A strong start on a long path

Just a little over four years ago, President Obama, in his inaugural address, challenged us a nation to “wield technology’s wonders to raise health care’s quality and lower its costs.”  This was an awe-inspiring, “we will go to the moon” moment for the healthcare delivery system.  But the next thought that ran through the minds of so many of us who work on health IT issues was this: how were we going to get there?

We were essentially starting from scratch.  Less than 1 in 10 hospitals had an electronic health record, and for ambulatory care physicians, the numbers weren’t much better – about 1 in 6 had an EHR.  Hospitals and physicians reported an array of challenges that were holding them back.  No nation our size with a healthcare system as complex as ours had even come close to universal EHR use.  Yet, the President was calling for this by just 2014.

And it was clear why.  The promise of EHRs was enormous and we knew that paper-based records were a disaster.  They lead to lots of errors and a lot of waste.  I have cared for patients using paper-based records and using electronic records – and I’m a much better clinician when I’m using an EHR.  In the weeks that followed Obama’s inaugural address, the U.S. Congress passed, and the President signed the Health Information Technology for Economic and Clinical Health Act, which contained a series of incentives and tools to drive adoption and “meaningful use” of EHRs. None of us knew whether the policy tools just handed to the Obama administration were going to be enough to climb the mountain to universal EHR use.  We were starting at sea level and had a long climb ahead.

On Tuesday, just about 4 years after the passage of HITECH, Health Affairs and the Robert Wood Johnson Foundation held a briefing about where we as a nation are vis-à-vis health information technology.  Mike Painter, who is the RWJF lead, captured it perfectly in his reflection that when you climb a mountain, it’s important to take breaks, celebrate the progress, and enjoy the vistas.  July 9 in Washington DC was just such a moment.  It was a day to celebrate how much progress we have made.  No “Mission Accomplished” banners.  Just a day to take a breath and say – we are off to a very strong start.

Why do I say this?  In 2008, 9% of U.S. hospitals had at least a basic EHR.  In 2012?  That number is 44%.  A staggering near 5X increase in 4 years.  And the gains on the ambulatory care side have also been impressive.  What’s more, the numbers suggest that HITECH led to an inflection point – it catalyzed the adoption of EHRs across U.S. hospitals.  This is the proportion of U.S. hospitals with at least a basic EHR:

EHR graph

Beyond EHR adoption, the story gets a little less joyous.  A key part of using EHRs to improve healthcare delivery is clinical data exchange – getting physicians, hospitals, other providers to electronically share clinical data with each other.  There are lots of paths to achieving this goal – but the one that has had the greatest policy attention has been through entities called Health Information Exchanges or HIEs.  These entities have sprung up around the country and many of them are getting funds through HITECH (passed on through states) to help ensure that data can follow patients as they go from one clinical setting to another.  At the Health Affairs briefing, we heard from Julia Adler-Milstein an update on how these HIEs are doing.  The good news is that they are growing by leaps and bounds.  We’ve been surveying these entities for more than 7 years now – and between 2010 and 2012, there was a 60% increase in the number of HIEs that are actively exchanging clinical data (119 in 2012 compared to 75 in 2010).  Nearly 30% of U.S. hospitals are exchanging clinical data with non-affiliated providers using these HIEs (a doubling from 2010) and approximately 10% of ambulatory care practices in the U.S. are exchanging clinical data using these HIEs (a threefold increase from 2010).  While the gains are important – the data also point to the long road ahead.  Most physicians and hospitals are not exchanging clinical data using HIEs.  A bigger issue that the Adler-Milstein paper raises is this:  Most HIEs are not financially sustainable now (they are largely dependent on grants, etc.) and 3 in 4 report that finding a sustainable business model is a challenge.  There is substantial risk that as the HITECH funding runs out – many of these HIEs will go under unless the doctors and hospitals that are using them are willing to pay for it.

Two other big challenges that lie ahead are worth discussing.  First, there is a large proportion of healthcare providers that are left out of HITECH.  Who is left out?  Nursing homes, rehab hospitals, mental health providers and facilities, etc.  It’s a big problem.  If you think about high cost patients– and the kinds of care they need – they spend a lot of time in these facilities and with these ineligible providers.  The best data we have suggests that these providers who are ineligible for financial incentives have abysmally low levels of EHR use.  No one is even tracking how these guys are doing.  And, without a concerted effort, we are unlikely to get them on board with electronic records.  So, we will end up with large parts of the healthcare system that are digitized — and large parts that are not.  While it’s easy to blame HITECH for not including these providers, as the bill was being crafted, choices had to be made.  Policymakers made the decision to take the money they had and focus it on ambulatory care providers (docs, nurse practitioners, etc.) and acute-care hospitals.  However, we have to figure out a strategy to get these other key providers on board.

The second challenge is the key to the kingdom: figuring out how to use Health IT more effectively.  As I’ve written before, Health IT is not magic pixie dust.  You don’t spread some into the healthcare system and see gains in quality or efficiency.  In fact, in most industries, IT has taken years, often decades to exert its effects.  I am confident that if we do nothing, health IT will have huge effects on healthcare delivery – but it might take a decade or two.  We need to figure out how to speed up the process.  In other industries, IT has been a source of creative destruction:  it has changed the way people work, destroyed a lot of jobs and created brand new ones.  We aren’t seeing much of that in healthcare yet.  In a terrific paper that Julia Adler-Milstein published last year (I was a co-author – but the idea was completely hers), she found that on average, doctors weren’t any more productive or efficient if they used an EHR.  However, if these doctors had nurse practitioners or other advanced non-physician providers in their practice, EHR use was associated with much higher likelihood of being a high performer.  If doctors did not have these advanced practitioners, EHRs tended to be associated with lower likelihood of being a high performer.  It’s exactly this kind of insight that we need to better understand how to use EHRs to make care better.  EHRs are best when they change the way we deliver care.  Half of the physicians in the U.S. may now being using an EHR – but most have not used the EHR to change the way they work.  Until they do, we should not expect to see big gains in quality or efficiency from the EHR.

The Robert Wood Johnson Foundation 2012 report on the state of health information technology in the U.S. is an essential read to understand where we are on health IT adoption and use – and this year’s report tells us that we are making a lot of progress.  HITECH is having an important impact on the healthcare marketplace.  However, the President, in his inaugural address, did not say that we will use taxpayer dollars to help doctors and hospital buy technology.  This is not a technology program.  He said that we will use technology to “raise healthcare quality and lower its costs”.  If that is the goal – if that is the moon that we have to reach – then we should celebrate the accomplishments to date – but, at the same time, remember that our work is just getting started.