Dog Bites Man

Mark Segal

In a past life, my doctoral dissertation examined the dynamics of public policy issues over time, including shifts in professional, trade, and popular media coverage.  Simplifying many pages of academic prose, my argument was: if initial reports on an issue focus on “man bites dog,” (in my case, salt is bad for you) then, as day follows night, before long you will see academic and lay media emphasizing that, in fact, what is really going on is “dog bites man” (salt is not bad for you).  And so on.

This simple dynamic sheds light on the recent flurry of articles raising questions about whether or not healthcare information technology (HIT), or electronic health records (EHRs), or the $20-30 billion federal EHR incentive program (AKA “meaningful use”) are good things and meeting their promise. Many of these pieces link disparate bits of “data” to suggest that the meaningful use program was not, in fact, a good idea, was not justified by the evidence, or has not yet met its promise.

For example, a recent commentary by two RAND Corporation researchers was positioned (and reported) as repudiating the optimistic projections of a 2005 detailed analytical projection by other RAND researchers on potential benefits of widespread EHR and HIT adoption. John Halamka succinctly addressed issues raised in this report, which covers no new ground and expresses surprise and disappointment that a program in active operation for less than three years has not yet revolutionized healthcare or its cost structure, nor, in this brief period, led to the 90% adoption rate assumed by the original RAND team.  This latest “RAND” analysis, which sometimes substitutes footnotes for data (for example incorrectly citing an ONC blog post as evidence that “federal initiatives needed to achieve higher levels of interoperability. . . are already triggering resistance from providers and vendors”)  simply makes the obvious point that neither EHR adoption nor health care delivery and payment systems have yet reached the point that we can transform health care delivery nor “bend the cost curve.”

As readers of this blog know, EHRs and the broader set of HIT products and services are tools, nothing more. They operate within a complex ecosystem involving many individuals and organizations, complicated and flawed payment systems, and incomplete infrastructure to connect data across many HIT systems. And for goodness sake, let’s stop asking “why can’t HIT and data exchange work like ATMs?” — ATM data and exchange is orders of magnitude simpler than healthcare data and interoperability.

Digitizing our complex health care system is a massively complex undertaking but one worth doing.  Can anyone truly argue that such a large sector of our economy should remain paper-based? If not, then it seems to me that focusing on studies that seek precision in the potential benefits of EHRs and other HIT is beside the point.

More concretely, the EHR incentive program, established just four years ago through the HITECH Act, has generally been successful in meeting its intended purpose and is proceeding at a reasonable pace, especially when considering its broader impacts on increasing EHR and HIT adoption even where formal “meaningful use” has not been achieved. Since passage of the Act, EHR adoption and incentive payments for demonstrated meaningful use of certified EHRs have climbed. It appears likely that the U.S. is at or past a clear tipping point in use of EHRs and other health IT.

Notably, 71.85% of physicians have adopted EHRs as of 2012 according to the NCHS, up from 57% in 2011.  Likewise, a recent Commonwealth Foundation report indicates that 69% of primary care physicians used EHRs in 2012, up by 50% from 46% in 2009. The meaningful use program has no doubt accelerated this growth, which is almost certainly focused on EHRs with robust functionality designed to help physicians and practitioners prepare to meet meaningful use certification criteria, including the foundations for interoperability. For example, a recent Office of the National Coordinator for Health Information Technology analysis of the NCHS data shows high and increasing levels of implementation of most key capabilities needed for meaningful use.

In terms of the EHR incentive program and what it will bring, it is clear that Stage 2 (starting in 2014), along with Stage 1, and especially the “2014 Edition” certified EHR capabilities on which GE and other software developers are hard at work, provides a solid base for effective use of EHRs. In particular, Stage 2 and the 2014 capabilities needed for either stage include key interoperability building blocks, such as standardized clinical terminology, standards for clinical summaries suitable for exchange, and data transport standards. Moreover, our health information exchange infrastructure, while clearly needing more work, continues to expand and will benefit from the demand created by both meaningful use and the accelerating growth in accountable and integrated care.

We are still in early days of the journey to transform our healthcare system. EHRs and other HIT can play an important role but we need to be patient, prudent about what goes into Stage 3 of meaningful use, and not act surprised that capabilities still in initial use or under development have not achieved what we all agree needs to be done and what has been held out as the potential promise if the stars are aligned. Change, especially safe and lasting change, takes time; this reality is especially true of complex HIT implementations. As John Halamka observes, we are truly “moving as fast as we can”.


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One thought on “Dog Bites Man

  1. Mark ,Its always good to have a long term perspective… thanks as always for yours. and along the way clearing away some of the mud…

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