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Wednesday, February 13, 2013

The health IT "Grand Experiment": mid-study check-up

It seems that whenever there is something negative about health information technology (HIT) in the popular press, I get emails from people inside and outside the field, asking "What's wrong?"

A case in point is a recent article in the New York Times 1, reporting on a "negative" point of view from two researchers from the RAND Corp. that was published in the journal Health Affairs 2.

One of the interesting twists of the Health Affairs piece was that it was written by researchers from RAND, the same organization that published a modeling study in 2005 that concluded that investment in HIT could provide potential annual savings to the healthcare system of $142-$371 billion 3. About the same time, another model-based study from the Center for Information Technology Leadership (CITL) found similar potential savings 4. This data in part led to the inclusion of HIT in the Health Information Technology for Economic and Clinical Health (HITECH) Act, the program from the American Recovery and Reinvestment Act (ARRA) of 2009, also known as the economic stimulus bill, that invested up to $29 billion in the adoption and "meaningful use" of the electronic health record (EHR) and other HIT 5.

What can we conclude from this recent publication and reporting about it in the popular press? As always, it is best to look at exactly what has been claimed, what evidence supports it, and where it fits in the larger picture of this topic.

The 2005 RAND study modeled savings that could occur from HIT adoption 3:
--reduced adverse drug events that extend hospital length of stay in the inpatient setting and avoid hospitalization in the outpatient setting,
--increased used of cost-effective immunizations and screening interventions, and
--improved efficiency of chronic disease management.

Their model, however, noted that HIT adoption alone would not be enough; also required would be "interconnected and interoperable systems" that were "adopted widely" and "used effectively." This had an implicit assumption of change in the healthcare delivery system away from payment for volume toward payment for value. The paper describing this work was published in Health Affairs, along with several dissenting views 6-8. An analysis by the Congressional Budget Office also took issue with the conclusions 9.

The CITL study used a somewhat similar modeling approach and drew similar conclusions. The CITL model focused on different types of health information exchange (HIE), from simple transmission of documents to full semantic interoperability of EHR systems. The latter approach was shown to achieve the most benefit, up to $77 billion per year.

Can we assess the correctness of these modeling studies, now that we have substantially increased EHR adoption through HITECH? The recent paper from RAND noted that the question is not simple to answer, but that HIT probably has fallen short of its promises, especially in terms of reducing costs 2.

Of course, one of the challenges in answering the question of cost-reduction is that it is difficult to attribute avoidable cost in the healthcare system. We do know that healthcare costs have reduced their rate of growth in the last few years, probably mainly due to the economic recession 10. But we cannot know for sure how much of that reduction might be due to HIT adoption.

But an even bigger reason why we cannot know if the modeling studies are true is that we have achieved the kind of HIT environment that these studies assumed in the development of their models. The original RAND study assumed, as noted above, interconnected and interoperable systems that were adopted widely and used effectively. The authors of the new RAND paper note that HIT failure has come in large part because of failure to reach those assumption. In particular:
--We do not have interconnected and interoperable systems. In part, this is because many EHR systems are still closed and proprietary. In addition, HIE efforts are still early and nascent.
--We also do not have wide adoption yet of systems, especially advanced systems. While HITECH has led to increased adoption, there is still a long ways to go.
--And probably the biggest shortcoming has been lack of EHRs being used effectively. The adoption incentives in Stage 1 of meaningful use focus (by design) on building the data foundation. More effective use will come based on that foundation in Stage 2 and beyond.

The RAND authors conclude that the potential of HIT in reducing costs is still very real, but critical focus on interoperability, patient-centeredness, and usability must be prioritized.

Therefore my view echoes that of the RAND researchers in the new Health Affairs piece, which is that yes, HIT has not yet delivered on its promise to improve efficiency and reduce cost in the health care system.

But the proposition that it inherently is not able to do so is also not known. As such, if we hope for that improvement, the grand experiment should go on. There is no question that the required time will be longer, the resources required will be larger, and the cultural change will be more difficult.

There is also quite valid concern that there are some untended consequences of the staged approach in HITECH, which may be locking clinicians and hospitals into monolithic systems that are difficult to use and expand. I sympathize with the notion of current market-leader systems locking us into an "EHR trap," where the EHR should not be a monolithic application but instead a platform on top of which we can build apps that provide innovative functions and/or make new use of the data 11.

Over the last few years, I have ended many a talk on informatics noting that a "grand experiment" in our field was taking place, with the complete results unlikely to be years away. This study can be viewed as a mid-study assessment, and we can conclude that the benefits have not yet accrued, but that it may be too early to conclude that they will not occur.

Although I agree that we probably need some mid-course correction in our approach, I also argue that we cannot go back nor should we end the experiment prematurely. We also must remember the motivations for implementing HIT and reforming healthcare in the first place, which is the error-prone and financially dysfunctional existing system, which both undermines competitiveness of U.S. companies globally due to high employee healthcare costs as well as threatening to bankrupt the U.S. government through unsustainable Medicare cost increases.

References:
1. Abelson R and Creswell J, In Second Look, Few Savings From Digital Health Records, New York Times. January 10, 2013. http://www.nytimes.com/2013/01/11/business/electronic-records-systems-have-not-reduced-health-costs-report-says.html.
2. Kellermann AL and Jones SS, What will it take to achieve the as-yet-unfulfilled promises of health information technology? Health Affairs, 2013. 32: 63-68.
3. Hillestad R, Bigelow J, Bower A, Girosi F, Meili R, Scoville R, et al., Can electronic medical record systems transform health care? Health Affairs, 2005. 24: 1103-1117.
4. Pan E, Johnston D, Walker J, Adler-Milstein J, Bates DW, and Middleton B, The Value of Healthcare Information Exchange and Interoperability. 2004, Center for Information Technology Leadership: Boston, MA.
5. Blumenthal D, Launching HITECH. New England Journal of Medicine, 2010. 362: 382-385.
6. Himmelstein DU and Woolhandler S, Hope and hype: predicting the impact of electronic medical records. Health Affairs, 2005. 24: 1121-1123.
7. Goodman C, Savings in electronic medical record systems? Do it for the quality. Health Affairs, 2005. 24: 1124-1126.
8. Walker JM, Electronic medical records and health care transformation. Health Affairs, 2005. 24: 1118-1120.
9. Orszag P, Evidence on the Costs and Benefits of Health Information Technology. 2008, Congressional Budget Office: Washington, DC, http://www.cbo.gov/ftpdocs/91xx/doc9168/05-20-HealthIT.pdf.
10. Hartman M, Martin AB, Benson J, and Catlin A, National health spending in 2011: overall growth remains low, but some payers and services show signs of acceleration. Health Affairs, 2013. 32: 87-99.
11. Mandl KD and Kohane IS, Escaping the EHR trap--the future of health IT. New England Journal of Medicine, 2012. 366: 2240-2242.
This post by William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, appeared on his blog Informatics Professor, where he posts his thoughts on various topics related to biomedical and health informatics.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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