Medicine Meets the Computer

The sources: “Use of Electronic Health Records in U.S. Hospitals” by Ashish K. Jha et al., “No Small Change for the Health Information Economy” by Kenneth D. Mandl and Isaac S. Kohane, and “Stimulating the Adoption of Health Information Technology” by David Blumenthal, in The New England Journal of Medicine, April 16, March 26, and ­April 9, 2009.

The endless manila folders that hold the medical history of most Americans seem curiously antiquated in a world of routine in vitro fertil­ization. So the Obama administra­tion’s $19 billion effort to goad the medical establishment into computerizing medical records sounds like an easy part of the huge economic stimulus package. But there are monumental challenges in install­ing adaptable systems that will truly improve patient care and cut ­costs.

Only 1.5 percent of U.S. hospitals have electronic rec­ords systems covering all their clinical units; an addition­al 7.6 percent have systems in at least one such hospital division, writes Ashish K. Jha, M.D., who collabor­ated with seven col­leagues at Harvard and one at George Washington University on a survey of 3,000 hospitals. Fewer than one in five doctors uses any kind of electronic records ­system.

Hospital officials attribute the delay to a lack of capital for the initial purchase and subsequent costs, as well as physician resist­ance and concerns over whether computerization would cost more than it would save. Privacy con­cerns, which loom large in the public discussion, were not among the most commonly cited barriers to ­implementation.

The Obama administration has offered extra Medicare payments of up to $44,000 per doctor for “meaningful use” of a “certified” electronic health-record system and $2 million bonuses to ­hospitals.

But in a world where technology changes at warp speed, will the newly named coordinator of the program, David Blumenthal, M.D., certify tech­nol­ogy that is flexible and innovative enough to keep up with fast-changing medical and information ­systems?

Current technologies, write Kenneth D. Mandl, M.D., of Children’s Hospital in Boston and Isaac S. Ko­hane, M.D., of Harvard Medical School, can be expensive and rigid. Big decisions need to be made up front to prevent hospitals and doctors’ offices from buying the medical equivalent of VHS video­tape technology in a world that eventually might go Blu-ray.

“Ideally, system components should be not only interoperable but also substi­tut­able,” Mandl and Ko­hane say. They cite as a model the Apple iPhone, which has a soft­ware plat­form that allows users to down­load new appli­cations and toss out old ones. And inform­ation should have “liquid­ity” and “substituta­bility”—at least at the level of an ATM—­so that a doctor could use billing soft­ware from one vendor, a ­pre­scription-­writing program from another, and a laboratory inform­ation system from a third. Competition and innovation might flourish if vendors could specialize.

To prevent physicians from be­coming “scribes,” regulations must ensure that new electronic systems exhibit a “realistic respect” for physicians’ time, Mandl and Ko­hane write. A RAND Corpor­ation study in 2005 estimated that electronic health rec­ords could save up to $77 billion annually through reduced hospital stays, avoidance of duplicate or useless tests, better drug utiliza­tion, and other efficiencies. But physicians also must see a direct benefit from mastering the new technology if they are to be motivated to use it to the ­fullest.

Blumenthal outlines “huge challenges,” in an article that appeared only five days after he was named to the program coordinator position. He says that many of the electronic rec­ords systems that have already been certified are neither user friendly nor likely to improve quality and effi­ciency in the ­health ­care system. Tightening the certification process is a “critical early challenge,” he says, but if the requirements are set too high, doctors will lobby to change the law or just forgo the bonus and hunker down to accept the ­penalties.


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Reprinted from Summer 2009 Wilson Quarterly
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