonders to raise health care’s quality and lower its costs.”  This was an awe-inspiring, “we will go to the moon” moment for the healthcare delivery system.  But the next thought that ran through the minds of so many of us who work on health IT issues was this: how were we going to get there?

We were essentially starting from scratch.  Less than 1 in 10 hospitals had an electronic health record, and for ambulatory care physicians, the numbers weren’t much better – about 1 in 6 had an EHR.  Hospitals and physicians reported an array of challenges that were holding them back.  No nation our size with a healthcare system as complex as ours had even come close to universal EHR use.  Yet, the President was calling for this by just 2014.

And it was clear why.  The promise of EHRs was enormous and we knew that paper-based records were a disaster.  They lead to lots of errors and a lot of waste.  I have cared for patients using paper-based records and using electronic records – and I’m a much better clinician when I’m using an EHR.  In the weeks that followed Obama’s inaugural address, the U.S. Congress passed, and the President signed the Health Information Technology for Economic and Clinical Health Act, which contained a series of incentives and tools to drive adoption and “meaningful use” of EHRs. None of us knew whether the policy tools just handed to the Obama administration were going to be enough to climb the mountain to universal EHR use.  We were starting at sea level and had a long climb ahead.
On Tuesday, just about 4 years after the passage of HITECH, Health Affairs and the Robert Wood Johnson Foundation held a briefing about where we as a nation are vis-à-vis health information technology.  Mike Painter, who is the RWJF lead, captured it perfectly in his reflection that when you climb a mountain, it’s important to take breaks, celebrate the progress, and enjoy the vistas.  July 9 in Washington DC was just such a moment.  It was a day to celebrate how much progress we have made.  No “Mission Accomplished” banners.  Just a day to take a breath and say – we are off to a very strong start.

Why do I say this?  In 2008, 9% of U.S. hospitals had at least a basic EHR.  In 2012?  That number is 44%.  A staggering near 5X increase in 4 years.  And the gains on the ambulatory care side have also been impressive.  What’s more, the numbers suggest that HITECH led to an inflection point – it catalyzed the adoption of EHRs across U.S. hospitals.  This is the proportion of U.S. hospitals with at least a basic EHR:

EHR graph

Beyond EHR adoption, the story gets a little less joyous.  A key part of using EHRs to improve healthcare delivery is clinical data exchange – getting physicians, hospitals, other providers to electronically share clinical data with each other.  There are lots of paths to achieving this goal – but the one that has had the greatest policy attention has been through entities called Health Information Exchanges or HIEs.  These entities have sprung up around the country and many of them are getting funds through HITECH (passed on through states) to help ensure that data can follow patients as they go from one clinical setting to another.  At the Health Affairs briefing, we heard from Julia Adler-Milstein anupdate on how these HIEs are doing.  The good news is that they are growing by leaps and bounds.  We’ve been surveying these entities for more than 7 years now – and between 2010 and 2012, there was a 60% increase in the number of HIEs that are actively exchanging clinical data (119 in 2012 compared to 75 in 2010).  Nearly 30% of U.S. hospitals are exchanging clinical data with non-affiliated providers using these HIEs (a doubling from 2010) and approximately 10% of ambulatory care practices in the U.S. are exchanging clinical data using these HIEs (a threefold increase from 2010).  While the gains are important – the data also point to the long road ahead.  Most physicians and hospitals are not exchanging clinical data using HIEs.  A bigger issue that the Adler-Milstein paper raises is this:  Most HIEs are not financially sustainable now (they are largely dependent on grants, etc.) and 3 in 4 report that finding a sustainable business model is a challenge.  There is substantial risk that as the HITECH funding runs out – many of these HIEs will go under unless the doctors and hospitals that are using them are willing to pay for it.

Two other big challenges that lie ahead are worth discussing.  First, there is a large proportion of healthcare providers that are left out of HITECH.  Who is left out?  Nursing homes, rehab hospitals, mental health providers and facilities, etc.  It’s a big problem.  If you think about high cost patients– and the kinds of care they need – they spend a lot of time in these facilities and with these ineligible providers.  The best data we have suggests that these providers who are ineligible for financial incentives have abysmally low levels of EHR use.  No one is even tracking how these guys are doing.  And, without a concerted effort, we are unlikely to get them on board with electronic records.  So, we will end up with large parts of the healthcare system that are digitized — and large parts that are not.  While it’s easy to blame HITECH for not including these providers, as the bill was being crafted, choices had to be made.  Policymakers made the decision to take the money they had and focus it on ambulatory care providers (docs, nurse practitioners, etc.) and acute-care hospitals.  However, we have to figure out a strategy to get these other key providers on board.

The second challenge is the key to the kingdom: figuring out how to use Health IT more effectively.  As I’ve written before, Health IT is not magic pixie dust.  You don’t spread some into the healthcare system and see gains in quality or efficiency.  In fact, in most industries, IT has taken years, often decades to exert its effects.  I am confident that if we do nothing, health IT will have huge effects on healthcare delivery – but it might take a decade or two.  We need to figure out how to speed up the process.  In other industries, IT has been a source of creative destruction:  it has changed the way people work, destroyed a lot of jobs and created brand new ones.  We aren’t seeing much of that in healthcare yet.  In a terrific paper that Julia Adler-Milstein published last year (I was a co-author – but the idea was completely hers), she found that on average, doctors weren’t any more productive or efficient if they used an EHR.  However, if these doctors had nurse practitioners or other advanced non-physician providers in their practice, EHR use was associated with much higher likelihood of being a high performer.  If doctors did not have these advanced practitioners, EHRs tended to be associated with lower likelihood of being a high performer.  It’s exactly this kind of insight that we need to better understand how to use EHRs to make care better.  EHRs are best when they change the way we deliver care.  Half of the physicians in the U.S. may now being using an EHR – but most have not used the EHR to change the way they work.  Until they do, we should not expect to see big gains in quality or efficiency from the EHR.

The Robert Wood Johnson Foundation 2012 report on the state of health information technology in the U.S. is an essential read to understand where we are on health IT adoption and use – and this year’s report tells us that we are making a lot of progress.  HITECH is having an important impact on the healthcare marketplace.  However, the President, in his inaugural address, did not say that we will use taxpayer dollars to help doctors and hospital buy technology.  This is not a technology program.  He said that we will use technology to “raise healthcare quality and lower its costs”.  If that is the goal – if that is the moon that we have to reach – then we should celebrate the accomplishments to date – but, at the same time, remember that our work is just getting started.

Ashish Jha, MD, MPH is the C. Boyden Gray Associate Professor of Health Policy and Management at the Harvard School of Public Health. He blogs at An Ounce of Evidence. He is also the Senior Editor-in-Chief for Healthcare: The Journal of Delivery Science and Innovation.

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Ezekiel HosackJohn HalamkaWhatsen WilliamsMike Miesen (@mikemiesen)Southern doc Recent comment authors
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Ezekiel Hosack
Guest

Le diste en el clavo en la cabeza de mi amigo! Algunas personas simplemente no lo entiendo!

Michael Millenson
Guest

Al: I didn’t create that image. But feel free to filer all the posts and replies, and all events past, present or future, through your own preconceptions.

Al
Guest
Al

MM, I don’t really know what you mean by your comment. I was simply trying to provide a practical image of the doctors life in the 1970’s compared to today.

Michael Millenson
Guest

John: You’re one of my favorite medical HIT guys, but with all due respect, your historical analogy is not correct on HIT. I’ve done the first-hand research. In the mid-1950s, there were computerized clinical decision support systems. Lockheed offered an electronic medical record, as did others, in the early 1970s. This isn’t the AT&T picture phone, which the market didn’t want for various reasons. This was physicians rejecting computerization and a marketplace that deferred to physician preferences, having no mechanisms whatsoever to reward economic efficiency or quality of care. And so, computerization for clinical purposes lagged; for billing, it flourished.… Read more »

Al
Guest
Al

MM: “Lockheed offered an electronic medical record, as did others, in the early 1970s.”

You create an interesting and humorous image. A 1970’s doctor lugging around a huge computer in one hand and a stethoscope in the other. I think the i-pad and its smaller cousins along with wi-fi may very well be one of the major stimuli to electronic record keeping, but will continued government pressure to create a single system that meets government needs, not the physician’s and patient’s, inhibit development?

John Halamka
Guest

Of my 1330 BIDMC procured laptops, 1327 are encrypted. The 3 remaining are grant funded and belong to people who are on leave and are not responding to the encryption mandate. I’ve deactivated the enterprise credentials for these 3 people so no one can login to the three unencrypted laptops. Some may say – wow, you’ve encrypted all the clinical and grant funded laptops procured over the past several years. That’s great. Others may say, 3 laptops are unencrypted, how could you let that happen? I’ve heard the same kind of perspectives when discussing EHR and HIE adoption in the… Read more »

Whatsen Williams
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Whatsen Williams

You state “I have cared for patients using paper-based records and using electronic records – and I’m a much better clinician when I’m using an EHR.” And how many patients do you manage, exactly? Doubt very many since I never saw this on the internet on a doctor: “Is Dr. Jha accepting new patients? If you are a new patient, please check with Dr. Jha before scheduling an appointment.” Additionally, the RWJ report is folly since it failed to address thebfailure of these devices to improve outcomes or reduce costs. And how about listing the adverse events, near misses, and… Read more »

Mike Miesen (@mikemiesen)
Guest

It seems to me that it is in our best interests to focus on the future of health IT rather than its past. Certainly, how past government regulations have affected the abilities of clinicians and entrepreneurs with respect to Health IT should be discussed, but mostly as a guide for what role the government should play in the future. With that said, and adhering to the broad strictures by which the current Health IT space operates, I’m curious if anyone would disagree with the following: *Interoperability of enterprise EHR systems is a crucial component of successful Health IT use –… Read more »

Southern doc
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Southern doc

“It’s a problem with providers – that they have little appetite to share data.”

What planet are you describing here? It’s certainly not one that I’ve visited during my medical career.

Michael Millenson
Guest

Thanks, Adrian. I always learn from your deep knowledge of the industry. Michael

Adrian Gropper MD
Guest

Michael, HITECH accelerated vendor lock-in through the introduction of Certification and CCHIT. The micromanagement of technology, even when justified to fix a market failure, is a risky strategy when software and connectivity are advancing faster than Moore’s law. Strict certification requirements eliminated a lot of the incentive for innovation, pushed start-ups out of the race and are completely incompatible with community supported open source software. Worst of all, strict technology certification requirements do not reward improvements in usability and user experience. This has soured a huge number of physicians on health IT and will take years to undo. But all… Read more »

Dr Pullen
Guest

Our small private family medicine group was on the bleeding edge of EHR, in 1997 “going live” and so 16 years into it we have a robust system internally, but still struggle to connect to much of anyone outside our lab and our patients externally. Hospital interface? Heck no, they treat their info like propriatary secrets. It’s frustrating that all the vendors are not mandated to become accessible to each other. That would be healthcare reform.

Ashish Jha
Guest

Dr. Pullen — thanks for your thoughtful note. Getting health information exchange to happen has been very hard — and our latest paper (referenced above) shows in stark detail how slow moving it is. I said at the briefing that this is not a technology problem. Its also not, I don’t think, ultimately a vendor problem. Its a problem with providers — that they have little appetite to share date. Until we change the healthcare business model, it’ll be hard to make a business case for doing the right thing: sharing patients’ data with them and with other providers who… Read more »

Al
Guest
Al

@Ashish: “Its a problem with providers — that they have little appetite to share date.”

Physicians share information all the time. In fact one should take note of the concierge physicians that are providing patient records directly to the patient in the form of a CD or perhaps a memory stick.

By the way when I hear that the IRS released social security numbers and that supposedly closed records have likely been violated for political reasons I wonder how safe our personal health care records will be in the hands of experts and the government.

Al
Guest
Al

@Adrian: “We need patient-centered accountable care with physicians as the patient’s agent not the institution’s EHR data entry clerk.”

I remember fax machines when they were rather expensive and can’t remember a government agency providing incentive payments to physicians or hospitals so that they purchase the machines. I also don’t recall too many physicians that didn’t have fax machines available in a relatively short time frame.

Thank you for your clear cut information.

Michael Millenson
Guest

Al, medical records have been developing “from the bottom up” for decades. IBM offered it in 1965, Lockheed in the 1970s, etc. The problem was not the technology, it was doctor culture. “We don’t need computers.” The patients who died because doctors resisted health IT are not, alas, here to post their opinion. The data about CPOE adoption not happening because of evidence, only because of incentives, is also clear, and that’s from 1993-2008. Dead airline passengers are a lot more visible than dead patients, yet the heavy hand of government got us flame resistant fabrics, seats that don’t tear… Read more »

Al
Guest
Al

MM, I know from experience what I wanted to do and what I was permitted to do by our government. If it weren’t for the Stark Laws and a few others I believe we would have an integrated EHR system today. You talk about doctor culture, but no sooner than doctors convert to laparoscopic surgery they are changing to robotics. Health IT as we are seeing it develop does not save lives. It costs money and likely costs lives in the trade offs. If you wish to improve quality you have to increase transparency and change the incentives. If that… Read more »

Ashish Jha
Guest

Great discussion guys. I have to say that I find it baffling to think that government has been stopping EHRs from developing. I think the following are some evidence-based facts: 1. Paper is a terrible way to deliver healthcare 2. EHRs have lots of potential problems (including cut-paste) but when used well, they can lead to much better care. 3. Left to itself, we saw that EHR adoption rates were abysmally low and the reason why (based on national surveys of physicians and hospitals) was simple: they had to foot the bill and payers and patients got the benefits. 4.… Read more »

Al
Guest
Al

“Paper is a terrible way to deliver healthcare” “Democracy is the worst form of government, except for all those other forms that have been tried from time to time.” ___Winston Churchill. Same with paper. But until the EHR is made to improve healthcare rather than billing, research, political payoff, etc. it will remain in its infancy. That means the experts and government have to leave the immediate scene. As I stated earlier, I am one of the early users that wished to go a lot further and actually had the knowledge at hand to do so. “EHR adoption rates were… Read more »

E Tal
Guest
E Tal

To your points: 1. Agreed 2. Agreed, but let’s make an important distinction between the abstract concept of EHR and the formal definition of EHR as government (ONC) sees it, as well as what you might call Observed EHR (what’s available today or is likely to be developed soon). 3. Good point, though I remember a discussion around the time HITECH was being passed or soon thereafter, where the main reason for slow adoption was said to be bad usability. Doctors were rightly complaining about having to work for the software, rather than the other way around. It was an… Read more »

Michael Millenson
Guest

It’s true, Ashish, “bribery” is a far harsher term than “fixing a market failure.” Seriously: I don’t expect the health care industry to incur costs and implement a technology that is difficult to do right merely because the evidence says it is good for patients. But, the thing is, most patients do, and that’s the myth of professional obligation physicians encourage. I use the word “bribe” to be provocative, but, as a Chicagoan, I must say we have lots of politicians who believe in “fixing market failures.” Or, “Money talks, market failures walk.” Last note: most of the doctors who… Read more »

Al
Guest
Al

MM writes: “Last note: most of the doctors who resisted health information technology did so because in THEIR experience, THEY didn’t need any help from a computer.”

Bull. Doctors have been technologically minded when it was suitable. Look at all the healthcare developments and look at how fast surgical procedures change.

In my opinion if telephone technology depended upon government intervention a portable phone would weight 200 pounds and have several miles of wire.

Michael Millenson
Guest

Ashish: Good post. In terms of the use of health IT technology by others than doctor offices or hospitals, the Assistant Secretary for Planning and Evaluating of HHS has a report on that issue coming out soon. (It was mandated in HITECH.) Stay tuned. As I noted earlier in a blog here (THCB) a few months ago, bribing doctors and hospitals to adopt technology worked when evidence failed. LDS Hospital showed it could reduce adverse drug events with CPOE to a bare minimum back in 1993, but CPOE adoption was just 27 percent in 2008 versus 72 percent in 2012.… Read more »

Ashish Jha
Guest

Michael — excellent points as usual. Two thoughts: 1. Is it really shocking that the healthcare industry is not persuaded by data on quality and safety? At the end of the day, we have an industry where doing going and doing well are often at odds with each other. You say bribing (and I get why) — and I say, its an effort by the biggest payer in the marketplace (CMS) to fix a market failure. 2. Agree regarding errors from EHRs — I was on the IOM panel that studied EHRs and patient safety. There is no doubt that… Read more »

Al
Guest
Al

Michael M “Paper kills.” It’s just that no alternative is perfect.”

Right and even EHR’s kill so why don’t we get smart and let medical records develop from the bottom up instead of the top down? Why don’t we move government a little bit towards the background so nature takes its course. The first time I tried to do exactly what the government wishes to do today I was prevented by government rules and regulations. That was in the 80’s.

By the way have you not noted the canned reports and inaccurate data that is copied from one EHR to the next?

Al
Guest
Al

We are now learning that EHR’s also offer errors and we are finding that costs of EHR’s that were never expected. I don’t think many are against EHR’s rather many are against the top down approach which in my opinion is a failure. I say that even though in the early 1980’s I voluntarily was placing the important features of my notes and treatment along with laboratory on a computer that could have been linked to others. What mucked up this type of development was experts that didn’t know the reasons behind the physicians notes and the government regulation that… Read more »

E Tal
Guest
E Tal

HITECH is a great success, if you measure success as Dr. Jha does here: the percentage of hospitals in the US who had managed to spend billions in “free” taxpayer money to buy poorly designed systems, to run within a misaligned data framework. The true measure of success is not in inputs (money spent, systems installed) but in output: rising quality of care, more efficient use of resources (especially doctors’ time), better overall outcomes for communities, etc. “I am confident that if we do nothing, health IT will have huge effects on healthcare delivery – but it might take a… Read more »

Ashish Jha
Guest

ET — a key point I made was that the real value of health IT comes when it begins to move the needle on costs and quality. It won’t happen easily or quickly — and we have to find ways to speed up the process. Not sure that we’ve been thinking about EHRs and how they should be used for 200 years — my sense is that as a nation, we’ve only gotten serious about them over the last five years or so.

Adrian Gropper MD
Guest

The visible and exciting progress that has been made has also had some side-effects. HITECH is like a steroid injection – it definitely takes care of the inflammation symptom but it may have severe side and long-term effects and may be doing little to cure the disease. Four years in, HITECH has done brilliantly to reduce the lack of EHR symptom but the side-effect has been massive consolidation and vendor lock-in by the EHR industry without much portability and no visible gains in transparency of either quality or cost. The vendor lock-in, in particular, has tremendous and long lasting cost… Read more »

tschwiet MD
Guest
tschwiet MD

Adrian, I think the steroid analogy is well placed for HITECH. The apparent reduction in inflammation seen with codifying clinical information for analysis and billing has resulted in an the atrophy of real meaning in clinical notes (templated gibberish), degenerative disorders in inter-physician communication (automated junk referral letters, poor data exchange), edema for the bill (over coding), and a catabolic effect on patient-centric efforts (apps, open data). MU is like adding a second drug to mitigate the flawed effects the first injection caused. Unfortunately, vendor lock-in from HITECH has made it very difficult to un-do the lasting effects of the… Read more »