April 2018

EHR Insider: Free Innovative Spirits to Deliver HIT's Promise
By Paul Brient
For The Record
Vol. 30 No. 4 P. 30

Let's acknowledge that the 2009 HITECH Act was a mixed blessing. On the positive side, it spurred the widespread promulgation of EHR systems in both the inpatient and outpatient settings and laid a digital foundation for 21st century technology-enabled clinical care. What it didn't do was produce its intended benefits of reducing costs and improving quality of care.

Interestingly, health care is the one industry in which productivity has suffered as a result of computerization. It is well documented that EHRs hamper physicians' clinical efficiency; they are even being called the main cause of physician burnout. Even as a recent study reports that HIT use improved at least one medical outcome in 81% of relevant research evaluated by its authors, EHRs' effects on physicians remain problematic. A physician survey from a leading hospital company revealed that physician satisfaction with EHRs is only in the 20% to 30% range. No other industry would accept customer satisfaction rates at this level.

Root of the Problem
In 2008, comprehensive EHR systems were deployed in less than 3% of US hospitals. A greater number had more limited EHRs, but only about 5% of hospital orders (and even fewer notes) were entered electronically. The reason for this was simple: The state of the art in HIT was such that it was more efficient for providers to work on paper (frequently in conjunction with a computer) than to work completely in the computer. Users were making a rational set of choices.

The federal government adding $40 billion in incentives and thousands of pages of often byzantine legislation did nothing to improve the situation. In fact, in many ways, it made it worse.

It resulted in "forced adoption" of technology that otherwise would have had to improve dramatically before it would be voluntarily adopted. What's more, health care has taken paper paradigms and moved them to the computer—a logical first step but one that doesn't necessarily yield meaningful change—but has yet to reimagine health care native to a digital environment.

From the HIT vendor side, nearly everyone over the past nine years has focused on meeting government-imposed requirements, typically to the letter of the law but not necessarily the spirit. This essentially killed innovation as research and development budgets and deployments focused on meeting the specific requirements of meaningful use rather than innovating to improve the cost and quality of health care. According to former Allscripts CEO Glen Tullman, "EHRs provide data that are necessary for changing how we deliver care, but they're not sufficient on their own. We need vision, leadership, and innovation to complete the task."

But exactly what innovation and what conditions will foster it? What might HIT look like if the government took a different approach?

Learn From Others
The airline industry offers some lessons. When the federal government lifted restrictions on fares, airline routes, and new vendor market entry through the Airline Deregulation Act of 1978, market forces began to work. The industry saw a massive upsurge in innovation and new competition—hello, Southwest and JetBlue—that, on balance, benefited the traveling public. Today you can fly from Boston to Nashville for $55, and the total number of passengers who fly annually has more than doubled.

Government bodies such as the Federal Aviation Administration and the Transportation Security Administration are still involved, but the industry has been freed to innovate.

A similar model for HIT might generate the same encouraging results. The government could get out of the business of prescribing features and functions—or even that systems are used—and instead work to understand some of the critical barriers that have crippled the industry, such as the following:

• A lack of an interoperability mandate: Vendors have too much economic incentive to remain closed despite their public pronouncements otherwise.
• A lack of a common patient ID: A political hot potato for sure, but something that would improve quality of care and make it much easier and cheaper to access health care.
• A lack of true incentives for delivering high-quality, low-cost care: The government pays for nearly one-half of all health care delivered, yet most of these payments are based on a fee-for-service paradigm. More meaningful and impactful ways are needed to encourage organizations to rework their care delivery systems to lower the cost of care and improve quality. As much as Medicare Access and CHIP Reauthorization Act sounds nice, for most providers it is just administrative overhead and another acronym to learn.

Not All Is Lost
In a positive sign, the federal government is soliciting input from health care industry stakeholders about reducing clinician burden associated with EHR systems. For example, a late February meeting between the Office of the National Coordinator for Health Information Technology and the Centers for Medicare & Medicaid Services is a step in the right direction and a sign that the right people are being asked the right questions.

In addition, if the government can step aside and find ways to encourage and unleash the creative energy that the health care system so desperately needs, technology developers can shift their focus away from meaningful use compliance to more creative endeavors.

Here, too, there have been hopeful developments.

Not long ago, consulting physicians had to spend the night in the hospital just in case their expertise was needed. Along came pagers, which allowed consultants the freedom to be available on an as-needed basis. Fast-forward to 2018, and today's technology allows providers to completely review up-to-the-second information about a patient and properly triage that patient directly from the provider's mobile device.

In some specialties, technology is leading to care delivery transformation. As the treatments for stroke have become more sophisticated and effective, for example, it is critical to have neurologists available around the clock. For many hospitals, this isn't practical or even possible. With a digital record, however, neurologists can work remotely and cover many hospitals, enabling more facilities to deliver world-class stroke care.

More creative and focused use of digital technologies also stands to benefit other clinicians and patients directly.

Allowing nurses to leverage mobile technology would free them from the constraints of the desktop computer and the nurse's station. Mobility enables nurses to spend more time with patients and communicate, document, and administer medications without dragging a workstation with them. It's been well proven that more nursing time leads to better patient outcomes; streamlining each nurse's administrative work through mobility is a cost-effective and logical way to make this a reality.

Nurses spend a great deal of time communicating with physicians, including requesting medications to help comfort patients, sending alerts of changes in patient status, and notifying when critical labs arrive. In most hospitals, this work follows the "page" and call-back model, supported in some organizations by unsecure text messages. Purpose-built communication tools that work in the patient context, with patient information, that allow nurses and physicians to communicate and easily act on information would be far more efficient.

While repeated studies have shown that use of patient portals improves chronic disease management, patient engagement, and overall health, adoption rates remain low. A recent study from The Journal of Medical Internet Research found that poor practice workflow and health care's IT infrastructure may be the culprits.

Unfettered innovation will likely create more mobile health care tools for clinicians and patients, more artificial intelligence-enabled clinical decision support applications, and the ability for physicians to see the totality of the relevant patient information regardless of where patients were seen or which personal devices patients may be using to track their health.

When these and other innovations take root, the industry will finally see the cost and quality impact expected from technology.

— Paul Brient is CEO of PatientKeeper.