By Anne-Marie J. Audet and David Blumenthal
In this week’s Annals of Internal Medicine, Catherine M. DesRoches of Mathematica Policy Research—and colleagues from The Commonwealth Fund, the Robert Wood Johnson Foundation, and the Mongan Institute for Health Policy at Massachusetts General Hospital— describe new findings from a 2012 national survey of physicians about their use of electronic health records (EHRs). The survey was conducted in the early phases of implementation of the HITECH program, which was a part of the 2009 stimulus package designed to promote the use of health information technology. The physicians were surveyed just one year into an evolving, multiyear initiative. Findings thus reflect work in progress. They may provide useful insights to guide implementation of the federal initiative. But the survey was conducted far too early in HITECH’s rollout to be used to judge the program’s ultimate success.
Nevertheless, debate about the success of the HITECH (Health Information Technology for Economic and Clinical Health) program is already animated, and the survey will undoubtedly play into ongoing disputes about the value of EHRs and the approach the federal government has taken to exploit their potential. Such discussions are inevitable and healthy in a program of this size and importance. However, the debate itself should not distract us from the larger issues at stake.
One reason our health care system is in crisis is that most doctors and hospitals collect and manage health information pretty much the way Hippocrates did 2,400 years ago. We have substituted paper for tablet and papyrus, but most everything else is the same. Yet, any clinician will tell you that they are only as good as the information they have about their patients when critical decisions are on the line. Fundamental health system reform will not occur until that information is liberated and circulated for widespread and effective use.
Such uses, by the way, go far beyond improving decisions about the care of individual patients, important as that is. Aggregated in various ways, health care data can be used to compare the performance of clinicians, hospitals, and health systems and, thereby, to hold them accountable for the cost and quality of care they provide. With proper privacy and security protections, that information can also support groundbreaking research to detect the value and risks of medications, the interactions between patients’ behavior and their health, and the comparative effectiveness of health care interventions.
Locked away in millions of tons of paper on the shelves of doctors' offices and in the basements of hospitals is a vital, untapped resource for improving the health and welfare of Americans. And there is only one way to mobilize that resource: to digitize it. And there is only one practical way to digitize it: by using EHRs, whatever their current deficiencies.
That is what the HITECH program is about: Getting these vast troves of unused information into digital form to enable the essential transformation of health care that cannot otherwise occur. The “meaningful use” program, as the new federal effort is known, offers extra payments to doctors and hospitals that participate in Medicare and Medicaid if they begin using electronic health records to improve the care they deliver. Those who don’t attain meaningful use by 2015 will face financial penalties. The cost of the program is estimated at up to $27 billion over 10 years, less than one-tenth of 1 percent of what the nation will spend on health care over that period.
The program has already had an impact. Between 2008 and 2012, the proportion of U.S. physicians with basic EHRs more than doubled, from 17 percent to 39.6 percent. U.S. Department of Health and Human Services Secretary Kathleen Sebelius announced that as of May 2013 more than half of all doctors and other eligible providers have received Medicare or Medicaid incentive payments for adopting or meaningfully using EHRs.
Perhaps the most important change has been psychological. The nation’s doctors increasingly accept that moving into the digital age is inevitable and essential.
But change is hard, and rapid change—no matter how essential—is almost always imperfect. As DesRoches and her colleagues demonstrate, physicians are just beginning to realize the potential of EHRs. In the first phases of adoption of most new technologies, users typically simply transpose the new tool into old workflows, which creates temporary inefficiencies until processes are reexamined and redesigned.
We saw this in the early 20th century when it took close to 20 years for manufacturers to understand how to realize the benefits of electricity. Initially, factories simply replaced the waterwheels and steam engines with new large electric motors but kept in place inefficient belt-and-pulley systems to transmit power from the central power source. Electricity’s potential was realized only after manufacturers totally reengineered factory processes and substituted many small motors throughout a factory so they could generate power where and when it was needed.
The survey results suggest that physicians are still using the EHR as the digital translation of the paper record, mostly to input data. The HITECH program is designed to move physicians and their records along a realistic and practical path to more and more powerful uses of EHRs, and the data they will store.
Given the scope and complexity of the effort, it’s no surprise the road to full digitalization is challenging. There is a lot of hard work involved—some accomplished, some ongoing, and more ahead. In the end the journey will be worth it.
Also read Electronic Health Records: Are We There Yet? What's Taking So Long by survey coauthor Mike Painter on the Robert Wood Johnson Foundation "Culture of Health Blog."