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Health should be at the heart of health IT

By Carol Diamond and Josh Lemieux

12 June 2009

With billions of taxpayer dollars about to be invested, the stakes are indisputably high to set the right priorities for accelerating the benefits of health information technology. What should those priorities be?

It would be easy to assume that the main focus should be on technology-related issues—standards, software, hardware, technical support, and so forth. After all, isn’t “IT” what we are talking about? But technology-related goals often seduce and distract us from the heart of the matter.

And the heart of the matter is: “What is the IT for?”

Clay Shirky and I have written about the misconception that simply creating technical standards will magically lead to the rapid adoption of health IT.¹ Ironically, one of the biggest obstacles to expanding the use of health IT may be a narrow focus on stimulating its adoption. Success is not how many doctors and hospitals use electronic medical records. Success is when clinical outcomes improve. Success is when everyone can learn which methods and treatments work and which don’t in days instead of decades.

Now that the federal government is investing upwards of $30 billion to help stimulate health IT adoption among providers and hospitals as part of the American Recovery and Reinvestment Act (ARRA), it’s critical that we define success in the right way.

As we have learned so many times before in other sectors, technology is just a tool. Without clearly set goals and expectations, IT cannot achieve what we hope to accomplish. We must use health IT as a tool to transform the US health care system as a whole, rather than simply computerizing the current setup. Indeed, the literature on computerization, stretching back to the 1980s, is unambiguous on this point: computers are amplifiers. If you computerize an inefficient system, you will simply make it a faster inefficient system. IT can improve the quality of care only when underlying system processes are transformed at the same time.

So, the heart of the matter is that health IT investments must be directed toward three clear and unwavering goals: improving health, protecting privacy, and slowing the unsustainable spiral in costs. In fact, a reason health IT subsidies were included in an omnibus law addressing the economic crisis is policy makers’ high hopes that IT will help our ailing health care system rein in spending growth while improving quality.

Over the past few years, the health IT conversation has focused a lot of attention on the need for technical standards. That’s understandable, since the benefits of IT accrue when shared information leads to better decisions. Most of us receive care from many providers over the course of our lifetimes and even over the course of an illness. Health IT is a critical communications tool that can help doctors and patients make better decisions by making patient information accessible and useable, while at the same time generating information on what works and what doesn’t. Standards are necessary to enable this kind of information flow. But technical standards are not adopted by decree; they are adopted through use.

Similarly, a great deal of attention has been placed on certifying electronic health records (EHRs), largely motivated by lagging adoption, in the hopes of creating purchaser confidence. However, the certification of software can’t be a proxy for ensuring that doctors will actually use the system to meet specific goals for health improvement, slowed growth of costs, or protection of privacy.

We will surely miss the mark without also taking on the much harder challenges—such as how to make use of health IT to achieve better health and health care, how to determine which financial policies will support this goal, and how to establish the information policies necessary to protect information and engender patient trust.

The big opportunity now is that the ARRA law establishes a framework for addressing exactly these challenges. It provides a set of privacy provisions as well as economic incentives that can be directed toward stimulating the use of IT in the health care industry. At the same time, it sets forth clear goals that go far beyond the mere adoption of technology: a key provision of the law requires providers to make “meaningful use” of IT in order to qualify for health IT incentives.

Markle Foundation’s Connecting for Health Collaborative recently convened a broad group of collaborators with very diverse perspectives and forged an initial set of practical recommendations. The document—Achieving the Health IT Objectives of ARRA: A Framework for “Meaningful Use” and “Certified or Qualified” EHR ² — is aimed at ensuring that both providers and consumers can make use of clinically relevant electronic information to improve patient outcomes and care delivery while controlling the growth of costs. We believe the earliest opportunities for demonstrating the potential of health IT lie in the areas of medication management and coordination of care.

That means, for example, using IT to make sure people are on optimal medications for controlling their chronic conditions or to prevent critical information from falling through the cracks when people are discharged from the hospital or when they see multiple doctors.

The group agreed that meaningful use could be demonstrable in the first years of
implementation (2011–12) without creating undue burden on clinicians and practices. We also agreed that the definition of meaningful use should gradually expand to encompass more ambitious health-improvement aims over time.

With these ideas in mind, we also must recognize the heterogeneity of the US health sector. Metrics for demonstrating meaningful use should allow for a broad range of providers to participate and to show improvement in a variety of ways. Medical practices that are capable of installing and supporting a comprehensive EHR system should be incentivized under ARRA to do so. However, assuming that only comprehensive EHR systems can achieve the goals of meaningful use might delay progress or lock out other lightweight, network-enabled solutions that may achieve the same goals in the near term and can provide greater functionality over time.

Our consensus statement is also clear that consumers, patients, and their families should benefit from health IT through improved access to personal health information without sacrificing their privacy. ARRA clarifies the individual’s right to request electronic copies of personal health information from EHRs for storage by information services of the individual’s choosing, an important aspect of achieving the meaningful use of health IT.

In terms of the technical requirements, we must make sure that processes for the certification or qualification of EHR technology allow for product and service innovation aimed at meeting expanding goals for the meaningful use of information. It would work against the goals of ARRA if certification regimens became a bottleneck that resulted in rewards only for existing EHR technologies, as well as having the unintended consequence of thwarting much needed innovation by narrowing marketplace incentives for a broad array of technology solutions. With clear goals in place, we can be open to new innovation so that health IT can help people across many different care settings—large and small, urban and rural, in doctors’ offices and in hospitals. ARRA must be an opportunity for smaller practices—which still account for the bulk of outpatient doctor visits in the United States—to benefit from market innovation, Web-enabled tools, and lighter-weight approaches that can be proven to improve health outcomes.

Because, after all, it’s use of information, not merely the existence of technology, that enables a consumer to play an active role in maintaining health and getting the best care, prevents a patient from suffering a medical error, helps a clinician prescribe the right treatment at the right time, allows a care team to coordinate care in the most effective and affordable way, and benefits efforts to improve quality, accelerate research, and advance public health.

Isn’t that the heart of the matter?

¹ Carol C. Diamond and Clay Shirky, Health information technology: A few years of magical thinking? Health Affairs, 2008, Issue 27, Number 5.

² This document was published in April 2009 and can be found online at The Markle Foundation.

Comment [15]

Agree? Disagree? Let us know what you think. Please include your full name with your comment. Comments may be edited.

Carol,
Thanks for a great article. For me the most significant piece was your final paragraph when you talk about the use of Information. I personally think that is the most important thing that we need to remember. The role of IT is all about using technology for information purposes. It is information that is the critical thing here – not technology. Too often we get hung up on technology for technology sake. We need to keep focusing on what we are trying to accomplish- we are looking to save lives by focusing on the information about patients. We need to be information-driven and keep that at the front of our thoughts. Being information (or data) driven saves lives.

Infrastructure and applicaitons are now becoming commoditised. The value is in unlocking and sharing the data.

So, I believe our focus must be on understanding the data, ensuring that we can acess that data from any system that we build or maintain, and being able to share that data throughout our network in a secure manner. I for one do not want my personal records shared accidentally with the outside world, but I do want to know that any hospital I go into has the correct data about me.

To accomplish this we need to adhere to standards like NCPDP, HL7 and HIPAA, but also have a broad governance strategy that enables us to always focus on the value of the data and be able to pull that data out of disparate applications across the health IT ecosystem.

Think data first and move our Health system to being a data driven enterprise.

Posted 26 June 2009, 06:31 by Chris Boorman
It’s interesting that Health IT is usually discussed with a strong provider focus. EHRs tend to be one topic getting a lot of attention. To get meaningful uptake of EHRs they need to integrate into an overall solution that works for and engages the patient.

Users are on average bored by just an EHR solution or HRA (health risk assessment) solution. If we start from the client / patient / user perspective, we need systems that are user-centric and support primary, secondary and tertiary prevention, i.e. wellness/lifestyle, early detection and chronic condition care management. These need to be fun and engaging so users can self-manage while feeling supported. They need to link in with existing EHR’s but also link into nurse and doctor-support beyond the traditional reactive models which still dominate. The tracking information a participant engaged online (whether via computer or phone) automatically creates can be used to target preventive interventions (whether they be coaching calls, information alerts etc.) in a manner that can push care management to the next stage of effectiveness and affordability.

Standards will continue to evolve to create more inter-operability and continued assurance of safety but that will not be what pushes these things to widespread adoption or maximize their potential value. Making the user

We’re trying to scale up solutions in this space and are working with former Sec of Health Tommy Thompson in the States, UK and internationally. Weblink is provided for anybody curious and always happy to connect and discuss offline also.

Posted 20 June 2009, 06:13 by Stefan Wisbauer
Hello,

The health IT investment should improve control over the growing expenses. Like for me the main problem of costs it’s connected with greednes of physicians and pharma companies. If taxpayers wish to get the transparent health financing system all sides of business should agreed on full transparency. If we will look on some costs of medical procedures, materials , devices and drugs we can recognize that the same thing can be cheaper by 30-50% in other countries. Also, the FDA regulations are killing the competition on US market and improving the costs of treatment. So, there is a lot of factors necessary to analyze before improoving IT system for slowing the spital in costs.

Posted 19 June 2009, 03:22 by Piotr Tokarski
I like the theme of the article as the overall goal of Health IT should be to improve outcomes. However, I thought the article stopped short of taking into account behaviors and life styles that lead to illness and doctor visits. I don’t think just throwing more data at the problem through EHR can significantly reduce costs. In my opinion incentives for a healthy lifestyle are misaligned.
For example having a burger and fries every day does not have any negative impact. Why not develop tools and technologies that could take a hair sample and could not only can tell if a person smoked but also how a person ate over the last 10 days and how much exercise the person had… It would be easy to then counsel a person during a doctor’s visit that they can easily move from the lower 25% to the top 25% healthy by following a personalized health program based on the analysis. Unfortunately we seem to be years away from a fully integrated Health IT.

Posted 18 June 2009, 17:31 by Bert Huelmann
I read this article with interest and do agree with much of its contents.
And obviously increased health outcomes should be a major aim.
However, cost savings in better stock control and enabling better leverage of lower prices from suppliers has also been a major benefit for us.
But, to return to the major point of the article – better health outcomes.
I believe none of us will deliver this by technology, connected information or even better trained Doctors alone.
One fundamental problem is that, whilst one of the EMR’s major benefits over pages & pages of hand-written notes, is that it enables (or should enable!) doctors to look holistically at the patient, doctors are not trained in medical school to do that. They are trained to take what is presented at the time and take the patient’s own version of their medical history.
Medical schools have to wake up to the potential of the EMR and change the way doctors use the available information.
The few doctors that can really see this potential are valuable contributors to the development of the EMR and the function of searching/displaying of information. Together we have a better chance to achieve the desired outcomes of better healthcare.

Posted 17 June 2009, 22:19 by shona
I agree with Joel. The information should be client-centric, where the origins of the data are not only from the doctor or the hospital, but also from the client’s employer, who probably spends the most time with the client, and often has medical information that is collected in the on-site clinic, which can be an early indicator of health-related problems. Unfortunately, the employer is excluded from the bigger picture of healthcare (this is a world-wide issue).
Dieter

Posted 17 June 2009, 21:18 by Dieter Stalmann
The IT issues notwithstanding, there remains a big issue of developing a standard medical taxononmy. If you receive healthcare in Boston and have a heart problems skiing in Utah, there’s a good chance that your EMR will contain subtle but important differences which pose interpretive problems to Utah-trained cardiologists. Back in 1993 when Hillary stimulated a lot of false hopes for funding solutions through DARPA this was scoped as a $100m task. The thought was that the standard might be created via the military and VA medical delivery systems given their large patient populations and market share and subsequently diffused across the industry.

There is also a lot of NIH in the healthcare industry and virtually no one has the scale to develop and maintain proprietary software, which is why they are anachronistic. The industry needs to become adult and do what other industries have done such as banking and migrate to third-party solutions.

After cleaning up the staggering information processing mess in healthcare which may be worth 25-35% of current costs, the next threshold for longterm cost reduction is to reduce the need for the most expensive elemnent in the delivery system—the need for the doc’s contact with the every patient. Can the IT industry develop sensors and diagnostic tools to do this?

Posted 17 June 2009, 18:44 by Frank Partel
It seems clear that there needs to be a Hippocratic Oath for IT systems. I am an IT industry analyst at Burton Group, and one of my colleagues was nearly killed by the failings of medical information systems. You can read about his life-threatening experience here and here. You can read my commentary about his harrowing experience here.

Posted 17 June 2009, 14:36 by Lyn Robison
Mike. I think you are missing the point. they are not suggesting a group take over the oversight role from doctors. They are saying that a focus for IT is to enable the doctors to better do the oversight.

Further, look closely at the trends in Heathcare costs. It is not sustainable and left as is there is more potential to bankrupt the country than spending money on the right information system solutions. The health system is archaic when it comes to its suboptimal use of informtion systems, manual processes, poor quality data. Maybe it is mom and apple pie but what Carol and Lemieux describe is pragmatic and gets some go forward. Strikes me as emminently more sensible that simply moaning about everyone’s ideas and doing nothing.

Posted 17 June 2009, 14:31 by Shayne
I think the most significant point in the ariticle (and there were many) is that IT can facilitate the successful implementation of technology but that does not necessarily result in success. A good example given above was with EHR. You can implement EHR but does everyone actually understand the overall goal? As stated by the author, success is not EHR implementation, thats only a step in the process. It’s the more rapid use of the information and improved quality of delivery that is the goal.

If institutions continue to focus on quality of delivery, and leverage tools like EHR that are being funded, successful implementations can be achieved without the need for an oversight board and audit that tries to hold people accountable.

Posted 17 June 2009, 11:12 by Jim Pearson