HIT Apologia

by Greg Scandlen, NCPA, February 10, 2014

Health Affairs recently announced its top 15 articles for 2013, and has made them available to nonsubscribers.

The top article was by a pair of RAND researchers updating what is known about the health information technology (HIT) roll out from the 2009 HITECH law, appropriating $20 billion to upgrade information technology throughout the health care system.

It doesn’t take long ― like just the abstract ― to figure out that people haven’t learned a blessed thing from flushing $20 billion down the toilet. Here’s the complete abstract with my comments −

A team of RAND Corporation researchers projected in 2005 that rapid adoption of health information technology (IT) could save the United States more than $81 billion annually.

This original “study” was horrendously flawed. They deliberately chose (and said so) to ignore any contra information, basing their projections on a best possible scenario that couldn’t possibly come true in real life. In the latest report:

Seven years later the empirical data on the technology’s impact on health care efficiency and safety are mixed, and annual health care expenditures in the United States have grown by $800 billion.

They are still minimizing the evidence. There is plenty of evidence that the HIT adoption process has increased errors and slowed productivity. Rather than “mixed” the evidence is overwhelmingly negative. Again, from the latest report:

In our view, the disappointing performance of health IT to date can be largely attributed to several factors: sluggish adoption of health IT systems, coupled with the choice of systems that are neither interoperable nor easy to use; and the failure of health care providers and institutions to reengineer care processes to reap the full benefits of health IT.

They have it exactly backwards. Rather than reengineering clinical practice to suit the demands of IT, IT must be developed to enhance what is happening clinically. This is fundamental to any acceptance of IT. There is a reason programmers used terminology like “desktop”, “inbox” and “trash” in creating office systems. You have to start with what the users are familiar with doing and adopt your technology to their comfort zone. The problem with this whole top-down HIT enterprise is that they put IT engineers in charge instead of letting clinicians develop what would improve their operations:

We believe that the original promise of health IT can be met if the systems are redesigned to address these flaws by creating more-standardized systems that are easier to use, are truly interoperable, and afford patients more access to and control over their health data. Providers must do their part by reengineering care processes to take full advantage of efficiencies offered by health IT, in the context of redesigned payment models that favor value over volume.

NO! Start with making it work in the doctor’s office and THEN build interoperability. DO NOT standardize it from the start, but allow a variety of systems in real-life settings and see what works best and THEN move to standardization.

Now, it might surprise you to learn that abstracts rarely reflect what is actually in the paper. In fact, the abstract is typically written by the editors of the journal, not the authors of the article, and these editors often have an agenda of their own. People who confine their reading to abstracts are doomed to be misinformed.

So, let’s look a little more closely at the article itself.

After a bit of tap dancing around the issue, the authors of this article, Arthur Kellerman and Spencer Jones, tell us −

…[I]t needs to be noted that the (original RAND) researchers attached the following caveats to their analysis early in their article: “Here we summarize the methodologies we used to estimate the current adoption of [electronic medical record] systems and the potential savings, costs, and health and safety benefits. We use the word potential to mean ‘assuming that interconnected and interoperable [electronic medical record] systems are adopted widely and used effectively.’ Thus, our estimates of potential savings are not predictions of what will happen but of what could happen with HIT and appropriate changes in health care.”

So, the original estimates on how well HIT will work are based on the assumption that HIT will work well (be widely adopted and used effectively). It’s not their fault that the health care system did not find all this attractive — even though virtually all the evidence in existence at the time predicted exactly that.

And, sure enough, the new article ticks off the failures one by one:

• Are modern health IT systems inter-connected and interoperable? The answer to this question, quite clearly, is no.
• Are modern health IT systems widely adopted? The answer here is no as well.
• Are modern health IT systems used effectively? Again, the answer is no.
• Has appropriate change in health care been made? Sadly, the answer here is no.

The authors explain a bit of this by writing:

Considering the theoretical benefits of health IT, it is remarkable how few fans it has among health care professionals. The lack of enthusiasm might be attributed, in part, to the sobering results of studies showing that in many cases health IT has failed to deliver promised gains in productivity and patient safety. An even more plausible cause for providers’ lack of enthusiasm is that few health IT vendors make products that are easy to use. As a result, many doctors and nurses complain that health IT systems slow them down.

Nonetheless, these writers continue to insist it is not the fault of the IT industry or the government, but of those damned providers who fail to “reengineer existing processes of care to take full advantage of the efficiencies offered by health IT.” So, doctors should practice medicine the way the IT people tell them to instead of having the IT people work to help the people who actually provide the care.

There was nothing wrong with RAND’s initial analysis, they write. The analysis would have worked out fine if the vendors and providers had fewer “shortcomings” −

The optimistic predictions of Hillestad and colleagues in their 2005 analysis of the potential benefits of health IT have not yet come to pass. This is not because of shortcomings in their analysis but rather because of shortcomings in the design, implementation, and use of health IT in the United States. When the preconditions these authors posited are finally realized, the benefits they predicted will be realized as well.

And we would all live in Paradise if only we had fewer shortcomings.

- See more at: http://healthblog.ncpa.org/hit-apologia/#sthash.mndLFGsk.dpuf