Saturday, December 06, 2008

Health Information Technology: Past Predictions, Current Reality, and Future Potential - Part 2 of 3

In my previous post, I discussed the great promise of health information technology (HIT), and explained why its actual economic and quality improvement benefits over the past five years have been disappointing. I will now examine several other reasons why HIT has not realized its potential: Low adoption rates, the double-edged sword of standards, and lack of a big picture blueprint.

Low Adoption Rates

Few providers have adopted HIT, and only a meager 2% of the healthcare industry's gross revenues is being spent on HIT. Although the adoption rate numbers can be confusing—since there are different rates for large organizations and small practices, by physician specialty [Reference];and since studies may combine EMRs, EHRs and computerized physician order entry systems (CPOEs) in different ways—the rate of HIT adoption is clearly low. Consider the following findings cited in the CBO report, which are from studies done between 2006-7:

  • HIT was used in about 12% of physicians and 11% of hospitals
  • 24% of office-based physicians used an EHR, with adoption rates of 16% for small offices and 39% for large ones
  • 12.4% of nonfederal office-based physicians used a comprehensive HIT system
  • 5% of hospitals used CPOE systems
  • 11% of nonfederal hospitals had fully implemented EHRs, which were more likely in large urban or teaching hospitals.

More recently, a 2008 national survey by the New England Journal of Medicine found that electronic records were used in less than 9% of small offices (those with one to three doctors), which comprises nearly half of the country's medical practices [Reference]. And market growth for EMRs in the near future is predicted to be slow [Reference].

When it comes to personal health records (PHRs), a 2007 report by Forrester research indicated that only 7 percent of consumers have used an insurer-based PHR; the reason: "34% of respondents said they do not trust the security of computer programs and 29% said they do not believe there is a significant benefit to maintaining a PHR" [Reference]. In another study done that same year, nearly two-thirds of adults were not familiar with PHRs [Reference].

Barriers to HIT Adoption

According to the RAND study cited earlier, barriers to wider adoption of HIT include:

  • High initial acquisition and implementation costs
  • Slow and uncertain financial payoffs for providers
  • Disruption of physician practices during implementation
  • Payment systems give most savings insurers and patients, while providers bare most adoption and care improvement costs.

Here's what the CBO report said about the primary barrier to HIT adoption: "How well health IT lives up to its potential depends in part on how effectively financial incentives can be realigned to encourage the optimal use of the technology's capabilities."

Without adequate benefits to providers and a sufficient rate of adoption, HIT cannot realize its potential. To make matters worse, there's a third reason HIT is failing to realize its potential: The mixed blessing of data and technology standards.

Standards: A Double-Edge Sword

Standards are models, principles, policies, or rules that provide an agreed-upon framework for doing and understanding things. The two most important types of standards for HIT are data and technology standards [Reference].

Data standards describe how health data are to be categorized and defined. They include terminology, care measurement, and care process standards:

  • Terminology standards include classifications and vocabularies that group together related terms so they can be more easily and consistently understood. Classifications arrange related terms for easy retrieval. Vocabularies use sets of specialized terms to facilitate communication by reducing ambiguity.
  • Care measurement and process standards, on the other hand, focus on diagnosing health problems, selecting and delivering treatments, and evaluating care performance and value.

Whereas data standards focus on making information understandable and useful to humans, technology standards—and messaging format standards in particular—focus on enabling the exchange of data (i.e., "transactions") from computer-to-computer across individuals and healthcare systems.

While such standards are no doubt important, they are a double-edged sword because:

  • Terminology standards are very difficult to agree on in healthcare since, for example, there are 126 ways to say "high blood pressure." And although setting an arbitrary standard for health-related terms is a way to foster widespread communications (e.g., by using the term "hypertension" to refer to all forms of high blood pressure), such standards force information loss due to "reduced semantic precision and nuance." Said another way, there are good reasons to have multiple ways of saying high blood pressure. For example, malignant hypertension refers to very high blood pressure with swelling of the optic nerve behind the eye, which is usually accompanied by other organ damage like heart failure, kidney failure, and hypertensive encephalopathy. Pregnancy-induced hypertension, on the other hand, is a pregnancy-induced form of high blood pressure (also called toxemia or preeclampsia). Referring to a patient's condition using only the standard term, "hypertension," while clearly conveying that the person has high blood pressure, looses these important details, which could very well affect treatment decisions and outcomes.

  • When it comes to care measurement and process standards, it is difficult to achieve wide-ranging and meaningful quality standards for every healthcare discipline. And even if you do, the standards should evolve continuously, changing as necessary to accommodate new knowledge. On top of that, there is often considerable external pressure from powerful groups with a vested interest in influencing the selection of the standards. Furthermore, simply maintaining nation-wide data standards is a slow and costly process.

  • In creating the technology messaging standards, the Healthcare Information Technology Standards Panel identified an initial set of 90 medical and technology standards, out of an original list of about 600, which included such things as how lab reports are to be exchanged electronically and entered into a patient's electronic record, as well as how past lab results are to be requested. More than 190 organizations-representing consumers, providers, government agencies, and standards development organizations-participating in the panel. Coming to a consensus was very difficult and fraught with politics involving intense negotiations and delicate compromises. And once such IT standards are set, software systems and databases must be designed to conform to those standards, even if there are more cost-effective alternatives [Reference].

So, the creation, maintenance, and use of HIT-related standards are additional sources of hassle and expense, which have been adversely affecting efforts to realize its potential.

Now here's a fourth reason for HIT's failure to achieve its potential: Lack of a big picture blueprint

No Big Picture Blueprint

Progress is being further stifled by the lack of comprehensive HIT blueprint. What is needed is a plan for designing a complete system, comprised of many different types of software tools, that enables the delivery of ever better and more affordable care by supporting collaborative knowledge-based efforts to increase positive quality, reduce costs, and protect populations.

Having examined why HIT's potential is not being realized, and discussed why has thus far failed to deliver strong ROI, my next post will focus on describing what has to be done to change things around in 2009 and beyond.

In my next post, I discuss what's needed in 2009 and beyond.


Anonymous said...

Form does indeed follow finance... as the CBO comments illustrate. I see the challenge with adoption of current HIT capabilities as one of bottom line efficacy. How will HIT help a solo FP or IM practice better medicine? More efficient, perhaps, but better? That's the challenge. It's the same challenge for hospitals - how will the EHR actually improve their quality at the single patient level? That's how hospitals live, one patient at at time.

The benefits of HIT come most measurably from global applications, but global applications are driven by local inputs. That becomes the Catch 22.

If all my care as a patient is based with one physician and one hospital, the quality of care improvement potential from HIT will be small and difficult to justify economically. Only when my care involves other parties, an ER visit, a first responder intervention, does the value, both economic and intrinsic, of the "electronic" file begin to be realized.

Dr. Steve Beller said...

The way HIT will make medicine (and non-medical) healthcare better at all levels of practice--from the hospital to the individual clinican's office--is by providing meaningful "consumer/patient cognitive support." Accomplishing this requires a new generation of HIT tools.

I discuss this issue at

Rajwant Sarkaria said...

Thank you so much Dr. Beller for giving all of this information.It's really useful.I'm a student of HIT.
Keep posting please.
Thanks once again! :)