When the panel on the future of Health IT at the AcademyHealth National Health Policy Conference began, I knew there would be a litany of hot-button issues that would be discussed. Meaningful use. Open notes. Improved inter-operability.
But, immediately, I was distracted by a memory that continues to strike me with particular poignancy. I was a medical student, shadowing an older, revered doctor. But, in my memory, he is not
Lisa Rosenbaum, MD, is a cardiologist and a Robert Wood Johnson Clinical Scholar in residence at the University of Pennsylvania.
the gentle, wise soul that you would trust to care for the person you love most. Instead, he is sweating, agitated and pounding on a keyboard with a single finger; he has uncharacteristically forgotten the patient sitting a few feet from him. What's his problem? He has been forced to use the Electronic Health Record (EHR) system.
EHR's threat? Perhaps my distress over this physician's struggle to deal with computers is slightly overblown, but my sense that our computer systems increasingly demand more attention than our patients has left me skeptical of the promises of the EHR. Decreased waste. Cost savings. Better patient safety. These potential benefits seem feasible in an abstract theoretical universe, where our policy discourse tends to occur. But I continue to worry that this intense focus on digitization threatens something fundamental to the practice of medicine.
That's why, when the HITECH act was passed in 2009, dedicating $27 billion to the widespread integration of health information technology, I raised my eyebrows. When the act was soon followed by urgent measures meant to motivate hospitals and clinicians to adopt the EHR, under the guise of "meaningful use criteria," I shook my head with disdain at the bureaucratic intrusion. And when physicians erupted with a collective groan, as money and time were poured into electronic health systems, none of which could talk to each other, (there are now more than 700 vendors who have created more than 1750 different products), I thought, "what a disaster."
RAND EHR cost study Not surprisingly, then, I felt vindicated, perhaps a touch smug, when recent data suggested that the empty promises were just that -- empty.
Photo: Hoag Levins
National Health IT Coordinator Farzad Mostashari was critical of press coverage about whether or not electronic health records actually lower health care costs.
First there was a Health Affairs piece suggesting that physicians order 40% more tests when they can view the results electronically. Then there was the perspective piece by Rand scientists Art Kellerman and Spencer Jones pointing out that the initial RAND Corporation projection, that adoption of Health IT could save the US $81 billion annually, had been unrealized, with the notable fact that annual health care expenditures have instead grown by $800 billion.
And then athenaHealth, whose own product is an EHR, announced that most of these tools increase the length of the doctor's day by about 18 percent. Finally, there were a series of articles, most in the lay press, suggesting that the presence of the EHR had enabled upcoding of clinical encounters, and consequent Medicare fraud.
Nevertheless, as I actually listened to the panelists, moderated by David Blumenthal speak, I realized I may have been too eager to drink the EHRs-have-failed Kool Aid.
Article controversy As Dr. Farzad Mostashari, who now heads the Office of the National Coordinator for Health Information Technology (ONC), fairly noted, "It's much easier to get an article published about how health IT has failed rather than how it has succeeded." But such efforts, he suggested, are not helpful. Indeed, it's not like we are suddenly going to return to paper records. So rather than pursuing what Mostashari calls, "uninflected stories" about health IT, such as, "'It works,' or 'It doesn't work,'" we should move beyond "whether" and instead figure out "how." So how can we make health IT work?
Consider for example, the experience of panelist Dr. Paul Tang, of the Palo Alto Medical Foundation (PAMF), who described the many successes of integrating HIT into practice. Patients are able to use the EHR to seek prescription refills, make appointments, view test results online, and, most notably, communicate with physicians and advice nurses. With three
Photo: Hoag Levins
Dr. Paul Tang said his Palo Alto Medical Foundation's metrics for diabetes treatment have been greatly improved by aggressive use of electronic record systems.
quarters of patients communicating with their physicians online, Tang pointed out that the Palo Alto clinic's metrics for diabetes and hypertension are far better than national average.
'Largely underappreciated' Of course, these performance metrics could have far more to do with the population served than the sophistication of the EHR. Furthermore, the PAMF, which adopted the EHR in 1999, has had far more time that the rest of the country to iron out the kinks. But this idea that "Patients everywhere will be able to get their own data and share it with whomever they want to share it with," is, as Mostashari points out, the next frontier of HIT dissemination. Nevertheless, Mostashari noted that this aspect of Health IT is "largely underappreciated" right now. But such under-appreciation just reinforces the need for careful research to figure out how to operationalize this unprecedented access to data.
To begin, what sort of systems do you establish to help patients understand their results? Is it possible that access to clinical information, often of uncertain significance, will lead to more testing? Are there more effective ways of engaging patients in managing conditions such as diabetes and hypertension through health IT? Who is responsible for dealing with a potentially constant stream of health information as patients more easily report measures such as their blood sugar and blood pressure to doctors at any time? Do we reimburse physicians for time spent online answering questions? And finally, how do you maintain privacy and security?
'The speed of trust' Well, As Mostashari notes, "Information moves at the speed of trust." And although my initial response was, "What a great line," before I started throwing the phrase into conversation, I had to admit I didn't exactly understand what he meant. Liberated, then, to invent my own meaning, the line has come to signify what I see as the fundamental IT challenge. Namely, does health IT build trust, or take it away?
As seems to be the case at PAMF, health IT has the potential to improve health outcomes, and foster better relationships between physicians and patients through an online community. But we have no idea what such digitization means for the patient/physician relationship on a larger scale. Indeed, consistently absent from these "meaningful use" conversations is the recognition that the full-fledged embrace of health IT may not only fall short in achieving its promised outcomes, but may also erode something fundamental to the practice of medicine along the way.
Fostering trust between patients and physicians, and trust in the security and accessibility of health-related information, need not be mutually exclusive ends. Indeed, with critical investigation, patience, and honesty, I think we could learn to use health IT in a way that frees us to spend more time practicing medicine in the manner of those we admire most. But if we are to achieve the promises of health IT, we must remember that trust is about far more than the flow of information.
