Raison d’Être

What is the purpose of health information technology? Why are we spending all these billions of dollars on this “thing” we struggle to understand, implement, and use? Is it achieving the goals of its purpose?

The French elaborated on the concept of “raison d’être,” suggesting that once the reason an object exists is defined, criteria to measure the object’s value can be developed and applied. Now that the Office of the National Coordinator for Health IT has finally released the definitions of “meaningful use,” it is worthwhile to step back and reexamine the reason health IT exists.

The raison d’être of health IT includes four key items: 1) enhance patient safety, 2) improve quality of care, 3) foster greater accessibility, and 4) facilitate a reduction in medical costs. In addition, all of these items must occur simultaneously and in cooperation with each other. There is no zero sum game in achieving these goals, as failure to advance one brings failure to all.

Considering the current state of healthcare delivery in the United States, the four aspects of raison d’être for health IT, as defined above, seem appropriate and timely. While our healthcare costs per capita are the highest in the world, we endure worse outcomes, poor accessibility to care, high rates of uninsured and under insured, and unacceptable levels of medical errors. Few can deny the poor value we obtain from the resources expended on care.

So how and when do reap these rewards of health IT? Those that embrace flexibility, creativity, and tenacity will be most successful.

Flexibility. Health IT is nothing more than a tool. It is how the person that wields that tool acts that delivers real value. We are at the stage where our understanding of the health IT tool is just beginning. Therefore, we must be flexible in how we use that tool, wielding it in different ways to discover how to achieve greater and greater value.

Creativity. It is not enough just to be flexible. Flexibility has value only when it is utilized by creativity, the development of new and innovative approaches to problems. Creativity is needed in the design of processes and workflows that utilize health IT tools in a flexible manner, allowing these new approaches to be tried, reworked, and reapplied. It allows for the evolution of the use of health IT.

Tenacity. Clinical care is complicated and uniquely personal. This latter characteristic separates the use of IT in the healthcare industry from its use in other markets. This personal, and therefore human, factor makes what is very complex even more so. The complexity requires a level of tenacity, “stick-to-it-iveness,” that can carry us through challenges, problems, and failures until we are able to get the technology, processes, and workflows blended synergistically together, delivering our expected benefits.

As we consider all that has occurred in the past year, including the raucous effort to reform healthcare, the $19+ billion earmarked for health IT, and the debate on meaningful use, we must remember our need to be flexible, creative, and tenacious. No single effort or event can make health IT valuable. Only through our dedicated work, application of our professionalism, and our keeping focused on the raison d’être can we achieve the benefits we seek from health IT.

Excerpts from: – Raison d’Être, PSQH, January/February, 2010.

Photo Courtesy of  Don Guerwitz Phtography - Bathed in Light, Strasbourg, France.

Looking Back…and Looking Ahead…on the Progress of EHR Implementation

In the December 2010 issue of the HIMSS Digital Office, leaders in health information technology share their perspective on the progress of EMR adoption in 2009…and their vision for implementation of electronic health records in 2010. Barry P. Chaiken, MD, FHIMSS, HIMSS Chair shares his vision on adotpion below. This is reprinted from that publication.

What do you think is the greatest achievement in health IT in 2009?
Advances in technology just offer new tools, while advances in politics, represented by meaningful funding levels, provide momentum for real change. The billions of dollars provided to the Office of the National Coordinator for Health IT established the ONC as a true driver of advances in health IT use. The appointment of a healthcare policy expert David Blumenthal, MD, rather than an informaticist, signals that the Obama Administration is serious about promoting the use of health IT through policy changes that impact how healthcare is delivered in the United States. In addition, recruiting John Glaser, even on his current temporary basis, partners Dr. Blumenthal with one of the country’s leading health IT experts, Therefore, solidifying the funding of the ONC, and appointing Dr. Blumenthal and Mr. Glaser is 2009’s top health IT achievement that will positively impact the use of health IT to deliver safe, high quality and cost effective healthcare.

What would you like to see happen in 2010 to help move forward the adoption of electronic medical records?
When ATMs first appeared in the 1970s, interconnected financial networks did not exist. Customers of a bank could only use their ATM cards in machines provided by their bank. There was no ATM interoperability. The banks soon realized that providing ATM interoperability was considerably less expensive than installing proprietary ATM machines throughout the country. In addition, interoperability gave all banks a national, rather than regional, presence as customers could withdraw funds from any connected ATM. To advance the adoption of EMRs, information technology vendors must honestly embrace interoperability, building their systems to easily accept and exchange clinical data. True interoperability would provide clinicians with more complete patient records allowing for better quality care. Offering a more complete record that provides more value to the clinician strongly works to advance the adoption of health IT applications.

Photo Courtesy of  Don Guerwitz Phtography - Rooftop Statues, La Pedrera. Barcelona, Spain.

Hospital Computerization Not a Budget Saver, Concludes Study

By Joshua Feblowitz

The recent survey of over four thousand hospitals found no connection between computerization and reduced costs. In addition, increased computerization led to only small improvements in the quality of care.

Researchers found that more “wired” hospitals had higher total costs and more rapid cost increases. They also examined a list of the “100 Most Wired” hospitals and determined that these institutions had performed no better in terms of administrative expenses or quality of care.

These findings contradict previous anecdotal evidence indicating the benefits of healthcare information technology (IT), a category that includes systems such as electronic medical records and computerized order entry. The study has sparked significant controversy, in part because President Obama and others have widely promoted healthcare IT as a tool for saving money and improving healthcare. The 2009 stimulus bill included over $19 billion to encourage the adoption of healthcare technologies.

Using twenty-four different measures of hospital technology, researchers created a composite “computerization score” and compared this with changes in administrative costs and quality of care during the years 2003 to 2007. The only area in which they found significant improvement was in the quality of care for heart attacks.

“There’s no evidence that what we are doing is actually working,” says lead author Dr. David Himmelstein, a professor at Harvard Medical School, who calls promises of improved quality and reduced costs “propaganda of the healthcare IT industry.”

“It’s easier than saying what needs to be said,” Himmelstein argues. “We need to abolish the private health insurance industry. It’s much easier to say that there’s a silver bullet here, and all we need to do is install these fancy machines.”

However, these results, experts say, are far from definitive. Certain hospital computer systems have proven to yield substantial benefits. Computerized physician order entry, for example, a technology used to enter prescriptions and order tests, has been shown to greatly improve the quality of care. Even things as simple as adding barcodes to medications can dramatically reduce medical errors, says Dr. Barry Chaiken, chair of the Health Information Management Systems Society.

These types of improvements in quality are well documented. A study at Brigham & Women’s Hospital in Boston, Massachusetts, showed that computerized order entry systems could reduce serious errors by up to 55 percent and the overall error rate by over 80 percent.

Computerization accomplishes these improvements, experts argue, by giving hospitals the ability to manage information more efficiently. “When a facility installs software, they are looking for something that gives them better control over the chaos in their department,” says Keith Herron, representative for Patient Care Technology Systems, a healthcare IT company. “They also want to be able to document the patient encounter and document more fully.”

“If your physician has more information about your health, they are likely to make better decisions,” says Dr. Ashish Jha, professor at Harvard Medical School. “In a paper-based world, important pieces of information are often missing. Mistakes aren’t caught as easily. There are many ways in which technology if designed and implemented effectively can improve quality.”

Experts also criticize the study’s methods of examining hospital computerization. “This study is very problematic because both their measures of cost and their measures of technology have serious limitations,” says Jha.

“If you look at something and don’t find it, it could be that there’s no effect,” Jha continues, “Or, it could be that the way you looked at it didn’t make sense.” Specifically, Jha notes that the study’s “computerization score” included factors unrelated to patient care, such as accounting and staff scheduling.

Jha also says that the study’s measures of costs and quality are very broad and may not accurately reflect the benefits of healthcare information technology. Data on computerization was reported by hospitals and collected by the Health Information Management Systems Society. Researchers compiled this data into their own composite scores of quality, costs and computerization before performing statistical analysis.

Others suggest the reason for these findings is that current hospital systems simply aren’t very advanced. Although many hospitals spend a great deal on information technology, says Dr. Robert Kolodner, former National Coordinator for Healthcare IT, the number of hospitals with sophisticated electronic health records is “vanishingly small,” less than two percent.

“They are using the best data they have,” agrees Chaiken. “But I don’t think we’ve reached a tipping point as to what healthcare IT can do.”

In addition, experts say, healthcare IT is only beneficial if applied in the correct way. “It all comes down to how you implement these systems,” says Dr. Adam Wright, co-author of the study, “It’s not the technical quality of the system that you purchase but the way you use it.”

In order to benefit from these technologies, says Dr. Michael Siegel, head of the Digital Health group at MIT, we must accept new approaches to healthcare. “We’re managing the process, moving at incredible speeds, as if things were still the same. There has been lots research done that when you introduce IT and don’t change what you’re doing, it doesn’t help.”

“I would call for some patience,” says Wright, who likens the process of development to the construction of the Transcontinental Railroad. “Imagine you’re building a railroad. Laying tracks across the country. It’s very boring and very expensive. And until you hammer in the Golden Spike, you can’t actually drive a train across the country.”

Reprinted from Scope, December, 2009.

Photo Courtesy of  Don Guerwitz Phtography - La Pedrera. Barcelona, Spain.

Making Meaningful Use Meaningful

A short three years ago, the Office of the National Coordinator for Health Information Technology (ONC) was funded at a level of less than $150 million. Today, thanks to the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH)—part of the American Recovery and Reinvestment Act (ARRA)—the ONC received a budget of over $2 billion. In addition, no less than an additional $19 billion is set aside to facilitate the adoption of electronic medical records over the next decade.

For both industry and government, budgets provide a more reliable picture of strategy than do policy statements. Therefore, there is little doubt that the current administration expects health information technology to play an important role in reducing healthcare costs while improving quality, safety, and access, a high priority of the president.

To accomplish this goal, adoption of technology is not enough. These new tools must be utilized effectively to achieve desirable and measureable results. Therefore, almost all of the incentive funding available to providers for the adoption of health information technology is tied to the “meaningful use” of that technology.

So what is “meaningful use?” Perhaps former Supreme Court Justice Potter Stewart provides some guidance. In a 1964 opinion on an obscenity case (Jacobellis v. Ohio) the late Justice Stewart described hard-core pornography as follows:

“It is hard to define, but I know it when I see it”

In spite of the work performed by many ONC committees to date, many working in healthcare believe the ONC is taking the same approach to defining “meaningful use.”

To its credit, the ONC is working to offer providers a hard and fast definition of meaningful use backed up by exactly defined, collectable measures. By statute, the secretary of health and human services has until December 31, 2009, to issue an interim rule on meaningful use. As the rule must go out for comment for a minimum period of time, a final rule is not expected until late Q1, 2010.

Source: Making Meaningful Use “Meaningful” – PSQH, November/December, 2009

Photo Courtesy of  Don Guerwitz Phtography - Young Pioneers, Havana, Cuba.

HIMSS CEO Receives O Moore Medal

To honor his contribution to healthcare information technology, the Healthcare Informatics Society of Ireland awarded the prestigious O Moore Medal to H. Stephen Lieber, CEO and President of HIMSS. As current chair of the board of directors of HIMSS it was a fine moment for me, and I am sure the entire HIMSS organization, to see Steve recognized for his decade-plus long effort to promote the use of HIT to improve the quality, safety. and cost of healthcare delivery throughtout the world. Under Steve’s leadership, HIMSS has grown to more than 20,000 members from all parts of the globe with conferences held in North America, Asia, and the Middle East. At this critical time, Steve provides exceptional leadership to the healthcare arena.

Please take a moment to watch the presentation of the medal to Steve and his acceptance remarks (Dublin, Ireland, November 19, 2009).

Barry P. Chaiken, MD, FHIMSS

Is There Any Doubt It’s Broken?

What have we learned from the Massachusetts healthcare reform effort? Although costs to the state are running higher than anticipated - a problem in a recession – about 97% of MA residents enjoy some type of healthcare insurance. Considering the national rate is about 81%, this is a monumental achievement.

As for our lessons learned, the individual mandate is necessary to achieve universal coverage and the employer mandate helps get you there. 

Additionally, a competitor to the insurers must be established, whether a public option or a non-profit regional option, to incent the insurers to better manage costs.  Currently, these options do not exist in Massachusetts. The state now subsidizes healthcare insurance for those who cannot afford it by paying private insurers to cover these individuals.

Realistically, the Massachusetts reform plan is just a partial framework for what is needed nationally, not the entire plan. Any federal effort must be more broadly based and far reaching, something states, due to existing rules on trade, Medicare, and Medicaid, cannot achieve on their own. 

Success requires all stakeholders to sacrifice a bit of their pie or fiefdom. Right now that is not happening fast enough or in significant areas to deliver meaningful reform. For example, there is a good argument presented by physicians for tort reform, but there is little talk about linked changes in licensing that can help identify and retrain poor physicians.

The goal needs to be universal coverage. Actually, we have that already. Unfortunately, it is very inefficient and possibly the dumbest deployment of universal coverage possible. (See – Marking 33 Years of Universal Health Coverage) Although the uninsured eventually get care now, it is the rest of us through our insurance and taxes who pay for it indirectly. And for those unfortunate enough to get seriously ill, they often lose their homes and life savings. About 50% of all bankruptcies in the U.S. are related to medical bills.

How we get to universal coverage is through a holistic approach that addresses access, quality, and cost. Considering the number of powerful stakeholders – physicians, insurance companies, pharmaceutical companies, hospitals, and consumer groups - passing any meaningful legislation would be an amazing accomplishment.

Paying $7,300 per capita per year for healthcare is way too much considering the poor outcomes we get from spending all that money. Other countries pay less and receive more value. And if you want to make the argument that the U.S. healthcare system is better at this procedure or that treatment, considering we are spending at least 40% more than the other countries, we should be trouncing those other countries on all measures of quality, safety, and clinical outcomes. Sadly, we are not.

If George Steinbrenner expects the Yankees to win the World Series every year considering he spends 40% more than any other team on payroll, is it wrong for us to expect the same from our spending on healthcare? Should we not receive the best care in the world?

Anyone who thinks healthcare is not broken is not paying attention to the facts. How it gets fixed, is debatable. Whether it is broken, is not.

Photo Courtesy of  Don Guerwitz Phtography - Daycare Center, Havana, Cuba.

We Need Privacy Now

Does the Fourth Amendment apply to our medical data?

The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no warrants shall issue, but upon probable cause, supported by oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized.

According to a report by Milt Freudenheim in the New York Times (And you thought a Prescription Was Private, August 9, 2009), it sure doesn’t look like it.

More than two years ago (Patient Information: Who’s Your Daddy) I warned that for-profit entities might use private patient data to market products to consumers.

Patient data may be used to target relevant product ads to individuals based upon the data contained in the medical record.

Today, patient information is actively being used to target market products and services to patients. Large pharmacy chains such as CVS Caremark and Walgreens regularly utilize pharmacy information to identify patients to whom they send out email messages, coupons, and flyers. Although the data they utilize is de-identified, they employ reverse lookup utilities to reconstruct the information with patient identifiers.

At a meeting with several health information technology leaders at the HIMSS 2008 Annual Conference, Google’s CEO, Eric Schmidt, was cautioned about the use of patient data contained within Google Health. Although WebMD and Microsoft currently acknowledge the privacy rules outlined in ARRA apply to them, Google disagrees. Freudenheim quoted in his article a representative of Google who said:

Google is bound by the privacy policy that people agree to when they sign up.

WOW. To this day I still have not met anyone who reads those legal notices we all are asked to accept before using software or accessing certain websites. To rely on the acceptance of the privacy policy upon sign up as a defense for using patient information in any commercial way deemed appropriate seems weak and suggests exploitation.

Excerpts from: – We Need Privacy Now – PSQH, September/Ocotober, 2009

Photo Courtesy of  Don Guerwitz Phtography - Surprised! Stonetown, Zanzibar, Tanzania.

Following Lance’s Lead – No Cheating

Post Update: Here is the latest article in the NY Times describing Senator Grassley’s effort to address this issue. Senator Moves to Block Medical Ghostwriting

Haven’t we had enough of cheating? According to the NYTimes (Medical Papers by Ghostwriters Pushed Therapy, 8/5/09), medical journals published articles written by ghostwriters paid for by Wyeth, the pharmaceutical company, to promote the use of Wyeth’s hormone replacement therapy for women. Further independent studies showed that the therapy promoted by these biased ghostwriters was harmful to menopausal women increasing their risk of heart disease, cancer, and dementia. Perhaps industry influence on medical literature is much more widesperead than previously known.

The cycling world has been rocked with numerous scandals where cheating seemed more the norm than the exception. This year’s Tour de France ended clean, with Lance Armstrong leading the way with frequent but negative doping tests. Isn’t it about time we figure out how to stop the cheating in medical literature? Cheating in sports is , well, just cheating in sports. No lives are lost. Cheating in the medical literature harms people. There is no place for it in science and especially in medicine. So, let’s figure out how to put a stop to it.

The use of comparative effectiveness research to identify those procedures and treatments that produce the best outcomes depends upon honest, unbiased scientific study. The effective use of clinical information tehcnology, in turn, depends on the application of trusted clinical knoweldge. So, if we expect to transform healthcare to make it safer, higher quality, and more efficient, we better be sure that the science we apply is as close to the truth as we can make it.

About two years ago I wrote an article about cheating in the medical literature. It seems that nothing has changed in the intervening time.  Here is the link to Anti-doping of Clincial IT and below are excerpts from my article that appeared in the November/December 2006 issue of Patient Safety and Quality Healthcare.

“As doping is fundamentally contrary to the spirit of sport, dishonesty in research is contrary to the spirit of medical research. An “anti-doping” policy modeled loosely upon that created for sport by the World Anti-Doping Agency must be developed for clinical research published in peer review journals. Of course, clinical research and IT issues are far removed from the factors that impact sports, but the key tenets are the same: ethics, excellence, and fairness.

“The decade-long drop in crime in the United States, according to law enforcement officials, is due mostly to deterring crime rather than catching more criminals. To reduce the prevalence of cheating in research, journals require a powerful deterrence factor that motivates authors to police themselves. To be effective, this deterrence factor requires cooperation from the research institutions, as employers and supporters of these investigators. Any anti-doping research policy must allow researchers to maintain relationships with various funding sources and influential partners. At the same time, the policy must strongly motivate the researchers to accurately and fully disclose all conflicts of interest to journal editors, peer reviewers, and readers.”

Source: Anti-doping of Clinical IT – PSQH, November/December, 2006.

Pan-Mass Challenge 2009

I just completed my 2 day Pan-Mass Challenge, a 193 mile ride that raises money for the Dana-Farber Cancer Institute (Jimmy Fund) here in Boston. It is the single largest athletic fund-raising event in the world, raising more than $250 million dollars over the past 30 years. Below is my letter to my friends and colleagues. Please consider supporting me in this effort to eliminate cancer at www.pmc.chaiken.com. (UPDATE: Link to PMC Photos 2009.)

Dear Friends,

Carol’s gone. Just like Eddie, she could not beat the disease away. She was courageous until the end. She spent her last days in her home in Texas with many of her close friends visiting the weeks before she died. Everyone had a chance to say goodbye.

It’s been 25 years since my dad succumbed to cancer. He was brave too, never showing fear. A year after his death, in 1985, I rode my first PMC. The August 1-2 PMC is my 25th ride and one I am looking forward to as much as any of them. The PMC is my opportunity to engage in the fight against cancer while honoring my dad. I sure wish he was here to watch.

Over these years, I rode for friends, colleagues, and people I did not know. I hoped to offer them hope and comfort through my connection to the wonderful PMC family. Perhaps the knowledge that over 6,000 riders and volunteers really cared provided them with a bit of help as they went through one more day fighting cancer. This fight will forever be personal. It has touched my family too hard to ever be forgotten.

Thank you for being part of my PMC family and supporting me now and in years past. Without you, this ride is just 193 miles long. With you, it is a crusade, that we are winning, against a disease that hurts too many of us. Please consider boldly investing in the miracles that are unfolding today. Every single dollar (100%) of your PMC donation fights cancer. We raised more than $35,000,000 last year. I think we can do better. Times may be tough for us, but times are tougher for those who are fighting cancer. I need you, and those looking for hope need you.

See you on the road.

Barry

HIT Alone Not the Solution

In 1980 a Stanford University School of Business professor Alain Enthoven authored a book titled Health Plan: The Only Practical Solution to the Soaring Cost of Medical Care. Dr. Enthoven provided the theoretical underpinnings of managed competition, an approach to reducing healthcare costs embraced by the Clinton administration’s Task Force on National Health Care Reform. Chaired by the then first lady Hillary Rodham Clinton, the task force failed to convince Congress to pass comprehensive healthcare reform legislation. This unsuccessful “breakthrough solution” was just one of many proposed over the last 30 years to save our healthcare system from collapse.

On the first page of Enthoven’s book he wrote about the strain healthcare costs were putting on federal, state and local governments. He then addressed the private sector, particularly the automobile industry, where soaring health insurance costs were a difficult burden on employers. According to Enthoven, healthcare costs made up 6.2% of GDP in 1965 and ballooned to 9.1% in 1978. (1) Today, healthcare costs eat up over 16% of GDP. In the 27 years since Enthoven published his book the United States has seen little progress in controlling healthcare expenditures.

Although our healthcare system struggles with access, covering the uninsured, and medical errors, generally Americans receive pretty good healthcare, especially when their illness is not routine. Unfortunately, the resources currently required to provide that level of care are beginning to impact our standard of living and competitiveness in the world.

Unequivocally, healthcare information technology alone cannot solve the problems our nation faces in delivering high quality, affordable healthcare to all Americans.

A comprehensive approach to healthcare reform is necessary. Everyone, including physicians, nurses, patients, administrators, and insurers must work together to form the solution. Continuing to approach illness and deliver care the same way we have been doing for decades is sure folly.

Physicians and nurses must begin to see their responsibilities in a different light and begin to do their tasks differently. Administrators and insurers must assist and incent them. Patients must take responsibility for their care and work to prevent illness rather than wait passively for resource intense medical miracles to fix them.

Therapies need to be driven by science and rational thinking rather than habit and personal preference.

Healthcare information technology can provide some critical tools to achieve this necessary change, but those working within the healthcare system must employ these tools in different workflows and processes. Utilizing the tools to “automate” existing processes only works to continue delivering unacceptable outcomes.

If we want to truly address our problem of spiraling healthcare costs, it is time to get to work fostering the change management necessary to reform our healthcare system for the better. Otherwise, we will read Enthoven’s book a decade hence and realize nothing has changed except for the slogan.

Source: Healthcare IT: Slogan or Solution? – PSQH, January/February, 2008