Step back from the details and what emerges is a huge challenge in innovation design. What role should government have? What is the right mix of top-down and bottom-up efforts? Driving change through the system will involve shifts in technology, economic incentives and the culture of health care.
“This is a big social project, not just a technical endeavor,” saysDr. David Blumenthal,the Obama administration’s national coordinator for health information technology.
This year is when the project really takes off. In the 2009 economic recovery package, the administration and Congress allocated billions— the current estimate is $27 billion— in incentives for doctors and hospitals to adopt electronic records.
Now, a new Congress with Republicans looking for budget cuts could take back the money. Legislation has been introduced by Representative Tom Latham, an Iowa Republican, to reclaim unspent stimulus dollars— and money for accelerating the adoption of electronic health records could be a target.
Still, steps to encourage adoption of computerized health records have had bipartisan support over the years, though only the Obama administration has pushed for big financing. Most health policy analysts say it is unlikely that the legislation will be overturned.
When well designed and wisely used, computerized records have proved valuable in improving care. Doctors have more complete information in treating patients, reducing the chances of medical errors and unneeded tests.
But the success stories to date have come mainly from large health care providers, like Kaiser Permanente, theMayo Clinicand a handful of others. Most physicians are in small practices, lacking the financial and technical support the big groups provide for their doctors. So it is scarcely surprising that less than 30 percent of physicians nationwide now use digital records.
Late last year, the administration, working with health professionals and the technology industry, set out a roadmap for what digital records should include and how they should be used, for doctors to qualify for incentive payments, typically up to $44,000. The program begins this year, and the requirements for using the records to report and share health information increase in stages through 2015. After that, penalty payments fromMedicareandMedicaidkick in for doctors who don’t meet the use and reporting rules.
The initial requirements to qualify for“meaningful use” are minimal, including being able to collect and electronically report basic information, likevaccinationsfor children or blood glucose levels fordiabetespatients.
The long-range vision is that computerized patient data is a step toward what health care specialists call a“learning health system.” That means data across populations of patients can be analyzed to find what treatments are most effective or to get early warnings on dangerous drug interactions.
“Islands” of such learning networks already exist, notes Charles P. Friedman, chief scientist in the federal health information technology office. By mining its patient data, Kaiser, for example, was first to identify a link between the pain-relief drugVioxxand a higher risk ofheart failure, well beforeMerckpulled the drug off the market in 2004.
Yet the road to a national computer-enabled learning system, specialists agree, promises to be long. A major obstacle is that so many doctors, especially in small practices, are leery of technology they see as needlessly hard to use and time-consuming.“Doctors don’t want to become clerks,” says Dr. Isaac Kohane, a health technology specialist at the Harvard Medical School.
And complex technology— designed for big health groups, not small practices— could well increase medical mistakes, specialists say.
Such issues, Dr. Blumenthal says, are a reason that the government’s standards, and perhaps even the timetable for adopting electronic health records, will evolve and remain flexible.
The government, he adds, is looking closely at safety and usability. Dr. Blumenthal’s office gave theInstitute of Medicinea grant of nearly $1 million for a yearlong study of electronic health records and patient safety. And his office is working with theNational Institute of Standards and Technologyto develop a“usability assessment tool” that can be used to evaluate the digital records offered by different companies.
Under Dr. Blumenthal, the office has tried to gradually build consensus on policy and technical standards rather than issuing edicts. However, the President’s Council of Advisors on Science and Technology, an independent group of academic and industry experts, saidin a reportlast December that the time had come for more“top-down design choices,” which it called“an appropriate government role” and one that“requires a more aggressive approach than has been taken in the early stages.”
THIS month, the health information technology office announced a step that showed its preferred approach to setting standards, one that borrowed from the Internet model of open-source software development in an initiative called the Direct Project.
Many companies and groups contributed to the government-endorsed Internet-based tools for exchanging health data among institutions. Developers wrote code and suggested ideas, and a consensus built around an approach that was selected by the government. The design was inspired by the Web, with its minimal specifications that leave ample room for innovation, says Dr. Douglas Fridsma, head of standards at the health technology office.
Without a brisk market in information exchange, the campaign to adopt electronic records cannot really pay off. And more is needed than data-sharing standards and privacy and security protections, Dr. Blumenthal says.
The incentives have to change as well. Two hospitals a few miles apart, he notes, do not now view themselves as allies, but as competitors. To a doctor or a hospital, a patient is, among other things, a financial asset— and holding a patient’s information is valuable.
Insurers, he suggests, will have to pay for providers to share data or penalize them if they don’t.“Information exchange has to be a business goal, rather than a competitive threat, for this to work,” he says.
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