Health IT: Glass Half Empty? Half Full? Shattered?

Jack CochranTechnology occupies an unusual place in health care. Some people say that electronic health records are clumsy barriers between patients and their doctors. Others suggest that technology is a kind of secret sauce.

In many places physicians and other clinicians are stymied by awkward technology. In other organizations — Kaiser Permanente included — electronic health records enable some of the finest individual and population health care ever.

This humorous equation speaks volumes about technology and health care:


New technology + old organization = Costly old organization. In other words, technology doesn’t change an organization. Change is about leadership and culture. It is about thinking in new ways and asking new questions.

For example, rather than ask how many patients can you see, let’s ask how many patients’ problems can you solve?

Instead of asking how can we convince patients to get required prevention, let’s ask how can we create systems that significantly increase the likelihood that patients get required prevention?

Instead of asking how often should a physician see a patient to optimally monitor a condition, let’s ask what is the best way to optimally monitor a condition?

When we begin asking these kinds of questions, we see technology as a tool — not a solution by itself, but as a powerful tool we can use to deliver better individual and population care. Technology, like data, is only useful when it enables clinicians and teams to work effectively to provide the highest quality care for patients.

Hospitals and physician groups throughout the country are installing and working with electronic health records at a rapid pace. Some organizations integrate the systems beautifully, others do not.

Bumpy Wired Road Ahead
Bob Wachter, MD, is a thoughtful voice on this topic and we look forward to the publication of his book, “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age,” due out next spring.

Technology’s application in health care is central to efforts to improve access, quality, equity, and affordability, yet the road to a wired system is undeniably bumpy. For all the challenges, however, we believe we are headed in a positive direction.

Dr. Wachter is by no means a Luddite. Far from it. He recently noted that “Meaningful Use” — a phrase which makes some stakeholders uncomfortable — has done a great deal of good (increasing the percentage of wired hospitals and physician practices from 30 to 70).* The Center for Medicare and Medicaid Services (CMS) defines the meaningful use incentive programs as providing “financial incentives for the meaningful use of certified EHR technology to improve patient care.” Wachter predicts that in a couple of decades “computers will have transformed healthcare … leaving it better, safer, and maybe even cheaper. Most of the kinks … will have been ironed out.”

Let’s remind ourselves that registries and electronic health records have enabled the medical profession to care for patients in ways never before imagined — managing thousands of patients in a diabetes registry, for example. Without the power of technology, the kind of population management increasingly common for chronic conditions would be unthinkable.

Some doctors may be distracted or annoyed by electronic records. Sometimes they are slowed down. Today, our role as physicians is to stand up for our patients as healers, leaders, and partners in their journeys through the rutted landscape that is modern health care.

How Long the Wait?

The transition period in which we find ourselves is both frustrating and invigorating. How much longer before we get it right? We are drawn to some perspective from Vinod Khosla, whose technology credentials are as solid as they come: Khosla was a co-founder of Sun Microsystems, a general partner at the technology venture firm Kleiner Perkins Caufield & Byers, and now leads Khosla Ventures.

Khosla recently observed on techcrunch.com that new health care IT systems can be “underwhelming and clumsy. By comparison, my first cell phone was the size of a sewing machine and floor mounted to a car with a cumbersome handset cord but has since evolved into today’s iPhone. Similarly, in 15 or 20 years, changes to health care will seem obvious, inevitable and well beyond what we envision compared to the somewhat crude digital health technologies we see today.”

At Kaiser Permanente we are known for pushing the technology frontier and that impulse has yielded multiple benefits for our patients. Decision support pop-ups sometimes annoy physicians, but they also provide guidance toward quality and safety, reducing unwarranted variation. Our KP HealthConnect system has allowed us to translate medical terms into clear language our members readily grasp.

When our oncology physicians agreed on clear cancer protocols and guidelines, we were able to embed them into our electronic system. And wherever a Kaiser Permanente patient appears within our system, technology tells the team member — whether receptionist, physician, nurse, etc. — exactly the tests and screenings for which the patient is due thus reducing care gaps. Better health for our members? Absolutely.

Jack Cochran, MD, FACS, (@JackHCochran) is executive director of The Permanente Federation, headquartered in Oakland, California.

Charles C. Kenney is a former reporter and editor at the Boston Globe and author of several books on healthcare in the United States.

5 replies »

  1. Ya oughta read Nicholas Cage’s “The Glass Cage, along with Simon Head’s “Mindless” and Morozov’s “To Save Everything, Click HERE.”

  2. An exiting style. Jack and Charles make us feel good about riding this horse into Camelot.

    We need a word or two about security of data. Not a peep here.

    Also a bit about the history of technological innovations. What are their chances of taking hold? What has happened to private flying? or the idea for standardized shipping containers, trucks. making them all fungible?

    We listen to benefits, but what about disadvantages, risks, dangers of HIT? Eg could too much care-coordination solidify and lock in wrong diagnoses? Cause diagnostic and therapeutic inertia? ..,decrease clinical innovation and individualized precise care?…decrease thinking?

    What about unanticipated side effects? Eg more folks lnowing exactly the details and thinking behind their care…would this cause more lawsuits? Why not?

    The security problem is so acute and unanswered that it suggest to me that we are going to have to have a two-tiered system eventually with portions of the EHR locked by the patient and one key behind a one way trap door.

    Of course the opportunity for control of the sector is increased when the bureaucracy has much more information about its workings. Are the trench workers going to accept this? What about the research, tip of speer scientists? Will they be chilled?

    I guess there is so much titillation about computers that this will be an idea that cannot be argued until it is tried, but its dominant purpose has never been explained well. Does it improve care? Does it improve productivity? Does it improve profits and bottom lines? Does it improve care coordination? Does it improve worker or patient satisfaction? The answers to all these are iffy. Tell us evidenced based answers, please.

  3. “The difference between a cell phone and an EMR is that the cellphone accesses a standardized system, so that innovation opportunity is available to everyone.”

    Yeah, see my post ‘Yet another ONC Interoperability “Roadmap””


    Imagine schlepping to Lowe’s or Home Depot to have to choose from among 8,319 sizes and shapes (today’s tally) of ONC CHPL “2011/2014 Certified” 120VAC 15 amp 3-prong wall outlets.

  4. It should be highlighted that KP HealthConnect is a modified version of EPIC, along with KP-created tools to assist in population management. It was modified because, as Dr. Cochrane pointed out, it did not originally answer the type of questions to assist in patient care.

    I believe that the analogy proposed by Mr. Khosla does not stand in the current market environment.

    The difference between a cell phone and an EMR is that the cellphone accesses a standardized system, so that innovation opportunity is available to everyone. Also, cellphones are bought individually, so that choice can be made with minimal disruption in changing over to new phones and new carriers. Therefore, the opportunity cost to enter the system with new products is comparably low for both manufacturers and consumers.

    The government does not ask for meaningful use regarding cellphones, though, as a father, I do ask my daughter regarding meaningful use on why she “needs” a cellpohone (FYI: She still does not have one because she has not shown meaningful use yet).

    The current EMRs, especially enterprise-wide ones like the EPIC system that KP uses, do not use standardized databases and the opportunity cost to enter this arena is very high. Having recently been moved from one version of EPIC to another version of EPIC, the difficulty in moving patient data between the 2 versions of EPIC would easily convince most CIOs never to invest in moving from one system to another in this current environment unless they absolutely have to (See Mayo chooses EPIC http://host.madison.com/business/mayo-clinic-chooses-epic-systems-corp-as-its-new-provider/article_585fa24f-a72b-5d93-bf75-8813031223eb.html ) .

    As large-scale hospital-based healthcare systems continue to grow and that EPIC has more than 50% installed base of enterprise-sized EMRs, unless a standardized data format for healthcare record is implemented soon, it is my belief that the chances for disruption within the EMR field is minimal at this time and for the near future.

    Just some thoughts stimulated by the article. I agree with Dr. Cochrane that disruption starts before the technology by asking better questions.

  5. A little background for those of us who are just joining the conversation.

    Dr. Cochran: How many hours a week do you spend using your organization’s EMR? It certainly sounds like you a true technology visionary executive leader.

    I am certain your example will inspire others in similar positions.

    How many hours a week / month do your require non-physician managers at Kaiser Permanente to use your system?

    Do you have any similar requirements for IT staff?