Thursday, June 14, 2012

The New England Journal Of Medicine Published Two Editorials On Health IT. Must Read Work.

The following were published overnight and are both free open access.
First we have:

Escaping the EHR Trap — The Future of Health IT

Kenneth D. Mandl, M.D., M.P.H., and Isaac S. Kohane, M.D., Ph.D.
N Engl J Med 2012; 366:2240-2242 June 14, 2012
It is a widely accepted myth that medicine requires complex, highly specialized information-technology (IT) systems. This myth continues to justify soaring IT costs, burdensome physician workloads, and stagnation in innovation — while doctors become increasingly bound to documentation and communication products that are functionally decades behind those they use in their “civilian” life.
Even as consumer IT — word-processing programs, search engines, social networks, e-mail systems, mobile phones and apps, music players, gaming platforms — has become deeply integrated into the fabric of modern life, physicians find themselves locked into pre–Internet-era electronic health records (EHRs) that aspire to provide complete and specialized environments for diverse tasks. The federal push for health IT, spearheaded by the Office of the National Coordinator for Health Information Technology (ONC), establishes an information backbone for accountable care, patient safety, and health care reform. But we now need to take the next step: fitting EHRs into a dynamic, state-of-the-art, rapidly evolving information infrastructure — rather than jamming all health care processes and workflows into constrained EHR operating environments.
We believe that EHR vendors propagate the myth that health IT is qualitatively different from industrial and consumer products in order to protect their prices and market share and block new entrants. In reality, diverse functionality needn't reside within single EHR systems, and there's a clear path toward better, safer, cheaper, and nimbler tools for managing health care's complex tasks.
Early health IT offerings were cutting-edge,1 but contemporary EHRs distinctly lag behind systems used in other fields. In 1966, members of Octo Barnett's laboratory at Massachusetts General Hospital invented a highly efficient programming language for the earliest EHRs; the Massachusetts General Hospital Utility Multi-Programming System (MUMPS) partitioned precious computer memory so parsimoniously that with only 16 kilobytes, the earliest personal computers could run an EHR supporting multiple users. But nearly a half-century later, most EHR vendors not only have failed to innovate but don't even embrace existing modular architectures with interfaces that allow extension of product capabilities, innovative uses of data, and interoperation with other software.
The rest with references is found here:
The second one is as follows:

Unraveling the IT Productivity Paradox — Lessons for Health Care

Spencer S. Jones, Ph.D., Paul S. Heaton, Ph.D., Robert S. Rudin, Ph.D., and Eric C. Schneider, M.D.
N Engl J Med 2012; 366:2243-2245June 14, 2012
There is ongoing debate about the wisdom of the $27 billion federal investment driving the adoption of health information technology (IT) under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. Proponents expect IT to catalyze the transformation of health care delivery in the United States from a fragmented cottage industry plagued by poor quality and high costs to a highly organized, integrated system that delivers high-quality care efficiently. Skeptics suggest that the productivity benefits of health IT have been overstated, arguing that it may create safety problems and could even increase costs.
Debates about the productivity yield of IT are new to health care but not to other sectors of the economy. During the 1970s and 1980s, the computing capacity of the U.S. economy increased more than a hundredfold while the rate of productivity growth fell dramatically to less than half the rate of the preceding 25 years.1 The relationship between the rapid increase in IT use and the simultaneous slowdown in productivity became widely known as the “IT productivity paradox,” and economists debated whether investing billions of dollars in IT was worthwhile. The Nobel laureate economist Robert Solow observed in 1987 that “you can see the computer age everywhere but in the productivity statistics.”1
That earlier IT debate and its resolution carry important messages for today's health IT debate. Solow's famous observation launched more than two decades of research on IT's effect on productivity, and that research revealed numerous explanations for the paradox — as well as evidence that earlier conclusions about the relationship between IT and productivity were incorrect and that under the right conditions, IT could indeed yield significant productivity gains.
Explanations for the IT productivity paradox fell into three categories: mismeasurement, mismanagement, and poor usability. Mismeasurement explanations traced the paradox to shortcomings in research; the latter two categories highlighted shortcomings in practice. All three categories proved relevant: some productivity effects of IT were hidden because of limitations in the data and analytic methods used to evaluate productivity, and some benefits were limited by ineffective management and poor usability.
The rest of the article with references is found here:
The message that comes from these two papers for me is that we really underestimate just how hard Health IT, how hard it is to measure benefit is and just how much transformation of the health system is required - enabled by technology - the real transformation to actually become obvious.
It is just not good enough to say Health IT is different, or to avoid using all that has been learnt in other industries to delivery systems and processes that really work. Sadly I fear we are no where near there either with our processes or out current systems.
Both these papers will reward careful reading (and re-reading) to extract the most insight and understanding regarding the scale of the challenge e-Health actually is! (I really hope many in NEHTA and DoHA read closely.)


Anonymous said...

Agree, David, very interesting and enlightening editorials. Curiously, I was discussing a similar issue with someone just the other day - the big vendors had "mofern" technology 8-10 years ago, but have not kept up with the times. Trouble is that public health, who spend most of the money on Health IT tend to go to the big players and have been conditioned to the fact that it will cost mega millions to implement and support. Technology now allows us to do the same at a fraction of the cost.

Anonymous said...

sorry - should be "modern"....

Anonymous said...

Why would NEHTA read these or any other such research carefully? It indicates that one can accomplish somethings without having to spend so much money or architecturally boil the ocean. Also why would the health IT department be interested? Why would the vendor community be interested - they market to the medical and health sector selling the message yes you are special and its big and its expense and it can kill and hurt people if we get it wrong... hence why the likes cisco and others create branded products for the sector defining a whole new class of product as "medical" or "hospital" grade. Why because its big and its expensive and it makes them all a lot of money.

Why would those who have clinical leadership of these initiatives be interested? - they are paid by all of the above to spruik the benefits of these sorts of initiatives and technology.

The clinical lead model in NEHTA and more broadly in ehealth is part of the problem.