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Health IT Initiatives: Not Magical, Just Practical

August 19th, 2008

Editor’s Note: Mark Leavitt’s post below is the first in a series concerning the package of articles on health IT published today on the Health Affairs Web site. Additional posts include tech guru Esther Dyson and consumer advocate Nancy Davenport-Ennis. In the lead article, the Markle Foundation’s Carol Diamond and New York University’s Clay Shirky argue that, if we are to unlock the potential of information technology (IT), we need to expand beyond narrowly focused standard setting. Health Affairs also published two Perspectives on this article, by Robert Kolodner, the national coordinator for health IT, and coauthors; and by David Kibbe of the American Academy of Family Physicians and Curtis McLaughlin of the University of North Carolina.

In their Health Affairs paper, Carol Diamond and Clay Shirky caution health information technology (IT) proponents against “magical thinking” — the belief that technology alone can transform a broken health care system. They urge an alternative route that “sets all of its sights on the crucial destination,” with integrated work on policy and incentives.

Regarding their call for technology and policy to evolve hand in hand, I wholeheartedly agree — in fact, I’ve described health IT and health care transformation as “the twins separated at birth.” Neither one alone can achieve a complete success without the other. But I don’t concur with their paper’s dim assessment of what has been accomplished in the past four years. From my perspective, there has been remarkable progress in that period, much more than we saw in the preceding four — or even fourteen — years.

What is a realistic four-year goal?

Health care represents a $2 trillion economic complex, developed over decades. Although it encompasses some of our best technology and many of our most dedicated workers, it also includes some very inefficient and wasteful processes. Diamond and Shirky’s “magical thinking” label would be well applied to anyone who claimed the ability to accomplish a significant transformation of this behemoth within four years.

Rather than magical thinking, I think the health IT initiatives represent eminently practical thinking. The strategy is pragmatic: what tools and points of leverage do we have, and what can we realistically accomplish with those in a short time? While there may have been some missteps and dead ends as we felt our way along, there are also notable successes — not just in the technology arena, but also in the policy realm. The Certification Commission for Healthcare Information Technology (CCHIT), for which I serve as chair, has been monitoring health IT adoption factors as part of its work, so I have data to support that statement.

Let’s look at the three major historic barriers to health IT adoption, and assess our collective progress in overcoming each of them over the past four years. I’ll offer my own one- to five-star box scores, but I would enjoy hearing others’ opinions as well via this blog.

Barrier #1: Awareness

Many observers report cost as the number one barrier to health IT adoption, but while it may represent the highest hurdle, it’s not the first stumbling block in the road. Before health professionals can even think about whether electronic health records (EHRs) make financial sense, they must become aware of the technology’s existence, see themselves as potential users, and finally embrace the potential for benefits.

Has progress been made in the past four years? I would say: an incredible amount, on all levels. Health IT has become a regular topic within the State of the Union address, we have a National Coordinator for Health IT and an associated office with numerous programs, and we have a secretary of health and human services (HHS) who leads a health IT advisory panel and actively promotes its benefits in his travels. Health IT is on the congressional agenda and has been included in bills proposed and legislation passed (the Medicare Improvement for Patients and Providers Act, or MIPPA, for example). We have multiple private- and public-sector organizations now dedicated to health IT progress, and the conversation reaches down to the grass-roots level as well. I subscribe to an electronic clipping service and receive five to ten articles per day just on the topic of EHRs and health IT. A few years ago, health IT development was so slow, it was adequately covered with an annual publication.

Addressing a concern raised by Diamond and Shirky, has this attention been unduly focused on technical standards, to the neglect of broader issues and policy? Reviewing the clippings from the past week, I see articles on EHRs, e-prescribing, privacy, value-based health care, health information exchange (HIE), health IT adoption, use of EHR data from research, and more. Technology and policy are integral to the wide-ranging dialog on health IT today. For a box score on raising health IT awareness, I say: five stars.

Barrier #2: Cost

The financial issues hindering health IT adoption are well known. The up-front capital cost is especially burdensome for small physician offices. Even if capital is available, the return on investment is not always sufficient, and it has been pointed out that most of the benefits may accrue to entities other than the provider buying an EHR system.

Although EHR costs may eventually come down as a result of competition and increased market volume, we have to do something more to jump-start adoption from its current low levels. Financial incentives or assistance is needed, and the most logical sources are the entities that should benefit from higher quality, safer, more efficient health care: purchasers and payers.

CCHIT has been researching health IT incentive programs in order to prepare a contractually required report, and we’ve been positively surprised by the number and extent available. We believe the extent of this activity has been underestimated because there has been no clearinghouse for the information. We hope to release a more complete report this fall, but here are some highlights:

  • The Centers for Medicare and Medicaid Services (CMS) EHR demonstration project includes incentives for EHR adoption, coupled with quality improvement, totaling some $150 million. While not every U.S. physician can participate, the number is substantial: 1,200 practices can receive up to $58,000 per physician or $290,000 per practice.
  • The Medicare Improvements for Patients and Providers Act (MIPPA) of July 2008 includes positive incentive payments for physicians who use e-prescribing technology. While the differential for using the technology is small (2%), it is available to almost all physicians. Health IT is also included in other Medicare quality measures, carrying additional bonuses.
  • We found state, regional, and local governmental programs in California, Colorado, Massachusetts, Michigan, Minnesota, New York, Vermont, and other areas, offering grants, loans, and other mechanisms of financial support for adoption of certified EHRs.
  • Private sector health plans are offering health IT financial incentives, including Hawaii Medical Service Association, Highmark in Pennsylvania, and CareFirst in the Maryland, D.C., Delaware, Virginia area.
  • A safe-harbor exemption from the Stark/Antikickback laws was established in 2006, permitting donation of certified EHRs to physicians by hospitals and other entities. Our research has found more than two dozen hospitals offering this option to their affiliated physicians. Many of these projects will make cost-reduced EHRs available to hundreds of physicians and represent well over a million dollars in potential cost savings.
  • Discounts are being offered on physician liability insurance to offices that implement certified EHRs. We are aware of four of these so far.

Bottom line? Incentives are coming from all directions — federal, state, local governments, health plans, hospitals, liability insurers — and we need a clearinghouse to track them. Almost all doctors are eligible for some incentives, and thousands of doctors are eligible for really substantial incentives. We’re continuing our research on this, but by my rough estimate, the total dollar value of these programs — resulting in EHR cost reductions — is in the hundreds of millions of dollars. While that will not buy every doctor a free EHR, I don’t believe we should be doing that anyway. Is it a credible jump start? Yes, and I think these results merit at least three out of five stars.

Barrier #3: Risk

Finally, even with the financial issue addressed, providers may still hesitate to adopt health IT because of perceived risks. Will the system perform the functions I need? Will it be compatible with other systems I own, with my hospital, with colleagues across town, and with the emerging national network? Will it protect my patients’ privacy?

Risk reduction for those contemplating health IT adoption is one of the primary responsibilities of CCHIT. We measure our success along several dimensions.

Evidence of acceptance and trust by physicians is indicated by the fact that the major physician professional associations — representing pediatricians, family physicians, internists, emergency physicians, cardiologists, and more — have all endorsed the EHR certification process. These organizations also participate actively in CCHIT’s development work and assist with programs to encourage health IT adoption by members. We also have surveys showing awareness of health IT certification in more than 70% of physicians. In the hospital domain, a similar acceptance is shown by the support of professional associations including the American Health Information Management Association (AHIMA) and the Healthcare Information and Management Systems Society (HIMSS), active participation in our processes, and a survey showing 66% awareness of certification among hospital chief information officers (CIOs).

The impact of certification can also be measured by the degree to which it is sought by health IT vendors. In the ambulatory EHR market, 44% of vendors were certified in the first year, and in hospital EHRs the first-year figure was more than 60%. Collectively more than 150 products have been certified in the first two years, representing over 75% of the marketplace. Statistics also indicate that certification has provided a level playing field that encourages competition, with a diversity of large and small, newer and older companies participating.

Finally, to have a positive impact, health IT certification must have credibility, which results from broad participation by stakeholders and an open, transparent process. The level of volunteer engagement in CCHIT has grown each year, an excellent indicator of the vitality of the initiative. I’ll take this opportunity to thank them for all their hard work and dedication to this effort.

But there is still much to be done. We have really only begun to establish and certify compliance with standards to make systems interoperable. Besides previous requirements for laboratory results and e-prescribing, certification this year added the requirement to send and receive a clinical summary, the Continuity of Care Document. The standard was brand new, not yet tested in the field, and we found that it was not universally understood among EHR vendors. As Diamond and Shirky point out, there are things that must happen between the drafting of standards on paper and their wide acceptance. Expectations may have been raised too high about how quickly that can occur, so adjustments are being made. The American Health Information Community (AHIC) Successor organization has already recognized the need to have clear business cases to provide a motivation for standards adoption. I think there has been both essential learning and substantial progress made in reducing the risk of health IT, and I think those results rate four stars.

Summing Up

The health care industry has clearly expressed its position that government leadership is needed to break the health IT adoption deadlock. Federal leaders responded to that call, launching a number of initiatives that, although not flawless, have in my opinion achieved real and remarkable progress. This election year, with an upcoming transition of the administration, represents a critical juncture. Cynics would seize upon any loss of continuity, questioning the government’s long-term commitment to health IT leadership. Now is the time to build upon, refine, and strengthen our collaborative efforts to accelerate the adoption of health IT and bring the benefits of higher-quality, safer, and more accessible and efficient health care to all.

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3 Trackbacks for “Health IT Initiatives: Not Magical, Just Practical”

  1. Debate on Feds HIT Policies Continues « Chilmark Research
    August 25th, 2008 at 6:06 pm
  2. Health Affairs Blog: Mark Leavitt “not magical just practical” | Ted Eytan, MD
    August 22nd, 2008 at 10:15 am
  3. » Health IT Initiatives: Not Magical, Just Practical
    August 19th, 2008 at 1:24 pm

5 Responses to “Health IT Initiatives: Not Magical, Just Practical”

  1. acavale Says:

    First of all, let me celebrate this landmark moment in HealthAffairs Blog history. This is the first time (to my knowledge) where the blog originator has responded to the readers’ comments. So thank you, Mr. Leavitt. Even your namesake does not do this on his own blog!

    Coming back to reality, unfortunately, mere sympathy does not incentivise me to continue providing the type of care I provide. It is obvious to me that in order for any type of P4P program to succeed, the process of data collection must be simplified and the collection of data must not be the responsibility of the physician – this takes away the physician’s focus from providing high quality care to documenting care and collecting data (as has happened with current PQRI process). As far as private insurers voluntarily offering incentives for EHR use, I can say for sure that its untrue in our area – SE PA. I know that for a fact because of my inquiries over the past 3 years with all major carriers in our area. They do not even like to mention this in any discussion. But I will check out the website further. It would serve everybody if Mr. Leavitt could provide evidence as to how CMS selected the “small practices” for its EMR study; because I am on its list-serve, and I was not offered such an option. It appears to me that only those connected to large university-based/affiliated groups got the opportunity. If this was the case, I am afraid, it is going to be a short-lived effort. I hope I am wrong, for a change.

  2. Mark Leavitt Says:

    Responding to these comments:
    I sympathize with the challenges “acavale” has experienced as an early adopter, and the fact that he hasn’t himself seen an offer of bonuses from private or public insurers (although he did get a liability premium discount) for having an EHR. But the CMS experiment for large group practices he mentions is not their latest program — if fact, Medicare’s new program is focused ONLY on small practices, 2400 of them. From private payers, we have new survey data showing that over 25% of plans now offer EHR incentives (up from 12% a year ago) in their pay-for-performace programs. The problem is that busy doctors don’t have time to hunt down these incentive programs. We’re going to try to improve that situation by adding an easy-to-use incentive finder on our physician-focused website,

    I agree with “suehouck” who points out the gap between potential and reality in realizing EHR benefits. EHR software can and should get better, faster, and easier to use with time, and we also need more skilled implementation help. Also, we need all of our doctors and nurses to be using this technology during their training so the switchover won’t be so traumatic later. Some implementations still fail (which is certainly the case in her example of a 20% productivity drop a year after go-live), requiring re-examination of the whole picture: clinician leadership, adequate staff buy-in, workflow re-engineering, template and pick list set-up, etc.

    “johnrgraham” went right to the ‘elephant in the room’ question: Why does the doctor not face the right incentives? I believe the answer is because our payment system rewards volume; not quality, safety, or cost-effectiveness. Bonuses for Health IT aren’t bribes, they are just small examples of correct incentives within a larger dysfunctional system.

    I appreciate the dialog! Mark

  3. johnrgraham Says:

    If the doctors do not face the right incentives, then the Health IT agenda is missing the obvious question: Why does the doctor not face the right incentives? How is it that the doctor does not benefit from the adoption of Health IT? The doctor is the patient’s agent in the acqusition of appropriate health goods and services. If the doctor does not benefit from Health IT, then it is a waste of resources.

    For a third party to bribe a doctor to do something for which neither the doctor nor patient are willing to pay themselves, because the 3rd party believes it will improve health care, seems the height of fallacious central planning.

  4. suehouck Says:

    Having worked on a number of EHR (electronic health record) implementations as well as national IT collaboratives, I would concur with the box score of 5 on raising health IT awareness.
    That said, the Real World 101 of IT in the delivery of care leave much room for improvement. Many providers don’t record clinical data into discreet fields in the EHR, making data extraction no easier than with paper records. In addition, many providers don’t utillize their EHR’s coding module which enable more accurate coding for work done but often under coded, particularly in primary care. Per an excellent Oct 2005 Health Affairs regarding the ROI on EHR’s, 51.7% of total financial benefits were from increased coding levels.

    Steve Jobs and Apple has not developed an easy to use i-pod of EHRs, so learning curves are steep and useability a challenge with many sytems. A year after implementation, one client who’d put enormous resources into implementing a CCHIT certified system suffered from a 20% drop in physician productivity a year later.

  5. acavale Says:

    As a 6-year user of electronic records with a paperless office, I have to respectfully disagree with your optimistic observations about the health IT industry. I have been lucky that I found a willing and able IT partner to work with me over the past 4 years to help make our use of an EMR fairly successful and rewarding. However, no private insurer or Medicare has ever offered to provide any incentive or bonus to our small practice or to assist us in our efforts, contrary to your statements. Even the latest CMS experiment selected only large group practices and totally shunted out small practices (which still provide a majority of care to most communities). The only financial benefit (albeit small) is a 2.5% discount in my liability insurance premium this year. So it is time to stop the talk and walk the walk, as far as payers are concerned. While all the talk has been on how to incentivize new adopters of technology, there is no talk of similar programs to reward those who took the risk and emptied their own pockets voluntarily in such an endeavor years ago.

    One of the main obstacles to more IT adoptions by physicians stems from the unscruplous tactics adopted by most of the IT companies, and the absence of any standards regarding contractual obligations, reasonable charges for ongoing services, resolution of disputes without getting tied up with litigation, etc. Another major problem that we all face is complete lack of interest in collaboration from all other parties such as Surescripts, national laboratories, local hospitals, etc. Just like how small practices have no leverage with payers, similarly they have none with these organisations. Costs of interoperability should not be the physicians’. It is in the consumers’ (patients) interest that data be readily shared amongst various repositories. This is where governmental action will be beneficial.

    Finally, CMS and all payers must learn that 1-2 % bonus payments are nothing but an insult to physicians, who honestly strive every day to provide the highest quality care to their patients. Even a plumber will return such a paltry bonus payment. Besides, looking to add CPT-II codes while trying to help an ill individual, is not a natural process (assuming one can understand and implement the convoluted PQRI process). Start looking at the big picture, Mr. Leavitt and play ball with the small players as well. Who knows, you might find a lot more stars amongst this group. Look forward to your response.

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