What can we conclude from this recent publication and reporting about it in the popular press? As always, it is best to look at exactly what has been claimed, what evidence supports it, and where it fits in the larger picture of this topic.
The 2005 RAND study modeled savings that could occur from HIT adoption :
- Reduced adverse drug events that extend hospital length of stay in the inpatient setting and avoid hospitalization in the outpatient setting
- Increased used of cost-effective immunizations and screening interventions
- Improved efficiency of chronic disease management
The CITL study used a somewhat similar modeling approach and drew similar conclusions. The CITL model focused on different types of health information exchange (HIE), from simple transmission of documents to full semantic interoperability of EHR systems. The latter approach was shown to achieve the most benefit, up to $77 billion per year.
Can we assess the correctness of these modeling studies, now that we have substantially increased EHR adoption through HITECH? The recent paper from RAND noted that the question is not simple to answer, but that HIT probably has fallen short of its promises, especially in terms of reducing costs . Of course, one of the challenges in answering the question of cost-reduction is that it is difficult to attribute avoidable cost in the healthcare system. We do know that healthcare costs have reduced their rate of growth in the last few years, probably mainly due to the economic recession . But we cannot know for sure how much of that reduction might be due to HIT adoption.
But an even bigger reason why we cannot know if the modeling studies are true is that we have achieved the kind of HIT environment that these studies assumed in the development of their models. The original RAND study assumed, as noted above, interconnected and interoperable systems that were adopted widely and used effectively. The authors of the new RAND paper note that HIT failure has come in large part because of failure to reach those assumption. In particular,
- We do not have interconnected and interoperable systems. In part, this is because many EHR systems are still closed and proprietary. In addition, HIE efforts are still early and nascent.
- We also do not have wide adoption yet of systems, especially advanced systems. While HITECH has led to increased adoption, there is still a long ways to go.
- And probably the biggest shortcoming has been lack of EHRs being used effectively. The adoption incentives in Stage 1 of meaningful use focus (by design) on building the data foundation. More effective use will come based on that foundation in Stage 2 and beyond.
Therefore my view echoes that of the RAND researchers in the new Health Affairs piece, which is that yes, HIT has not yet delivered on its promise to improve efficiency and reduce cost in the healthcare system. But the proposition that it inherently is not able to do so is also not known. As such, if we hope for that improvement, the grand experiment should go on. There is no question that the required time will be longer, the resources required will be larger, and the cultural change will be more difficult. There is also quite valid concern that there are some untended consequences of the staged approach in HITECH, which may be locking clinicians and hospitals into monolithic systems that are difficult to use and expand. I sympathize with the notion of current market-leader systems locking us into an "EHR trap," where the EHR should not be a monolithic application but instead a platform on top of which we can build apps that provide innovative functions and/or make new use of the data .
Over the last few years, I have ended many a talk on informatics noting that a "grand experiment" in our field was taking place, with the complete results unlikely to be years away. This study can be viewed as a mid-study assessment, and we can conclude that the benefits have not yet accrued, but that it may be too early to conclude that they will not occur. Although I agree that we probably need some mid-course correction in our approach, I also argue that we cannot go back nor should we end the experiment prematurely. We also must remember the motivations for implementing HIT and reforming healthcare in the first place, which is the error-prone and financially dysfunctional existing system, which both undermines competitiveness of US companies globally due to high employee healthcare costs as well as threatening to bankrupt the US government through unsustainable Medicare cost increases.
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