The journal Health Affairs released yesterday three papers that address issues revolving around HIT adoption. Quick synopsis follows with my views in italics.
The first, by Carol Diamond (Markle Foundation) and Clay Shirky (Prof. at NYU) provides a thoughtful analysis on why the current government focus on standards and certification processes for HIT may be misguided and ultimately could hinder long-term adoption of HIT. Their argument is basically that current technology standards initiatives supported by the government are to prescriptive (limiting flexibility to respond to real market needs) while government policies addressing information use are sorely lacking.
Of the three papers, this one was by far my favorite. Thoughtful, well reasoned analysis that reflects many of my own beliefs. If you only have time to read only one, this is it. Where I do differ with the authors is their lack of attention to addressing the business case for HIT adoption. They touch upon it but do not drill down on it. This is the crux of the biscuit. Frankly, there are few incentives for any physician to adopt HIT (with the exception of revenue cycle mgmt), and plenty of disincentives not to. When there is a way for physicans to either clearly make money or save money via adoption of HIT, it will occur. Now what’s so hard about understanding that?
The second paper by HHS executive Robert Kolodner, et. al., attempts to defend the direction that has been taken at HHS to promote HIT adoption with an almost point-counterpoint style of writing in response to the Diamond-Shirky paper. Kolodner defends the direction that the government has taken stating that EMR adoption is accelerating as a result of government actions. He also goes on to state that information policies are very difficult to reach consensus on, a process that often lags advances in the technology itself.
This paper comes off as a defensive (not too surprising), though it begins by stating they fully agree with Diamond-Shirky that HIT will not solve the many ills that plague our healthcare system. Kolodner et. al., make several valid points where HHS initiatives have helped, but take far too much credit for EMR adoption. Little if any EMR adoption, to date, can be directly attributed to the feds, unless of course they paid for it in full through a grant. Rather, EMR adoption is occurring and accelerating for the simple reason that it makes economic sense for the adopting entity (and one can not ignore that part of that economic sense is that the solutions are getting cheaper and easier to deploy and support). Increasingly, physician practices of all sizes will have an economic justification for adopting HIT which has little to do with any government initiatives, except for that massive payer CMS, who has one hell of a carrot/stick to use if necessary. For example, the carrot today and the stick tomorrow for adopting eRx solutions that CMS has put in place. Next up, how about CMS reimbursement for eConsults?
And finally, I strongly disagree that information policies often move to slow in relation to technology advances. The trouble with this statement is that properly constructed policies, that provide frameworks (guardrails and sign posts) are useful and can be agreed upon without hindering technology development, adoption and use. Where we get in trouble is when we make such policies prescriptive.
The last paper by David Kibbe and Curtis McLaughlin takes a dig at the current processes and players that are recruited for various government led HIT initiatives. They argue that various committees, be they for standards or policies, are dominated by the old guard of the healthcare sector and fail to bring in outside players, such as new, Web-based solution providers. This has resulted in glacial, often reluctant advances in standards development, a continuation of the status quo and the lack of new perspectives/views to solve many of the seemingly intractable problems in the healthcare sector.
My least favorite of the three papers, this one is reminiscent of the many articles and papers I read in the late 90’s (the dot com era) where proponents loudly pontificated about how the Internet changes everything. For example, they state:
Over the past six years, expert panels and policy analysts have often ignored the analogy driving the public’s high expectations for health IT: namely, their experiences with Web-based applications in information-intensive activities such as banking, travel, finance, education, music, and interpersonal communication.
Simply ain’t so. Sure, there is a very small portion of the populace that may agree with the above statement and there have been plenty of public surveys that basically support this statement as well. But in my own informal discussions with consumers at almost every chance I get, very few really care – they simply are not engaged at the same level with the healthcare sector as they are with their music, their finances or their friends on Facebook. For most of us (the 80% that do not have a chronic health condition), healthcare is episodic, we worry about it when we have to and forget about it the rest of the time. This will change in time as the baby boomer generation moves into elder age and the multitude of health issues that will accompany them which they will need to manage, but it isn’t now (though we would be wise to prepare for it and Google, Microsoft and others are doing just that). The only exception to that statement is the increasing use of incentives by payers and employers to encourage healthy behaviors. But even here, there is most often a financial motive.
As in the case of Google, Microsoft and others, changes will occur when the end user sees value in that change. Quality, price and transparency, sure I’ll want to see that when I’m pulling out my credit card to purchase a healthcare service that is not covered. Ease of engagement with the healthcare system, yes I’ll want that to and my doctor better be prepared to work with me by communicating electronically. When healthcare stakeholders see more and more consumers like me, they will adopt the technologies necessary to engage me and retain me as their customer. It will be in their best financial interests to do so.
As I commented over on Matthew Holt’s blog (which by the way is where I first caught wind of these papers, thanks Matthew!), this whole problem of HIT adoption, value, standards, certifications, etc. can easily be boiled down into one simple thing, it is a supply chain problem. Suggest this industry start looking at manufacturing to better understand how they overcame many similar problems as well as where even in manufacturing, they still struggle today.