Thursday, June 11, 2009

Wharton on Healthcare IT: Can I Go Home Now?

Professors at the Wharton School of the University of Pennsylvania (one of the most prestigious business colleges in the world) had some very interesting observations about healthcare IT yesterday in an article entitled:

"Information Technology: Not a Cure for the High Cost of Health Care."

I have been writing on these same themes - irrational exuberance, HIT not being a panacea or cybernetic miracle, HIT as a facilitating tool in medicine, not a revolutionary one (but only if "done right"), inadequate research to back up the often grandiose claims, and so forth for over a decade ("Contemporary Issues in Medical Informatics: Common Examples of Healthcare IT Failure", link). I penned such sacrilege, often at risk to my career due the unpopularity of these ideas, itself due to the irrational exuberance of the HIT community (these attitudes were perhaps in part manufactured by a healthcare IT lobby).

Here are excerpts of what Wharton professors observed. Do read the entire article at the link above:

President Obama made information technology a linchpin in his plan to reform health care when he included $19 billion in computerized medical record funding in the $787 billion American Recovery and Reinvestment Act of 2009. The goal: Use technology to reduce costs and improve the quality of care. The reality: Technology could increase health care costs without markedly improving quality, according to experts at Wharton [except perhaps in very highly specialized projects, not easily portable, such as here - and not without its own set of problems - ed.]

... "No one has done the careful research to indicate that if one health care system has information technology and the other doesn't, then the care is different. There are no controlled trials," says Mark Pauly, a health care management professor at Wharton. All that technology is no panacea, he warns. In fact, he believes IT could actually raise costs because of culture clashes, training, the implementation of the systems [I would say "the mayhem that often goes on during the implementation" - ed.] and the labor required to maintain the new technology.

"The best-case scenario is that information technology will improve quality but not lower costs. The worst case is that there's no difference at all." [I believe if HIT is "done well", we can achieve best case, and lower costs as well to an extent, but there is enormous complexity behind the two simple words "done well" that I'm not sure we've fully mastered as a society yet - ed.]

... That opinion is echoed by other experts at Wharton and the University of Pennsylvania. "The focus on IT in health care is a good thing, but there's way too much hype about it [an understatement - ed.] and misunderstanding about what the benefits will be and how quickly they will come," says Peter Gabriel, medical director of clinical information systems at the University of Pennsylvania Health System.

[Kevin Volpp, professor of medicine and health care management] agrees that tracking real cost savings from health care IT is a difficult task, but he expects there to be some benefits from spotting and eliminating redundant care. [Agree - ed.] But those benefits aren't likely to add up to big savings, says Lawton R. Burns, director of the Wharton Center for Health Management and Economics. "I agree that information technology is important, but it's not the slam dunk it's portrayed to be," he says. The chase to reduce costs, improve quality and expand coverage is deemed the "iron triangle of health care. A lot of us wince [at that goal]," Burns notes. "It's arguable that we can't do any of those things well."

David A. Asch, a Wharton health care management and economics professor, agrees that technology is a big part of reform. "No one is arguing against it, but that doesn't mean that it's not oversold," he says. Gabriel likens the fascination over IT in health care to a shiny new object that's easier to focus on relative to more daunting issues.

... In addition, it's unclear what cultural issues [a big theme in my writings - ed.] will emerge as information technology is adopted. These cultural issues are in the forefront of primary care physician relationships. Experts at Wharton and Penn say physicians are generally skeptical of the technology movement. How much will a technology overhaul add to operating costs? How much will it cost to retrain workers? What's the electronic record learning curve? And what happens when a doctor has a laptop between him and the patient?

"Individual physicians just don't know where the money is going to come from," says Pauly. "If IT is tied to reimbursements it could work, but [many] are skeptical." Burns adds that the physician-patient relationship can also be altered. "Technology adoption changes the way you practice. What happens when your primary care physician is looking at his screen instead of you?"

All themes obvious to me after an informatics fellowship and term as CMIO at a major hospital, and to a number of my like minded colleagues as well. However, these themes were as hard to get published and recognized (i.e., turned into "memes") as a book against Global Warming ...

The Wharton article concludes with this pithy wisdom:

Experts say these projects are worth the effort, but the industry should keep its expectations in check [i.e., ditch the irrational exuberance - ed.] and closely scrutinize investments. "To the extent [that] these technologies improve the quality of care and get the patient more involved, I'm all for them," says [Richard Neill, residency director and vice chair at the University of Pennsylvania's Department of Family Medicine and Community Health]. "But the technology is not a sea change -- just a chance to change."

Anyone in Washington listening?

Finally, after a decade of writing on these same observations to a public apparently inclined to believe the myths and promised cybernetic miracles nourished by the IT industry, and getting nowhere until some very serious organizations caught on this year and joined in (the Joint Commission, the National Research Council, UK House of Commons, JAMA, AMIA, Wharton, etc.) I ask: can I go home now?

-- SS


Anonymous said...

I went to see my eye doctor yesterday and we had an interesting talk about IT. Something went wrong with her stand alone system and she had spent over two days working on data retrieval and getting the software bugs out. This is a system she bought and pays for regular updates.

Many of the insurance companies she deals with use the web for general information. Relying on one such site she charged a co-pay. The entire claim was denied. Finally getting someone on the phone they claimed she was a specialist, even though she was a listed provider. Now she and the patient have to come to an agreement concerning cost. She will loose again.

The ultimate came when some people from a nearby nationally recognized health insurance company processing center wanted to use her as a medical provider. Searching the web she could not find a way to access their eye coverage.

Eventually she received a call from someone in management. Yes, they offered eye, but had contracted this out to a low cost nationally recognized chain operation. And by the way, they have a goal of putting the solo practice out of business.

Computers appear to have become a tool in the insurance industry's arsenal to not only control cost, but control entry into the medical services field. The chance to change may be the chance to limit coverage, and increase profits for the insurance industry, while limiting options for the patient paying for coverage.

MD's are not alone in dealing with IT failures or manipulation.

Steve Lucas

MedInformaticsMD said...

Something went wrong with her stand alone system and she had spent over two days working on data retrieval and getting the software bugs out.

I once had a Chevy Vega that I often had to debug, for example, for coolant leaks so the aluminum engine would not overheat and warp, or manually closing the choke with my finger after pulling the air filter so the car would actually start on a cold morning.

Doing so did not make me a better driver.

-- SS

Benjamin Chodroff said...

What is needed in health care is IT, but not IT done with the current process. For IT to be done right in health care, the focus has to be on defining standardized data models, establishing governance for sharing information, and then creating a natural process around this. Until we have these standards for storing and sharing information we can spend all the money in the world and not come any closer to solving today's problems.