Comments by Dr. Reed Gelzer on RAND Health IT Report and Op-Ed in Pittsburgh Post Gazette

A 2005 RAND Corporation report predicted that health IT could save the U.S. healthcare system $81 billion a year. Since then, however, annual health spending has increased by almost a trillion dollars, and quality and efficiency have not budged much, even with an increase in health IT adoption, according to researchers Arthur L. Kellerman and Spencer S. Jones in a Jan. 2013 RAND study published in Health Affairs.  Kellermann is chair in policy analysis, and Spencer Jones is an information scientist..

A new Op-Ed by Kellerman and Jones entitled "IT in health care is MIA" appeared on Mar. 3, 2013 in the Pittsburgh Post-Gazette.

They wrote:

Because information technology has so quickly transformed people's daily lives, we tend to forget how much things have changed from the not-so-distant past. Today, millions of people around the world regularly shop online; download entire movies, books and other media onto wireless devices; bank at ATMs wherever they choose; and self-book travel while checking themselves in at airports electronically.

But there is one sector of our lives where adoption of information technology has lagged conspicuously: health care.

Some parts of the world are doing better than others in this respect. Researchers from the Commonwealth Fund recently reported that some high-income countries, including the United Kingdom, Australia and New Zealand, have made great strides in the use of electronic medical records among primary-care physicians. Indeed, in those countries, the practice is now nearly universal.

Yet some other high-income countries, such as the United States and Canada, are not keeping up.

Of course, the U.K. recently suffered a rather severe blow, on the order of 13 billion Pounds' worth, to its National Programme for Health IT in the NHS (NPfIT).  Australia is not exactly an "Emerald City" in terms of health IT, either, as can be seen from numerous links at the blog of Sydneysider Dr. David More, Australian Health Information Technology.

The RAND authors throw in some boilerplate grandiose predictions of certainty about health IT, which seems to have become a common phenomenon in newspapers and even scientific publications of late:

 ... The U.S. government is trying to help. In 2009, Congress passed the Health Information Technology for Economic and Clinical Health Act. HITECH has undeniably accelerated IT adoption, yet the problems of usability and interoperability persist.

... The sky is the limit when it comes to potential gains from health IT ... The payoff will be worth it. Indeed, as with the adoption of IT elsewhere, we may soon wonder how health care could have been delivered any other way.

Read the whole Op-Ed at the Gazette.

(My mother, an unwitting expert with significant experience on health IT adverse effects, is unavailable for comment, as she is dead due to a HIT-related accident.)

However, another expert is available:

Reed D. Gelzer, MD, MPH is an EHR/HIT systems and policy analyst for private and Federal agency clients, primarily in program integrity and clinical quality support.  In clinical practice for 11 years before transitioning into health IT, he also co-chairs the HL7 Records Management and Evidentiary Support (RMES) Workgroup.  He served US Navy Medicine’s Data Quality Office, various private insurers, as well as three years on CCHIT workgroups.  He was the Prevention Workgroup Chair for the 2007 ONC study on mitigation of EHR mediated waste fraud and abuse.

I find his opinions posted at the Gazette comment board of interest.  Some of the themes are very familiar. His comments are reproduced here with just a few comments of mine interjected:

Good afternoon Mr. Kellerman and Mr. Jones,

Thank you for the recitation of the arguments for HIT. I am particularly pleased that you note that a principle block to advancing HIT in the US is the fact that systems are not standardized.

One of the reasons many of our Industrialized Nation peers are far ahead of us is that they, in effect, standardized their systems by having one customer, a government entity operating health care. I assume you are not proposing that. If not then what, in the absence of regulation, will achieve your proper objective of standardizing HIT?

Well, we could simply let the market decide among the current non-standardized, non-regulated systems by accepting the accompanying burdens of cost, patient harms, and highly variable to unreliable data, and so on, in a nationwide experiment using the citizens of the U.S. as the test subjects [without informed consent or opt-out provisions, I might add - ed.] . A free market though would necessitate an absence of market-corrupting subsidies and transparency on comparing products, so that we can all equally hear when systems don't work as expected or cause problems for users, clinics, hospitals, and patients. No subsidies, no advantage to legacy vendors, and publicly available information about system problems, defects, and harms for a free market in HIT seems as unlikely as a single payer, government run system in the U.S., so what other options do we have?

We could say, we as a country want to improve this faulty and expensive industry, and so that is what we will hold providers responsible for. Doctors, hospitals, nurses, clinics, everybody -You have a duty to achieve better.  IT is a means, not the end. Purchase and apply the tools you decide you need to fix the problems you see. If you find you cannot do it, then close your doors and go to work for someone who can.

In support of this, as we do with drugs, we do not expect doctors, hospitals, nurses, clinics to independently research what is safe, what is usable in medications, in lab and imaging equipment and medical devices. We make sure that the tools available are safe, reliable, and do what they are intended to do. We do not de-regulate pharmaceuticals to speed innovation [due to the common claim by HIT hyper-enthusiasts that regulation would harm IT innovation, one might surmise they presumably would support pharma deregulation as well - ed.], we regulate minimum requirements of safety and efficacy so that such tools of medicine can be delivered to the bedside without the clinicians having to spend hours worrying about whether they're even fit for use.

Improving the safety, value, and effectiveness of patient care is not dependent on HIT.  Fit HIT is an indispensable enabler of KNOWING that we are doing our best and KNOWING where we are falling short and where improvements can best be directed.

Meanwhile, there can be no doubt that we will increasingly regulate HIT simply because it is the only way we can ever have non-anecdotal and systematic reporting on what HIT actually does (or doesn't do) for benefiting patients. Otherwise we will continue to be stuck where we are now: between a defective government policy that has bought the vision and promise (and there's a "no return" policy) without evidence, and the accumulating evidence of the difficulty, complexity, costs, and harms rendered by the current national experiment. [This evidence is often ignored or denied by the hyper-enthusiasts - ed.]

Again, thank you for reiterating the necessity of standardization. This should progressively elevate the attention to the vast library of HIT standards existent (and still evolving) that remain unused by vendors. Not just vendors, though. Standards also remain unused by doctors, nurses, hospitals, and clinics (and their organizational advocates) who still, amazingly do little, if any due diligence on the fitness of HIT to their use as patient care tools and records thereof.  [This is known as "negligence" and perhaps "gross negligence" - ed.]  Given that Meaningful Use has lowered the Certification bar so much lower than it was in 2009 and since subsidies have made it a Sellers market (and a race to avoid penalties) it is hard to imagine how the geometric progression of risk of non-standardized [systems] untested for safety, usability, or fitness will not assure pain and suffering of many kinds for years to come.

I look to you RAND to project your dynamic model for how Standardization will be achieved. In the meantime, of course this means that, among other things, they are not standardized for fitness in use for patient care.

RDGelzer, MD, MPH.

These are good thoughts.

I repeat my warnings that until sanity and caution is restored to the health IT sector (or started, as it may never have  existed) it is not likely that "we may soon wonder how health care could have been delivered any other way."

-- SS