On Monday, I participated in the Harvard School of Public Health event, Public Health and Technology (PHAT) which brought together a diverse views of healthcare, reform and the role that IT will play. The morning session focused on the status quo so to speak addressing the challenges of HIT in the clinical setting and the fed’s initiatives regarding the HITECH Act to get clinicians wired. The afternoon session, which began with a keynote by Keas founder Adam Bosworth on consumer access and use of IT to self-manage their health and health of loved ones. A lot of ground was covered over the course of this day long event with highlights provided in a mash-up below.
Current State, Clinicians, ARRA and HITECH Act:
Harvard professor Asish Jha gave a fairly disheartening current state of HIT adoption by clinicians and hospitals in the US. His presentation was based on research he has been doing to understand current adoption of EHR in ambulatory and acute settings.
Over 90% of hospitals have no functional comprehensive EHR today. Those that do tend to be large hospitals and teaching hospitals. Inadequate capital (73%), maintenance costs (44%) and physician resistance (36%) are cited as the top three barriers to adoption.
In the ambulatory setting, 83% do not have a functional EHR today, though 17% of those stated that they have purchased such but have not implemented and another 26% plan to purchase such within the next two years. Top three barriers to adoption: lack of capital (67%), finding a system that meets their needs (54%) and uncertainty of ROI (51%). Interestingly, in fourth at 45% was the fear that the EHR would become obsolete. This particular fear may be one that EHR vendors with an SaaS solution could easily defend against.
In both the acute and ambulatory settings, the number one hurdle, access to capital, may be rectified through the HITECH Act, that is if those expecting reimbursement meet meaningful use criteria. And therein may be a challenge for John Halamka, in his keynote stated that there will be no partial reimbursement for meeting just part of meaningful use. Its all or nothing folks.
In comparing US adoption rates of HIT with other countries, the US is in good company regarding acute care setting adoption but in ambulatory settings, we are far behind our peers.
Halamka gave a great overview of HITECH Act, its many nuances and what the future may portend. His slide on the ARRA business model was particularly enlightening.
During the morning panel discussion we heard such things as:
David Cutler, Harvard economist and adviser to Obama administration stating: “Anyone wonder where all the middle managers have gone since the start of the recession? They are now in healthcare. There are now more mid-level administrators in the healthcare sector than nurses.” Sobering statistic!
Prof. Jha has found no conclusive evidence that shows EHR adoption contributes to lowering costs or improving quality. Steve Lohr, reporter for the NY Times wrote an article on Ja’s findings just prior to this event.
Karen Bell, formerly of ONC and now with MassPro was quick to point out that one should not despair that no conclusive evidence has been found as to the efficacy of EHRs for it takes several years for IT to make its impact known and measurable. She’s correct, just look at the productivity paradox that occurred in manufacturing which began adopting IT in earnest in the 80’s and true productivity gains do not begin to present themselves until a full decade later. We can expect similar results in healthcare.
Bell: “Doctors starting from scratch today in adopting an EHR will not likely meet meaningful use criteria for reimbursement in 24 months, hurdle is too high, experience in effectively using these systems too low. More likely to meet criteria in 36 months.” Hmmm, might the regional extension centers provide assistance here? Oh, that’s right, these are not in place yet either. Train wreck coming?
Cutler: “Underwhelmed by the healthcare industry’s adoption of best practices from other industries.” I share this belief despite all the calls from healthcare stating, but we are different. Complete BS and there are some forward thinking individuals in healthcare who are, for example, adopting lean and six sigma – hat’s off to them.
Jha and Halamka: Both see tremendous value in HIT as it relates to quality and comparative effectiveness research. Big issue here is that few if any EHRs in the market today are structured to collect, analyze and report on such metrics.
Bell: “There has been plenty of talk on HIT standards but woefully little on implementation guidance, i.e., how to bring data in, incorporate it into workflow, make it actionable and facilitate efficiencies in care.” Amen.
Consumer Empowerment through HIT:
While I would love nothing more than to provide a complete report on this portion of the event, unfortunately I was moderating the panel and thus, did not take notes. But I will report on what Adam Bosworth had to say as well as some results of a quick survey I did of the audience.
Adam Bosworth, formerly head of Google Health’s initiative and now launching his start-up, Keas gave the afternoon keynote. Drawing from personal experience (health), IT knowledge (one of the original developers of XML), and the healthcare sector, Bosworth gave a wide ranging talk about the challenges this country faces (declining number of primary care docs, tripling of obesity in 20yrs, healthcare costs projected to hit $3.4T by 2013, etc.). A couple of key points Bosworth’s made:
There is no demand for EHRs, demand today is artificially derived through incentives. Today’s EHRs are not easy to use, are not intuitive and there has yet to be a proven and repeatable model for ROI.
In every industry there are methods for direct data transfer between entities. There are no “regional exchanges” to assist with data transfer so why are we focusing on building regional HIEs? In healthcare if doctors could only have access to two things, they would choose labs and meds. Bosworth claims that between SureScripts, LabCore and Quest, we have those basic needs met. Not so sure about that as hospitals still perform a lot of tests themselves and I don’t believe SureScripts handles all classes of medications.
Before the afternoon panel formerly began, I asked the audience of about 100 a few questions, here are the responses:
Q: How many have used the Internet to conduct a health related search in the last year?
A: 99% answered yes.
Q: How many have a smartphone?
A: About 50% of audience use a smartphone.
Q: Of those with a smartphone, how many have a health related app on their phone?
A: About 65% have a health-related app installed.
Q: How many found their current doctor online?
A: About 25% of the audience.
This last question and answer was the most shocking to me. Yes, it was a self-selected crowd. Yes, the audience had a significant number of young people (~50%) as many grad students were in attendance. But still, nearly 50% of this demographic finding their doctor online – WOW! Get a clue doctors, this is the next generation of highly educated digital natives. This is the future and it won’t be too long until this generation will begin raising families and they have very high expectations as to how they expect you to interact with them. I’ll give you a hint, it ain’t paper, it ain’t a fax and it ain’t a phone call.
The organizers of this event did a fabulous job of bringing together some very diverse views and perspectives on healthcare IT, not an easy thing to do and the results were thought-provoking, enlightening but also showed the large riff between what are two nearly diametrically opposing views on healthcare IT policy. On one side you have the status quo, or at least that is how it appears, of driving physician adoption of HIT, a model that can be argued is based on a premise of the provider remains in the driver’s seat. It represents the legacy, provider-centric model of care.
On the other side, you have those arguing that where we really need to invest is in consumer engagement insuring that the consumer is the end beneficiary of healthcare IT investments, thus a consumer/patient-centric model of care. In this vein, investment needs to be directed at new tools that allow for more proactive and productive engagement and communication between physician, patient and community in support of care.
Ultimately, the market will decide but in the meantime, we taxpayers may end up wasting a lot of Stimulus dollars on a program that is forcing systems on clinicians rather than letting the market push from the ground up. It is quite clear from that little survey I did of this audience that change is occurring and this change will accelerate with or without Stimulus dollars.