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The Glitch That Wasn’t

The Health IT industry is abuzz with a recent Wall Street Journal op-ed by Professor Stephen Soumerai of Harvard Medical School and Professor Ross Koppel of the University of Pennsylvania.   The opinion piece, “A Major Glitch for Digitized Health Care Records” (subscription required), transforms a timid literature review on the value of information technology for medication management into the final word on IT’s ability to deliver savings in healthcare.

The authors not only make sweeping pronouncements about the much-discussed ability of Electronic Health Records (EHR) to contain costs but go on to make equally questionable claims such as that the Meaningful Use program will cost $1 trillion – a figure they attribute to “installation, training and maintenance costs.” They also contend that the effort to share patient records between organizations has already been proven a failure, even as the industry is gearing up to meet the Stage 2 requirements of the Meaningful Use EHR Incentive Program.   

Given that Soumerai and Koppel have published numerous papers and articles questioning everything from the functionality to the safety and efficiency of EHRs (as Health Data Management’s Joe Godert points out), it’s enough to make you wonder whether their attack on the Meaningful Use program is motivated by more than academic interest. Really, they seem to have a bit of an axe to grind, judging not only by the WSJ piece but also their heated response to a recent New England Journal of Medicine study that found EHRs improved diabetes care (Soumerai and Koppel’s critique was refuted by the study’s authors).  

In a response to the WSJ op-ed, Ashish Jha, M.D., Professor of Health Policy and Management at the Harvard School of Public Health, argues that the study at the heart of the op-ed simply asked the wrong questions and wasn’t framed appropriately.  I agree. 

There are four factors that I think are critical to understanding this issue:

  1. Fundamental payment and delivery system reforms are needed to motivate physicians to worry about the cost of care.  In today’s fee-for-service system, more care equals more dollars to their bottom line, and the use of an EHR in and of itself certainly isn’t going to fix this inherent flaw in our healthcare system.  In fact, my own physician told me earlier this week in the middle of a combined exam and discussion of health policy (the hazards of having me for a patient) that she explicitly tries not to think about or even be aware of the cost of the care she’s delivering because she doesn’t want that to influence her decision.  She meant it in a positive way – that she didn’t want to hold back on care just because of the cost – but it could also be seen as a negative because it means she isn’t mindful of unnecessary costs, either. In any case, I’d like to imagine that Professors Soumerai, Koppel and their academic brethren would see the value in devoting their talents to aiding the much-needed transformation of the U.S. healthcare system so that healthcare providers are motivated by both quality and cost.  
  2. While numerous studies demonstrate the benefits of EHR, it’s clear that the promised cost-savings cannot be fully achieved until data exchange and care coordination are mature enough to enable providers to reduce duplicate tests and other sources of waste. Unfortunately, the infrastructure for that information exchange is not yet in place on a wide scale, nor is the Direct Project widely utilized.  Not to mention the challenges with governance that are obstructing information exchange even where the functionality exists in a given community.
  3. Relative to interoperability, the vendor community has been requesting clearer, more stringent information exchange standards for literally years.  For proof, just read our public comments submitted on pretty much any regulation.  We have consistently requested standards so that the work of building an interoperable, connected community of health can be completed and patient data can begin to flow. 
  4. Most importantly, the vast majority of data the study’s authors reviewed were pre-Meaningful Use.  I can’t really imagine why anyone assessing the value or efficacy of EHRs would look back to 1972 because the reality is that the health information technology industry today is hardly recognizable from the one that existed even one decade ago, much less 40 years.  It’s almost like gauging the success of the Internet or its value to untold constituencies based on an evaluation of ARPANET or the state of TCP/IP in 1988.

Now, I know there are people out there who will discount what I say here because I work for a software vendor.  So, I’ll let someone with credentials more impressive than mine – Dr. Jha at Harvard – close it out. 

Dr. Jha suggests that the right question to ask at this stage in the dissemination of EHRs is not “Do EHRs save money,” but rather “How do we ensure that EHRs help improve quality and reduce healthcare costs?”

He goes on to write: “Now that we have made an important investment in EHRs, we need to figure out how to use this new technology to address the fact that the healthcare system is a mess.  We need to figure out how EHRs can promote coordination of care across sites, seamless flow of good clinical information, and smart analytics, to name a few things.  We simply can’t do that in a paper-based world. . . . The debate over whether we should have EHRs is over.” 

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