Change we can believe in. That is the motto used by current President Barack Obama during his 2008 presidential election campaign. As the debate on improving national healthcare continues, this motto bears much impact on the future of healthcare. Most surveys conclude that a majority of Americans desire true ‘change we can believe in’ when it comes to the overall healthcare status quo in this country. However, it is much harder, and ironic, to convince those within the industry to believe in, or embrace change. This is one of the issues at the forefront of health information technology, or HIT. There are many who are yet to believe that embracing HIT will make a significant difference in cost containment and in delivering improved health quality.
President Obama gave particular significance to HIT as a way to save money in the healthcare system when he included the topic in his speech to a special joint session of Congress. But can deploying a full and robust HIT program within the healthcare industry really make a difference? What are the apparent benefits and liabilities of deploying a HIT within the entire healthcare system? What stands in the way of HIT permeating the system? What are some examples of successful HIT implementation that could be replicated nationally?
After taking into account all of these important facets of HIT, I will propose the implementation of a new and affordable technology that enters the market in 2010. As well, I will discuss its ease of integration with an already emerging technology named ‘cloud computing’. I will describe how the convergence of these two technologies can break through the current barriers of HIT implementation, cut costs, and improve quality of delivered care. It is an ambitious but achievable plan.
HIT: An Overview
As trends and technology continually evolve, the healthcare industry must also evolve in its ways of creating, storing and sharing information. It is no secret that the current healthcare system is stuck in an outdated system of massive quantities of paper records within a system red tape that makes sharing and access tedious at best. When one pictures the current system, they see stacks and stacks of file folders in a doctor’s office, with decades of information stored in cardboard boxes stacked multiple stories high in warehouses all over the country. While the average individual can order just about anything online or Tweet how they feel within a second to everyone around the world, the current healthcare system still requires you to acquire paper prescriptions physically from your doctor, take them physically to a pharmacy, and then physically pick up the filled prescription.
When you want access to a doctor, you have to physically see them, and fill out paperwork. To access your own health records, you must physically visit a bureaucracy of records and again, fill out paperwork, to access them. Or, if you are in the hospital, and your doctor needs to see x-rays or other records of your history from the past twenty years, you have to have that doctor physically request the files and have them sent by fax, physically delivered by courier, or physically mailed. It is the equivalent of a comparison between email and the old pony express. It is a tedious realm that many are afraid to change, for fear of new technology, lack of incentive, legalities and cost.
Regardless of the obstacles, HIT is an inevitable necessity for the healthcare industry. There are four goals that make HIT necessary: 1) to advance health care quality, 2) to better assist patients with acute and chronic conditions, 3) to diminish disparities in treatment, and 4) to reduce medical errors. (Health Information Technology in the United States: The Information Base for Progress, 1:2) Prominent figures in power are starting to take note. As mentioned, President Obama gave significance to the need for HIT implementation and improvement in his speeches, and in his actions. According to a recent press release from National Health IT Week, the American Recovery and Reinvestment Act passed by Congress earlier this year “includes more than $20 billion to aid in the development of a robust IT infrastructure for healthcare and to assist providers and other entities in adopting and using health IT.” (National Health IT Week, Press Release, 2009) Even as the healthcare debates move forward, congressional leaders are also waking up. “Under the current paper system, when a person is traveling or in the case of emergency, doctors may not have immediate access to a patient’s paper medical records,” said Congressman Tim Murphy, PhD (R-PA), Co-Chair, 21st century Health Care Caucus. “Health IT brings the 18th century medical paper file system into 21st century medical care by providing crucial information in a secure and confidential manner in a matter of seconds.” (National Health IT Week, Press Release, 2009)
National health organizations are also beginning the push. According to a joint study put forth by the Institute for Health Policy, the George Washington University Medical Center and the Robert Wood Johnson Foundation, HIT “has the potential to advance health care quality by helping patients with acute and chronic conditions receive recommended care, diminishing disparities in treatment and reducing medical errors.” (Health Information Technology in the United States: The Information Base for Progress, 3). Finally, in a recent RAND study, it was determined that “properly implemented and widely adopted, Health Information Technology (HIT) would save money and significantly improve healthcare quality.” (“Health Information Technology: Can HIT Lower Costs and Improve Quality?”, 1)
The consensus between government and healthcare industry leaders is obvious. The implementation of HIT throughout the healthcare system would bring about cost savings and quality of care improvements. Given this, the consensus begs the following questions. Where is it? Why is it not already in place? Why are we still using outdated information methods and practices? This paper attempts to answer those questions and provide a potential breakthrough.
Obstacles in the implementation of HIT
Regardless of the overwhelming support and recent push for HIT implementation, it is proving difficult to achieve for a variety of reasons. A closer look at these obstacles reveals greater overall systemic problems of the U.S. healthcare system. With a disorganized and fragmented system currently in place in the U.S., deployment of any sort of HIT system would face many tedious obstacles. Here are a few these obstacles.
Productivity and Cost
Many argue that you cannot change the tires on a car that is racing down the track. This notion fits with the argument that trying to transition from traditional information recordkeeping to new HIT methods would cause a disruption in the industry. Providers would have to hire extra, specialized staff whose sole job would be to move information from paper to a digital medium. If they could not hire these additional staff members, they would have to re-purpose existing staff members to the task, which would disrupt their normal productivity levels with patient care. It may also cost providers additional money for training their staff on how to use new systems. Finally, it is perception, or belief, that stands in the way. Providers have to perceive and believe that they will benefit in the long run. There exists a “disconnect between who pays for HIT and who profits from HIT. Patients benefit from better health, and payors benefit from lower costs; however, providers pay in both higher costs to implement HIT and lower revenues after implementation.” (HIT: Can HIT Lower Costs and Improve Quality?, 3)
Current Market Conditions
Understanding the current market conditions helps for better understanding of why HIT has yet to take hold in a meaningful way. HIT has simply not permeated into the overall health community in a uniform and convincing way. It is sporadic at best. “Relatively few providers have access to HIT. Only about 20 to 25 percent of hospitals and 15 to 20 percent of physicians’ offices have a HIT system.” (HIT: Can HIT Lower Costs and Improve Quality?, 3) This erratic disbursement of HIT systems makes it even more difficult to determine who needs what and where, not to mention how to interconnect with what is already in place. Plus, many believe that the current disparities in the system could cause unforeseen health issues.
One area of focus, electronic health records, poses particular difficulty to address. Those that have EHR systems arguably provide better quality to patients through better accuracy of records. But the opposite is also feared to be true. “EHR adoption, if uneven, may further exacerbate existing health disparities” (HITUS, 4:29) In other words, the lack of uniformity in the current market could pose problems for patients with low income or socio-economic status, as they might reside in areas with less affluent facilities capable of purchasing and integrating EHR and other forms of HIT. The concern is that quality of care suffers in these areas as a result, creating a disparity in care between different population groups. (HITUS, 4:29) Of particular concern is use of EHR systems in Hospital Emergency Outpatient Departments, where uninsured and Medicaid patients frequent. Between 2001 and 2003 (last year data publicly available), only “31 percent of emergency departments and 29 percent of hospital outpatient departments have an EHR.”(HITUS, 4:32)
These problems all lead back to the lack of centralized organization within the U.S. healthcare system. Organizational factors such as the size of a practice play a part in the current market. Larger practices are more likely to adopt an HIT system out of necessity than a smaller practice. This also goes back to the cost problem, as the enhanced financial position of a larger practice enables easier adoption of HIT. This is also true for hospitals in terms of network memberships. Larger networks are also in a better position to pay for and integrate HIT than smaller independent or rural hospitals, pharmacies and physicians. (HITUS, 5:46)
Technology & Connectivity
Building on current market conditions, another problem in rolling out HIT in a universal and uniform distribution relies on the proper interconnectivity and the availability of the right technology. In the current market environment, “connectivity—the ability to share information from system to system—is poor. HIT implementation is growing, but there is little sharing of health information between existing systems.” (HIT: Can HIT Lower Costs and Improve Quality?, 3) Concerns that must be addressed include the exchange of: 1)information between hospitals and admitting physicians, 2) information among hospitals with a community, 3) information between physicians and community physician groups, 4)information between patients and hospitals, 5)information between patients and physician offices beyond lab results, emails and appointments, 6)information between health plans and patients and 6)information between or among hospitals, physicians, pharmacies, nursing homes and home health care providers. (HITUS, 2:16)
With all of these dimensions to consider, the reality is that most providers at present do not have the systems or technologies available to coordinate patient care, share information, monitor prevention efforts and measure and improve performance. (HIT: Can HIT Lower Costs and Improve Quality?, 1) Reasons vary but include concern over the constant evolution of technology. Many simply do not have the guidance to know when to jump in to the technology cycle and get their systems, afraid that these will become outdated before they have time to integrate them. Plus, current systems are often regarded as “unwieldy and difficult to use.” (HITUS, 5:46) Finally, lack of proper training for these systems is yet another concern. In sum, “HIT dissemination has not occurred rapidly, due in part to the high costs of electronic health record (EHR) systems for providers of care—including the upfront capital investment, ongoing maintenance and short-term productivity loss.”(HITUS, 1)
Broader Solutions That Promote HIT Implementation
If the right mix of solutions could be found to help completely implement HIT across the board, studies show that there are a variety of benefits that could result. First, a primary concern, safety, would be enhanced. Avoiding mistakes in prescriptions, adverse reactions when mixing drugs and misdiagnoses (based on lack of information) could all be avoided. Just the implementation of an HIT system with computerized physician order entry across all hospitals would make a significant impact. According to a RAND study, “around 200,000 adverse drug events could be eliminated each year, at an annual savings of $1 billion.” (HIT: Can HIT Lower Costs and Improve Quality?, 2)
Screening for disease prevention would also benefit greatly from implementation of HIT. “HIT helps with prevention by scanning patient records for risk factors and by recommending appropriate preventive services, such as vaccinations and screenings.” (HIT: Can HIT Lower Costs and Improve Quality?, 2) Vaccination records be better maintained, reducing the potential for outbreaks, vaccine shortages, and other disparities. This would aid in the public health sector, maximizing effective national prevention efforts. Further, HIT can help with chronic diseases by tracking patient testing needs, vital stats and more, helping to better regulate care and reduce the need for hospitalization.
Where to start? There are three areas that need to be addressed in order to facilitate HIT implementation. Studies recommend addressing financial incentives and assistance, uniform technology and training systems and uniform government policies. Only with these three combined can HIT integrate into the healthcare system in a way that is both viable and equitable.
Financial Incentives and Assistance
The biggest hurdle to be addressed first is cost. Despite the fact that estimates place annual savings from efficiency of HIT to be $77 billion or more, the cost of implementation remains a major barrier. According to studies, “the largest savings come from reduced hospital stays (a result of increased safety and better scheduling and coordination), reduced nurses’ administrative time, and more efficient drug utilization. (HIT: Can HIT Lower Costs and Improve Quality?, 1) With this obvious savings within reach, barriers remain because “economic incentives in the health care industry generally do not reward good performance, reducing the motivation of self-interested health care actors to acquire HIT and compete more effectively.” (HITUS, 5:43) In addition, most providers are uncertain that, if they pay for the high cost of HIT systems, they will receive any sort of benefit in terms of return on investment. Changing payment policies to reward good health care performance “creates a non-specific incentive for providers to improve their quality and reduce costs of care.” (HITUS, 5:48). Other solutions include reimbursing providers that use HIT in clinical care and providing grants or low-interest loans to those who acquire HIT systems.
Uniform Technology and Training
Training and technology remain consistent barriers to HIT. On the surface, the idea of improvements in technology sounds like it would be beneficial for HIT implementation. On the contrary, constant improvements and evolution of technology causes frustration within the healthcare industry. Provider “concerns about ease of use and obsolescence were second only to financial barriers as a primary reason for not adopting this new technology.” (HITUS, 5:46) Indeed, providers worry that they will spend a lot of money on technology that will have to be thrown out or changed before they even finish recouping the expenditure. They fear pouring money into a constant and never ending cycle of technology upgrade and replacement. There are no standards to dictate the style of investment (rent, lease, purchase, etc.). Additionally, providers are very wary of investing in HIT when there are training issues. Adapting to a new system requires training and time. The concern is a lack or loss of productivity as a result of trying to transition to new HIT. In addition, current HIT software and programs available are often considered “unwieldy and difficult to use.” Finally, there are simply not enough skilled and trained people in HIT to go around, a situation also indicative of the overall lack of skilled and trained workers in the health care industry as a whole.
Uniform Government Policies and Certifications
A final issue regarding HIT is a lack of standardization, subsidization and certification. Currently, there is no centralized, top-down policy for HIT implementation throughout the United States. HIT adoption is sporadic and varied. Financial solutions go hand in hand with government sponsored solutions and certification efforts. If government can establish a streamline set of standards for technology and software for HIT that everyone can subscribe to uniformly, financial solutions can then be put in place to speed up acquisition. For example, “forcing providers to be more transparent about their performance, through public reporting of efficiency and quality data, may stimulate doctors and hospitals to join larger groups and integrate into systems.” (HITUS, 5:49) New government policies will also reduce the phobia of legal problems that come with HIT adoption. “The use of certain technologies is associated with an actual or perceived increase in legal burdens.” (HITUS, 5:49) Many are concerned about accreditation issues, privacy of information, liability and the legal issues involved. Centralized training programs, government subsidies for purchases, certification standards for HIT training are all ways that the government can intervene.
Glimmers of Hope
While national and centralized efforts to implement HIT may be slow to come around, successful state programs are beginning to surface. Successful HIT approaches are at work in many states. Two examples to be explored in greater depth are Maine and Arizona.
One example of finding a workaround in the current market is the creation of the Maine Telehealth Network. In this example, Maine embarked on an ambitious plan to use technology to set up remote telehealth centers, where people could be seen in rural areas by providers using ISDN-based video equipment to ‘see’ people from a distance and transmit health data back and forth. This helped those who could not afford or were unable to travel extensive distances to see specialists or other providers for their conditions. However, the current credentialing system is problematic in that the technology cannot be adopted in every medical setting. Therefore, the telehealth idea could not be implemented in Maine hospitals.
Fortunately, a workaround for this certification barrier was achieved. According to Ron Emerson, Maine Telehealth Network’s director, “To meet Medicare, Medicaid, and JCAHO requirements, physicians must have admitting privileges at each hospital where a patient is seen. Rural health centers, which are not subject to such hospital regulations, can more easily serve as telemedicine sites.” (AHRQ – Health Information Technology, 2005 – Maine Telehealth Network) Despite the setbacks, the Maine example of HIT integration is succeeding, expanding healthcare accessibility through the implementation of some 250 telemedicine sites throughout Maine. As well, costs are saved on home health care, as patients can now transmit necessary data, eliminating the cost of a nurse to visit.
Successful HIT implementation is also happening in Arizona. While Maine is working around current policy and certification issues, Arizona may have found new answers to all previously noted barriers. First, Arizona has developed the Health-e Connection Roadmap, a “plan outlining where efforts should lead within the fields of technology and health care.” (AHRQ – Health Information Technology, 2008 – State of Arizona) To create this roadmap, the governor pulled together hospitals, health plans, consumer groups, doctors, pharmacists and laboratories. The roadmap sets universal standards to achieve statewide electronic health data exchange and promotes implementation of both regional and centralized initiatives. In Arizona, a “legal working group has been established to address statutory and regulatory amendments that may be needed to facilitate the sharing of health information. In addition, a technical working group is addressing role-based access and authentication for a master provider index.” (HIT 2008 Arizona) Finally, the governor and the state legislature established a grant program, funded at $1.5 million in 2007, 2008 and 2009 for rural health care providers to incentivize the adoption of HIT.
Finally, there is some hope on the horizon from the federal government. According to the HITUS report, “federal efforts currently under way to promote standardization and certification should accelerate adoption. An example of such efforts is the Certification Commission for Health Information Technology (CCHIT) charged with developing criteria and evaluation processes for certifying EHRs and interoperability components.” (HITUS, 5:46) The Agency for Healthcare Research and Quality (AHRQ) has also “provided funding to the Research Triangle Institute (RTI)…granting funds to 34 states and territories for health information exchange and health IT efforts.” (HIT 2008, Arizona)
There is no easy way to bring about HIT reform and implementation. As shown, there is a lot of hesitance to embrace change without certain guarantees and incentives. Plus, without organizational deployment of a standardized HIT system, providers will be afraid to step out on a limb to spend the money for technology that may become obsolete or require changes constantly. Fears, financials and phobias must be met standardization, subsidies and sustainability.
The combination of cloud computing and Que reader technologies mentioned in my addendum delivers a plausible solution for the needed transition to HIT within the healthcare industry. Mine is but one possible solution in addition to several others that are currently being tested in places like Maine and Arizona. Hopefully, the continued attention that HIT is receiving from higher level players such as healthcare leaders, government officials, and the President of the United States can bring together the right solution that addresses all concerns. Only then will the healthcare industry propel itself into the 21st century with improved technology, information sharing, and data accuracy. Only then will patients see improved quality of care and experience true systemic improvements. Only then will the goals of HIT truly be realized and actually provide real ‘change we can believe in’.
- AHRQ. “Agency for Healthcare Research and Quality (AHRQ).” September 2007. Health Information Technology (Health IT), 2007 – East Liberty Family Health Center Community Health Center. 20 November 2009 <http://www.ahrq.gov/about/casestudies/healthit/hit2007b.htm>.
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- —. “Health Information Technology (Health IT), 2008 – State of Arizona.” October 2007. Agency for Healthcare Research and Quality (AHRQ). 20 November 2009 <http://www.ahrq.gov/about/casestudies/healthit/hit2008.htm>.
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- Mell, Peter and Tim Grance. “Cloud Computing – Definition.” 2009. National Institute for Scientific Standards. 20 November 2009 <http://csrc.nist.gov/groups/SNS/cloud-computing/cloud-def-v15.doc>.
- National Health Information Technology Week. 2009. 20 November 2009 <http://www.healthitweek.org/>.
- RAND. “Health Information Technology: Can HIT Lower Costs and Improve Quality?” 2005. RAND Health. 20 November 2009 <http://www.rand.org/health>.
- The Robert Wood Johnson Foundation. “The Robert Wood Johnson Foundation.” 2006. Health Information Technology in the United States: The Information Base for Progress. 20 11 2009 <http://www.rwjf.org/files/publications/other/EHRReport0609.pdf>.