Health should be at the heart of health IT

张琨

Health should be at the heart of health IT [1]


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