Consensus from Contradiction: An Emerging Case for Healthcare Payment Reform plus Health IT

 

The verdict on the value of health IT has always been divided and increased attention to the issue has done little to narrow that divide.  Indeed, the entrance of a new administration committed to including health IT in its healthcare agenda has produced a near daily barrage of reports and commentary on the value of health IT – with their verdicts increasingly disparate.

 

How should the Obama administration read this “scatter-gram” of recommendations? Should it conclude that health IT is so immature and unreliable that each study has legitimately arrived at a very different conclusion? Should President Obama modify his vision of moving all Americans to electronic health records from a horizon of 5 years to something considerably longer?

 

I think not. I believe that a careful read and “read between the lines” of most studies reveal these common threads:

·         Health IT is not fully mature, and does not yet contain all of the features that are necessary for it to serve as the infrastructure of 21^st century healthcare; however, it is mature enough in most settings for use today;

·         Health IT per se is quality, safety, and effectiveness neutral and in some settings will show worsening of care, in some will show no effect, and in some will show improvements to care;

·         Adoption of health IT alone will not and cannot result in healthcare reform; however meaningful healthcare reform is not possible without near universal adoption of advanced health IT;

·         Health IT implemented in a dysfunctional and fragmented healthcare delivery and payment system will always show suboptimal and inconsistent results; this inconsistency will always be present, until the variables of healthcare processes and incentives are controlled;

·         Adoption of health IT without healthcare delivery and payment reform is not enough and all but guarantees that the time, effort, and dollars expended will disappoint the IT purchasers. It will certainly not give patients what they need and deserve – which is a better, safer, and more value-laden healthcare system.

Not all electronic health records (EHRs) are alike, some are much better than others, and none are fully mature.  That said, does that mean that the better EHRs do not provide value now, or that any EHR can’t be modified or enhanced to result in further value? Even less-than-fully-functional EHRs can and do produce improvements in care.   In fact, there is evidence to suggest that even mediocre health IT can lead to care improvement, when implemented well and implemented in a “defragmented” care delivery environment. That does not mean that health IT shouldn’t be improved, of course it should. However, policy makers need to be aware, as I believe the Obama team is, that improved health IT without dedicating resources to an expansion of trained informaticists and implementers will lead to less than ideal results.

 

The question of why health IT is not more mature is contentious, with some blaming vendors and others faulting the core technology. In my view the answer is neither, but rather lack of a demand. As someone who has  encouraged vendors to develop more advanced EHRs that help to facilitate care coordination, proactive care, and non-visit based care, the response has been consistent and predictable, “… aside from you, who else would buy it?” And, “…doctors are already complaining about how difficult it is to use an EHR. You are suggesting we make it even harder.”  I can’t disagree; without a sustainable business case for health information management and quality (meaning that a significant percentage of physician income is based on management and quality) physicians are not looking for these features, and vendors will not build them. Contrast that with coding support for billing, a feature that is entirely without value to patient care and quality, but built into almost every EHR.

 

Even if health IT were fully mature, it is at best an enabling infrastructure. It can do no more than support the business processes of the health system.  If the healthcare system contains fully aligned incentives such that all participants “do well by doing good,” health IT may fully realize its potential. If however, health IT is implemented in the context of the misaligned US healthcare system where “efficiency” for one stakeholder means built-in inefficiency for others, and where providing the most cost effective treatment is not a goal shared by all stakeholders – then we all but guarantee that the integration of health IT will not be fully optimal.

 

Policymakers tend to have it backwards. For example, former Senator Bill Frist (R-Tenn.) gave a keynote address at a major health IT conference during which he showed a very effective graphical representation of our fragmented healthcare system. Instead of then setting out a plan for fixing it, he turned to the audience of many thousands of IT professionals, and explained that health IT will unscramble and defragment healthcare. That is not possible as health IT is not magic.  Simply digitizing our existing system no matter how sophisticated the technology, will just make bad and/or competing processes happen more quickly. To see mediocre or hopefully better health IT optimize quality, safety, and effectiveness, health IT has to be implemented in a healthcare system that is far less broken than the one we have today.

 

Implementation of health IT can result in new or changed situations that call for new policy, but health IT adoption is obviously not synonymous with healthcare reform. We can have universal health IT adoption and still have the same dysfunctional healthcare system we have now. However, healthcare reform that is shaped around the Institute of Medicine’s laudable vision of 21^st century healthcare cannot be realized without widespread adoption of advanced health IT.

 

Not only have prior studies of health IT implementations shown suboptimal and inconsistent results, but all future studies will do the same– as long as the studies are conducted in an environment of fragmentation and reimbursement toxicity. A recent study from Texas looked at incremental value from health IT systems where the variable was not what health IT system was in place, but rather how much it was used. And to no one’s surprise, the more the advanced features of the system were used, the more care improvements were seen. 

 

The inherent value of health IT is to improve health information management and coordination. Translating this to provision of services, health IT can dramatically improve care coordination, chronic care management, proactive care, and non-visit based care (eCare). But, with the exception of demonstrations and pilot projects, none of these services are currently reimbursed.  Perversely, the more a physician uses a health IT system for optimal benefit, the worse the business case. For example, if my general internal medicine practice were to significantly reduce its volume of reimbursed office visits s in order to optimize time spent on unreimbursed care coordination, chronic care management, proactive care, and non-visit based care, we would go bankrupt in a matter of weeks.  Fix the misaligned reimbursement system, and even with our good (but not perfect) EHR, we could demonstrate consistently enhanced care delivery. 

Advanced health IT adoption is necessary but not sufficient for practicing higher quality and safer medicine. Advanced health IT is complex, expensive, and difficult to implement and maintain. The cost and pain of implementation are so great, that unless healthcare and payment reform are part of the broader agenda (though not necessarily simultaneous), health IT adoption is probably not worth doing.

 

While most readers are intently focused on the outcome of the economic stimulus / recovery package legislation (and where those billions of dollars are going), I would ask that we look instead toward where the new administration is going to take healthcare. Yes, dollars in the stimulus package are important, and can help to incent adoption of health IT and necessary infrastructure (such as broadband in rural areas); but whether or not that health IT is used to enhance care will be determined by what happens next.