I recently took part in a small workshop exploring the benefits and challenges for artificial intelligence in medicine. Many of the participants were innovative medical educators, and most of them were still practicing clinical medicine. Although the workshop covered a broad range of topics, one theme stood out to me, perhaps because of my role as an academic informatician. In a nutshell, when we arrived at the topic of implementing AI systems in clinical practice, many laments were expressed about their impact on clinicians and insuring that the use of AI "cannot be as awful as the EHR."
As one who has been working in biomedical and health informatics for over three decades, this discussion about impact on practice and the experience of the electronic health record (EHR) drove home that unquestionably the most profound event in informatics during my entire career has been the the Health Information Technology for Economic and Clinical Health (HITECH) Act. Our field was changed substantially with the passage of the HITECH Act as part of the American Recovery and Reinvestment Act (ARRA) in 2009, leading our present world to be substantially different from the world before it. I also find that many who lament about the negative impacts of the EHR on healthcare are not aware of the history of HITECH.
Those of us who have been around long enough can remember informatics before HITECH. While EHRs had been adopted by many healthcare organizations, including my own, overall use was modest. We were also encouraged, especially in the decade of the 2000s before HITECH, by the growing amount of research published showing that the EHR and associated clinical decision support functionality led to error reduction, cost savings, and improved outcomes. Indeed, a systematic review in 2006 summarized the mostly positive studies, although noting they mostly came from "health IT exemplar" institutions [1]. An updated review in 2009 found similar results [2]. My own view at the time was captured from my participation in a panel on the National Public Radio (NPR) show, Talk of the Nation - Science Friday, in 2005.
Another commentary published in 2010 noted that four "tribes" of healthcare improvement - focused on quality improvement, payment reform , consumer engagement, and health IT - were coalescing in the run-up to health care reform under President Barack Obama, for which HITECH was described by some as a "down payment" [3]. And the pre-HITECH enthusiasm all reached a boil when the ARRA legislation included the HITECH Act and its $30+ billion for incentives for EHR adoption [4].
Here is how I concluded a post in this blog from early 2010 highlighting the details of the HITECH Act:
This is a defining moment for the informatics field. Never before has such money and attention been lavished on it. HITECH provides a clear challenge for the field to 'get it right.' It will be interesting to look back on this time in the years ahead and see what worked and did not work. Whatever does happen, it is clear that informatics lives in a HITECH world now.
To many in informatics, the HITECH Act may now be a distant event, and some in the field who are younger may not even had yet started working in it. But clearly the informatics world is much different now. Informatics is certainly more prominent in operational healthcare settings. Ever increasing numbers of healthcare organizations have anointed clinical leadership devoted to informatics [5].
In retrospect, the widespread EHR adoption of HITECH was carried out too hurriedly, and glossed over some major problems, not the least of which was inadequate adherence to data standards and interoperability. Indeed, it can be said that the health IT components of the 21st Century Cures Act, passed with a bipartisan majority in 2016, were some necessary corrections to the problems emanating from the HITECH Act [6]. The Cures Rule enshrining SMART on FHIR for interoperability and information blocking prohibitions to facilitate movement of data can be viewed from that perspective.
Whether deserved or not, the informatics community is included in the blame for the facts that EHRs slow clinicians down [7, 8], fill the record with questionable and duplicative information [9], and contribute to clinician burnout [10, 11]. The informatics field should accept part of the blame but must also be part of the solution. Actions such as the AMIA-led 25x5 initiative to reduce the burden of EHR documentation to 25% of its current level within five years are important. I also believe there are technologies that will improve the capture of data and clinical thought processes into the EHR, such as voice recognition and reworking of the user interface to facilitate care rather than just documenting it.
Clearly the HITECH Act was the most profound event of our field in modern times. The informatics world before and after HITECH is very different, for better or worse. Ever the informatics optimist, there is great opportunity to improve the use of EHR and other systems to deliver modern healthcare. I am confident we will rise to the challenge.
References
1. Chaudhry, B., Wang, J., Wu, S., Maglione, M., Mojica, W., Roth, E., Morton, S.C., Shekelle, P.G., 2006. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 144, 742–752.
2. Goldzweig, C.L., Towfigh, A., Maglione, M., Shekelle, P.G., 2009. Costs and benefits of health information technology: new trends from the literature. Health Aff (Millwood) 28, w282-293.
3. McKethan, A., Brammer, C., 2010. Uniting the tribes of health system improvement. Am J Manag Care 16, SP13-18.
4. Blumenthal, D., 2011. Implementation of the federal health information technology initiative. N Engl J Med 365, 2426–2431.
5. Kannry, J., Sengstack, P., Thyvalikakath, T.P., Poikonen, J., Middleton, B., Payne, T., Lehmann, C.U., 2016. The Chief Clinical Informatics Officer (CCIO): AMIA Task Force Report on CCIO Knowledge, Education, and Skillset Requirements. Appl Clin Inform 7, 143–176.
6. Kesselheim, A.S., Avorn, J., 2017. New “21st Century Cures” Legislation: Speed and Ease vs Science. JAMA 317, 581–582.
7. Tutty, M.A., Carlasare, L.E., Lloyd, S., Sinsky, C.A., 2019. The complex case of EHRs: examining the factors impacting the EHR user experience. J Am Med Inform Assoc 26, 673–677.
8. Zheng, K., Ratwani, R.M., Adler-Milstein, J., 2020. Studying Workflow and Workarounds in Electronic Health Record-Supported Work to Improve Health System Performance. Ann Intern Med 172, S116–S122.
9. Steinkamp, J., Kantrowitz, J.J., Airan-Javia, S., 2022. Prevalence and Sources of Duplicate Information in the Electronic Medical Record. JAMA Netw Open 5, e2233348.
10. Gardner, R.L., Cooper, E., Haskell, J., Harris, D.A., Poplau, S., Kroth, P.J., Linzer, M., 2019. Physician stress and burnout: the impact of health information technology. J Am Med Inform Assoc 26, 106–114.
11. Murthy, V., 2022. Health Worker Burnout — Current Priorities of the U.S. Surgeon General [WWW Document]. https://www.hhs.gov/surgeongeneral/priorities/health-worker-burnout.
