Post-HITECH HIT: Still Waiting

flying cadeuciiWhen it comes to health information technology in the United States, are you an optimist or pessimist?

Do you think it’s likely people who want health information will soon have routine, seamless digital access to it?

Most physicians and hospitals have at least some sort of electronic health record, yet big adoption gaps remain among physicians as just over half now have electronic health records. We can declare success and move on, right?


Most of us still cannot get health information when we want or need it. Health professionals and care systems trying to implement value-based payment and delivery reforms struggle to get the information they need to do that transformation. Communities trying to improve the health of their citizens have trouble getting the data they need and turning it into useful information.

Last week, the Robert Wood Johnson Foundation released its latest and last in a 10 year series of health information technology reports. The title of this year’s report is: “Health Information Technology in the United States, 2015: Transition to a Post-HITECH World”. Like previous editions, this one is an independent assessment of the state of our national health information technology infrastructure. It examines the progress, mishaps and many of the remaining challenges.

Although, we do not yet have that health information infrastructure, we do have a range of opinions about what has gone right and wrong over the last 10 years. There’s even a wide range of opinion among past and current national HIT coordinators. This year’s RWJF report includes an interview with all of them. Their comments range from: if we hadn’t acted we’d basically still be “Waiting for Godot” to we did act and ended up creating a sort of Eisenhower-like HIT “military industrial complex”.

Farzad Mostashari:

“’Oh, the marvels of technology that would have emerged had the government not stepped in. Oh, you should have just waited.’ So, first of all, waited until when? We waited 20 years, right? Waited for what? Second of all, where’s the counterfactual? You know what the counterfactual is? Behavioral health. You know what the counterfactual is? Long‐term care. Show me the beautifully innovative technology that’s now easily adopted by long‐term care health professionals. It doesn’t exist.”

David Brailer:

“Three things are clear. First, there was significant uptake in adoption before HITECH because the industry knew it was time and desperately wanted improvements. They simply needed the government, as the biggest payer for health care, to lead. Second, a vast amount of expensive public capital has been spent in HITECH, largely as a substitute for private capital, and the market will be wary of new investments if there is ever the potential for new government money to pay for it. Third, HITECH left us with an unwieldy, confused regulatory scheme that will slow down or block the innovations of the future.”

Our HIT reality is probably somewhere in between. At this year’s Washington, DC RWJF report release event, current national coordinator, Karen DeSalvo, provided some wise glass-is-half-full leadership: We are making enormous progress. We also face hard challenges. Now is not the time to let up.

Personally, I remain a guarded optimist about this epic quest for our health information infrastructure. On the other hand, I’m also an avid cyclist who lives to ride two or three hundred miles a week precisely because it hurts so much.

What say you?

Michael Painter is a senior program officer with the Robert Wood Johnson Foundation. 

Categories: Uncategorized

18 replies »

  1. I love this response–especially “we are not waiting.” You go “girl”.

  2. I agree with you–that this technology can easily and often does reinforce the problems rather than embody the transformational solutions. It certainly could provide a huge lift–as you describe–if the other pieces were in place. Your experience is very telling.

  3. Very sorry about your wife’s problem. But there is a simple solution that can aggregate complete copies of ALL her records from ALL her providers in one place that she owns and can carry on her keychain, in a wallet or wear. It’s available today. It’s called MedKaz®. (see medkaz.com) Hope it helps!

  4. As the caregiver of a cancer patient over the last few years … and a very active user of health care … patients are no where close to getting complete, intelligible or convenient access to to their health care data on a uniform electronic basis. My wife currently has 14 patient portals in facilities across the US none of which speak to one another … nor allow clinicians to to easily access her historical data. Frankly it is much easier and more reliable for us to obtain her lab results and radiology reports in a hard copy format and hand carry them from one provider to the next.

    This really does not come as a big surprise since the “patient” was never the primary intended target market for Health IT. The target audience today … as in years gone by … are health CFOs, Medical Directors and CIOs. Simply creating a patient facing web page with lab results and the ability to schedule appointments is not what I consider a robust patient-centered use of health IT these days.

    Unless and until health IT can be routinely integrated into the doctor’s visit and patient care, most patients won’t find much long term value in today’s crop of health IT solutions. Nor do I see things changing any time soon.


  5. I’m really feeling the lack of a “like” button here … LOVE what Rob said.

  6. I think this post (and subsequent comments) are spot-on. Incentives are important, but won’t themselves fix the problems at hand. Adoption does not equate to using something as it should be used. I know that was the original intent of “meaningful use,” but the criteria became more the goal than the actual meaningful use of EMR systems. Why? Because the goal from vendors was to sell their products, and the way they sold their product was for MU compliance, not clinical utility (it turns out that these are sometimes opposed to one another).

    But the main problem, from the perspective of a very early EHR adopter (1997), enthusiast (Davies Award, 2003), and evangelist who has since gone rogue (left for a DPC practice in 2012), I see the primary cause of this is the system itself. Health IT always had the opportunity to transform our system, but was unfortunately transformed by the system. Instead of making care more efficient, it allowed the adoption of coding and documenting requirements that were not possible without computers. The core of the problem is a system which does not actually value patient outcomes (in that it rewards illness over health), instead focusing on increased data gathering and codification of care.

    Since living in a world where actual patient care is central to the success of the business, I’ve seen a dramatic transformation of both my use of IT and that of my patients. People are far more engaged with me since I am actually incentivized to use it (because I keep patients if I give them better care and lose them if I don’t). Perhaps the problem is that we are depending on the equivalent of the Con-Agra’s of the healthcare world to fix our problems on a macro level when the problem would solve itself if we took advantage of and created an ecosystem where these things would grow out of actual need and utility.

  7. Thanks, Mike. If you recall, we spoke about our solution to the lack of interoperability and the inability of patients to access/control their records. It’s called MedKaz®. I’m very upbeat because it meets these needs head-on by making the patient the focal point of his/her care.

  8. amenAmenAMEN, Francois.

    The healthcare system (in which I include the pundits you mention, since they’re the Spin Zone for the status quo, whatever status is quo with the big money players at any given time) has had this long, involved, *expensive* discussion still thinking they’re standing over the supine forms of patients who are too dim/unsophisticated/whatever to participate in the discussion the grownups are having.

    What I think we’ve experienced with the entire healthcare reform rodeo – ushered in with Bush II and David Brailer in ’04, then codified as “official system wide reform” (it isn’t, not yet, but it’s a start) via the ACA – is a confluence of our every-state-is-a-special-snowflake political system and what I call the Grover Norquist Effect, where drowning government in the bathtub is the stated goal. It’s hard to drive effective change when someone’s holding your head under water.

    Patients have had little (no?) voice or choice in the nuts’n’bolts work involved in making real reform a reality, largely because we don’t have lobby power on our own. We have to hang from the coattails of some bigger player in order to have a shot at having our voices heard. The risk to “the system” here is that we’ll start building our own care networks, perhaps a la the African-American benevolent societies of the 18th, 19th, and early 20th centuries. The rise of homo digitus makes this a real possibility, since the #wearenotwaiting crowd – of which I am a member, in case there was any question – has already started delivering peer to peer care models via groups like ACOR/SmartPatients and a host of other digital communities.

    We’re also swapping data. And talking about ripping up HIPAA and rewriting it. ICYMI – we are not waiting. Ignore us at your peril, Medical Industrial Complex …

  9. Thanks for the always thoughtful and smart comment, Bobby. It seems like we have a lot of pessimists here so far…

  10. It sounds like you’re in the same camp with Francois–see his comment above. Thanks for your thoughtful comment here too.

  11. You’re so right–value to the people using the technology is critical. Thanks for the comment, Paul.

  12. And if anyone knows health care incentives, Francis, it’s you. Folks would be wise to listen. Thanks for the great comment.

  13. The current structure is unsalvageable. The government has forced hospitals to instal 8-track players that are impossible to improve. Unfortunately, many groups are now in vendor lock, just in time for the money to run out. A free market is not going to solve anything because none of the stakeholders you mentioned even believe in one.

  14. I’ve always been an optimist that we can achieve true interoperability of EMRs so long as the government and private sector payers promote the type of financial incentives that will encourage and not discourage the comprehensive sharing of clinical records. In the RWJF report on the State of HIT, my colleagues and I wrote a chapter on the link between incentives and interoperability, and it’s a very strong link. Unfortunately, the government is using that link to discourage interoperability. Medicare’s misguided philosophy of encouraging the formation of integrated militates strongly against the sharing of health information across health care organizations. And for us who toil in the field of health care reform daily, we know that sharing information within an organization has nothing to do with sharing health information across organizations.
    And yet, it’s the across organizational health information sharing that consumer-patients want so desperately. The pundits answer that consumers don’t really know what they want, that they can get great care in an archipelago of Kaiser-like islands. But like for so many things, the pundits are wrong. Consumers have always wanted the freedom to choose. That’s what free markets are about. And when those consumers become patients and need expert care, they don’t want to be locked into their local health system. They want the freedom to find the best care for their condition. That requires the sharing of their clinical data with others, and that’s exactly what health systems are trying to avoid.
    Getting to true interoperability is very solvable as long as the government stops discouraging the creation of a real market for health care services. It seems to many of us that we’re going to have to wait another 15 months for that to happen.

  15. The big $ incentive and the penalties for non adoption induced adoption before the product was ready….and assured that big health system administrators would sign up….with far too little physician input. So the products actually interfere with doctors interactions with patients.

    It is as if in the 1990’s the govt. forced adoption of cell phones for everyone, locking in the old Motorola Star Tec phone as the standard….erecting a huge barrier to entry for new players……likely preventing or severely delaying the invention of the iphone.

    Someday in the far future EHRs will really help doctors and patients….but that time has been pushed out by Hitech…..while driving up the cost of healthcare for many years as non value add very expensive systems have been locked in.

    If we hadn’t had Hitech the vendors would have had to develop systems that helped doctors right off the bat….or they and the health systems just wouldn’t have bought them until adoption added value right off the bat.

  16. As a consumer, occasional-patient, and investment banker-turned-healthcare IT entrepreneur, I think both extreme views are partially right and wrong.

    If the government hadn’t forced care providers and hospitals to adopt EMR systems, I doubt many would have done so on their own and most would still be using paper. Why? Because there was no sound business reason to change. It simply made no sense for doctors or hospitals to spend enormous sums and endless man-hours to install a system which, if successful, would save lots of money for insurers and self-insured employers but very little for the care provider. HITECH’s carrot-and-stick approach provided the incentive. So most care providers took the carrot and most have installed EMR systems!

    I consider that a great accomplishment. However, most providers I’ve spoken with are angry, some even bitter, that they aren’t enjoying many—if any—benefits from them. Many with whom I’ve spoken feel they’ve been had. When I ask them how they like their new system, the almost-universal answer is “I hate it.”

    They feel they made a pact with the devil! The costs they incurred often were 6X or more than the government reimbursed them and they aren’t even close to getting a return on their investment. They’ve been reduced to data entry clerks and aren’t deriving any of the benefits they expected. They aren’t saving time. They’ve increased their costs rather than their income. They aren’t any closer to total interoperability and still can’t electronically coordinate care. Why? Because the government’s well-intentioned MU rules and requirements backfired. In effect it created a monopoly—do it our way or else!—that overwhelmed providers and hasn’t worked at all as expected.

    So what should we do now? We should ease up on the requirements and make room for other solutions to be heard and tried. I’m sure there are many other ways to achieve interoperability than trying to link provider silos with HIEs, HL7, or FHIR. Similarly, I’m sure there are other ways to advance the collection and exchange of data for public health purposes. Let’s encourage the free market to develop and introduce solutions that will benefit everyone: patients, providers, employers/insurers and government!

  17. “Do you think it’s likely people who want health information will soon have routine, seamless digital access to it?”

    No. I say that as a long-time analyst, former programmer (forensic environmental radioanalytics), DOQ-IT and Meaningful Use REC project coordinator, and now a patient under lengthy treatment for a potentially life threatening disease. The fragmentation and obstruction is as bad as ever, possibly getting even worse — ironically abetted by the wild proliferation of myriad IT apps in the healthcare sector. All of the cherubic talk about “interoperability” is just that, talk. I call it “interoperababble.” In fairness, the reasons have far less to do with IT per se than they do with policy and economics.