It's been 19 years since the prestigious Institute of Medicine urged greater adoption of computer systems in healthcare, and more than six years since then-President George W. Bush declared, "By computerizing health records, we can avoid dangerous medical mistakes, reduce costs and improve care."
So, how are we doing so far?
There are positive signs at places like Methodist Dallas Medical Center, which has a nearly foolproof way to make sure the right drug gets to the right patient in the right dose at the right time: It uses bar-code technology to clear all medications through a computerized program.
Pamela McNutt, CIO at Dallas-based Methodist Health System, says the technology means the hospital can avoid drug errors, which are responsible for an estimated 100,000 deaths nationwide each year.
That success encouraged McNutt to push forward with other IT initiatives. "The reason we continue getting everything into an electronic format is so we can analyze our data, look at what's going on for efficiency reasons and monitor quality as it's happening," she says. "And the only way you can do that is through the use of structured data."
While there are many success stories, progress in using IT to improve patient care and cut costs has been slow. Research suggests that healthcare IT has a long way to go to match the hype:
* Only 12% of U.S. hospitals had adopted electronic health records (EHR) as of last year, a modest increase over an adoption rate of 9% in 2008, according to researchers at the Harvard School of Public Health.
* A study by University College London found that many EHR projects fail, and "the larger the project, the more likely it is to fail." Researchers say the systems can improve auditing and billing but may make primary clinical care less efficient.
* Experts from the Institute of Medicine who visited healthcare facilities last year found that "care providers had to flip among many screens and often among many systems to access data; in some cases, care providers found it easier to manage patient information printed or written on paper."
Healthcare CIOs say they're optimistic that IT can help to dramatically improve patient care, but it will take time. And the types of challenges that IT leaders face in all industries -- such as high equipment costs and end-user resistance -- could limit what IT can actually deliver and how fast it can do so.
"This is really going to take a lot of work and a lot of evolution. It's going to take a little bit of carrot, a little bit of stick and time to get there," says William Spooner, CIO at Sharp HealthCare in San Diego.
The U.S. government is providing the carrot and stick. The American Recovery and Reinvestment Act of 2009 provides $19 billion in incentives to health care providers that demonstrate they are engaged in "meaningful use" of EHR systems, but providers that don't meet the government's meaningful-use guidelines by 2015 face cuts in their Medicare reimbursements.
What Doctors and Nurses Want
Half of healthcare providers are using some form of electronic health record system; 34% have a comprehensive system and 16% have a partial system, according to a July survey by the Computing Technology Industry Association. Overall, 56% of doctors and nurses rated their EHR system as satisfactory, while 41% fell into the middle category of "partly satisfied/partly dissatisfied."
Top reasons healthcare providers adopt EHR systems:
1. Better patient care
2. Save time, improve efficiency
3. Reduce errors or the risk of errors
4. Improve staff productivity
Improvements doctors would like to see in EHR systems:
1. Increased speed
2. Easier to use, less complex
3. Lower cost
4. Removal of unnecessary functions
5. Greater interoperability with other systems
(Tie) Better remote access
Most commonly used EHR software features:
4. Computerized physician order entry
5. Medications management
Top reasons for not adopting EHR systems:
1. Upfront costs
2. Ongoing operational costs
3. Impact on existing workflow or processes
4. Training and user-adoption issues
Base: 300 U.S. healthcare providers, including doctors, dentists, nurses, physician assistants and office managers; multiple responses allowed.
Source: Computing Technology Industry Association survey on healthcare IT, July 2010
"Getting hospitals to start using EHRs is critical," says Ashish Jha, associate professor of health policy and management at Harvard. "Paper-based medical records lead to hundreds of thousands of errors each year in American hospitals and probably contribute to the deaths of tens of thousands of Americans. This is not acceptable. There is overwhelming evidence that EHRs can help, yet the expense and the disruption that implementing these systems can cause has forced many hospitals to move slowly."
One well-known reason for adopting EHR systems is that they could enable health professionals to access a patient's medical history anytime, anywhere. Such access would even be available to a doctor treating a patient who needs emergency care while far away from home.
In addition, Spooner says computerized systems can alert doctors immediately when a patient's lab results indicate something abnormal, allowing caregivers to act quickly to prevent complications. And some systems can compile patient data onto dashboards at hospital nurses' stations, so the nurses can see all information at once, rather than having to check charts room by room.
Analytics for Healthcare
Experts say that an even more powerful use of electronic records would be to analyze large groups of patients, track trends, identify best practices and determine the best treatments. "That's the ultimate goal: to discover patterns in the population you wouldn't otherwise," says David Muntz, CIO at Baylor Health Care System in Dallas.
That's the goal, but we're far from it because of problems with data sharing, says Timothy Stettheimer, regional CIO at St. Vincent's Health System in Birmingham, Ala., and chairman of the board of trustees of the College of Healthcare Information Management Executives.
Not all healthcare providers have electronic records, many organizations can't share their records with other facilities unless they're affiliated with one another, and even those that can share with others outside their networks often have translation problems because there's no single data standard to facilitate the smooth transfer of information.
"That's one of the things we're struggling with -- the vocabularies, diagnostic codes, nomenclatures. There are a lot of them, and we're trying to bring them together," Stettheimer says. "There are a lot of efforts going on to create the ability to share information, but we're not there yet."
Timeline: Healthcare Reform and IT
1967-1973: The earliest electronic medical record systems are developed at the University of Vermont, Intermountain Healthcare in Utah, the Regenstrief Institute in Indiana, Kaiser Permanente in San Francisco, and Massachusetts General Hospital in Boston.
1991: An Institute of Medicine report calls for computerization of patient records by the year 2000.
1993: President Bill Clinton proposes a major healthcare reform plan, including a medical ID card, but it isn't enacted.
1997: The Health Insurance Portability and Accountability Act requires privacy and security safeguards for health records.
1999: Healthcare facilities scramble to prepare their systems for the Y2K date rollover.
2004: President George W. Bush sets a goal to make electronic health records available to most Americans in the next 10 years.
2009: Federal economic stimulus legislation encourages the adoption and "meaningful use" of electronic health records.
2009: A report by the Institute of Medicine urges the healthcare industry to increase its focus on using IT to improve clinical decision-making.
2010: President Barack Obama signs healthcare reform legislation that has numerous provisions affecting IT.
-- Mitch Betts
It may be 10 or 15 years before data sharing is widespread, because it's "a lot harder to achieve than most people appreciate," says Peter Gabriel, director of informatics at the University of Pennsylvania School of Medicine's Department of Radiation Oncology.
One looming issue is whether people will trust that their electronic medical records will be secure and private while all this data sharing goes on. Polls show that consumers are concerned that employers and marketers might gain access to their health records, for example.
The counterargument is that electronic records can be more secure than paper ones. Many computerized health record systems already use multilevel access controls that can limit who can view specific information, and some provide audit trails that show who accessed what details when.
But still unresolved are questions about how patients' records will be handled -- and how they want their records handled. Should they be able to opt into a system of shared electronic records, or should they have to opt out? And who will be the owners and custodians of the information -- the patients themselves, or the caregivers or facilities that created the data?
Will IT Cut Medical Costs?
Healthcare IT professionals expect that technology will not only improve patient care, but also deliver savings, by streamlining processes and eliminating costly mistakes. "We have known since at the least the 1990s that the highest-quality care results in the lowest-cost care," says Aaron Seib, CEO of the National eHealth Collaborative, a public-private partnership promoting a nationwide health information system.
McNutt says her hospital's prescription bar-code system is an example of a cost-cutting technology. By eliminating drug errors, it cuts out the treatments that would have been needed if a patient had been given the wrong medicine. McNutt acknowledges that eliminating those treatments saves money for the insurer, not the hospital. But she also points out that the system helps the hospital avoid costly lawsuits stemming from drug errors.
As the government moves toward a new reimbursement model -- one that pushes the cost of treating problems caused by poor care, such as hospital-acquired infections, back onto the providers -- IT systems could deliver even bigger returns, McNutt says.
Still, there's a rub when it comes to calculating return on investment in healthcare IT. Often, the cost savings from the use of technology don't go to the owner of the technology but to another player in the healthcare system, like the insurers.
Stettheimer lays it out this way: A patient comes into the hospital at night with heart trouble. Rather than calling a local cardiologist and waiting for a response, the staff sends test results to offshore medical personnel for an immediate evaluation. That quicker response means treatment can start sooner, often leading to a better and less costly outcome. But in that case, the hospital doesn't necessarily see the financial benefit; the insurance company -- and the healthcare system as a whole -- does.
A CIO at a for-profit company would have a hard time getting approval for an IT investment that saves money for the industry but not for the company.
"The incentives [in healthcare] are not aligned at all. In fact, there are perverse incentives there," Stettheimer points out. "That's very simplified, but it's a problem we need to overcome."
New payment models will help healthcare facilities big and small see the financial rewards of investing in IT, he says. Medicaid and some other insurers are paying healthcare providers by the condition, rather than per treatment or per day in the hospital. Those payment arrangements give doctors and hospitals incentives to deliver the best, most efficient care.
The new payment schemes are more likely to save big bucks than IT advances alone would, Gabriel says. "I'm a big proponent of healthcare IT, but I don't see a lot of evidence that information technology will save the healthcare system money," he says.
The Affordability Factor
Many financially strapped medical facilities have a hard time generating the upfront capital required to invest in IT in the first place. The Harvard study found that small, rural and public hospitals have fallen behind larger, private and urban operations in adopting EHR systems, further widening the digital divide.
Even with the federal stimulus money -- which is just a fraction of what's needed nationwide -- access to capital for IT is a big concern for many medical providers, says Bobbie Wilbur, co-director of Social Interest Solutions, a nonprofit healthcare technology provider. "Affordability is complicated by so many factors. Some just don't have the money. Others might not make it a priority because other needs rank higher," Wilbur says.
Spooner says IT costs could force small, independent operations to seek partnerships or mergers with larger institutions. "Independent physician practices or hospitals may become a thing of the past," he says.
Of course, healthcare IT won't do any good if it isn't used effectively, or isn't used at all. CIOs and researchers continue to report pockets of resistance among doctors and nurses, who in turn blame kludgy computer systems and then resort to work-arounds that involve pens, paper and Post-it notes.
Report Card: Healthcare IT
We asked experts to give letter grades for the progress that IT has made so far in improving the following aspects of the U.S. healthcare system. The graders:
Timothy Stettheimer, regional CIO, St. Vincent's Health System
Mary Griskewicz, senior director of ambulatory healthcare information systems, Healthcare Information and Management Systems Society
Bobbie Wilbur, co-director, Social Interest Solutions
Using IT to improve the quality of patient care:
B+ for the implementations (Stettheimer)
A for the technology that's available (Stettheimer)
Using IT to lower the cost of care:
Ensuring the privacy and security of electronic health records to help patients trust the system:
B+ for the technological capabilities (Stettheimer)
C+ for gaining people's trust (Stettheimer)
Making healthcare computer systems affordable for smaller medical offices:
Ensuring that the technology is usable enough for doctors and nurses to work with it easily and productively:
Sharing data among the various segments of the healthcare industry:
A for the technology (Wilbur)
B for the implementations (Wilbur)
C for the adoption of available technology (Wilbur)
To some degree, this is a generational issue. More and more medical professionals, like people in other industries, have grown up with technology or are becoming more comfortable with it.
In the future, Spooner says, caregivers will have no choice but to use computers; they'll be viewed as incompetent if they don't.
A bigger problem than getting healthcare professionals to accept technology is that there's been too much emphasis on computers alone, and not enough focus on streamlining workflows and providing software that could help doctors make better medical decisions, according to an Institute of Medicine report released last year.
Researchers who visited leading healthcare facilities found that "IT applications appear designed largely to automate tasks or business processes. They are often designed in ways that simply mimic existing paper-based forms and provide little support for the cognitive tasks of clinicians or the workflow of the people who must actually use the system."
During the visits, researchers "repeatedly observed healthcare IT focused on individual transactions (e.g., medication x is given to the patient at 9:42 p.m., laboratory result y is returned to the physician, and so on) and virtually no attention being paid to helping the clinician understand how the voluminous data collected could relate to the overall healthcare status of any individual patient," the institute's report said.
There's been a lot of hype suggesting that the benefits of healthcare IT will show up quickly and automatically, Gabriel says. "Simply implementing computer systems won't dramatically improve [healthcare] quality overnight," he says. "Very careful system design and configuration, along with a lot of thoughtful human process improvement, are necessary in order to make the technology truly helpful."
Pratt is a Computerworld contributing writer in Waltham, Mass. You can contact her at firstname.lastname@example.org. Computerworld's Mitch Betts contributed to this article.
This story, "Healthcare IT isn't living up to the hype" was originally published by Computerworld.