The New Health Dialogue

We had hoped to see progress in the Senate this week on the Wired for Health Care Quality Act, which would have given a big boost to the growth of health IT. Just last week, a reported agreement between Senators Patrick Leahy and Edward Kennedy on protecting the privacy of electronic health records generated movement on the bill. But some senators apparently still needed some persuading. And now of course, with WIRED as well as with countless other legislative issues dear to our hearts, we are sadly reminded just how hard it is to get things accomplished with Sen. Kennedy absent from the Senate, at least for now, because of his brain tumor. The senator and his family are in our thoughts, hearts and prayers.

News of Kennedy's illness had us all so stunned and distressed earlier this week that we didn't even notice right away two other key developments on the IT front, including the long-awaited report by the Congressional Budget Office, Evidence on the Costs and Benefits of Health Information Technology. For quite some time, CBO director Peter Orszag has been dropping hints that some of the claims about health IT's potential economic benefits were overstated. Sure enough, the CBO concluded that health IT won't save money unless IT initiatives are married with realigned financial incentives that encourage the optimal use of the technology. In other words, doctors, hospitals and other health care providers need to be financially motivated to realizing the savings. Otherwise it's just a medical record on a computer system, not a driver of savings and quality.

CBO does acknowledge that health IT, done right, could bring about savings. It could streamline handling of medical records, help avoid unnecessary and redundant medical tests, highlight potential medication errors and dangerous drug interactions, increase caregiver productivity and reduce hospital lengths of stay. Particularly integrated delivery systems, like Geisinger Health System, Intermountain Healthcare and Kaiser Permanente, realize internal savings from the use of electronic health records (EHRs) across their organizations. Organized, accessible electronic data bases (with privacy protections) can also help researchers both in public health and the growing field of comparative effectiveness.

We were not surprised, however, that the CBO was disparaging of the RAND and Center for Information Technology Leadership (CITL) studies that estimated net savings in health spending of about $80 billion a year—a number that has found its way into the presidential candidates' proposals. (The
Wall Street Journal's health blog looks at this angle) The CBO claims that both of those studies measured the potential impact of the health IT, not the likely impact, i.e. the best case scenarios not the likely real world scenarios. The result, according to the CBO, was a significant overstatement of what we can expect to save. For instance, the RAND estimate failed to take into consideration that hospitals may reduce their inpatient length-of-stays by transferring patients to a different setting, like a skilled nursing facility, which may net savings to the hospital sector but increase costs in the skilled-nursing sector.

We are not disheartened (or surprised) by these revelations, nor do we think more somber cost scenarios diminish the need for electronic medical records and more use of health information technology throughout the system. In fact, one of our core messages is that coverage, cost, and quality are inextricably linked and this is a great example. But we've got to get the medical community to adopt the technology—and use it well to reap the benefits to patients and to the overall system we all hope to see. We wholeheartedly agree that payment reform must be coupled with health IT, and Medicare as well as the private sector can bring about efficiencies and quality improvement. With the right incentives for doctors, we could, for example:

1) eliminate the need for most medical transcription and allow a physician to enter notes about a patient's condition directly into a computerized record;

2) eliminate or substantially reduce the need to physically pull medical charts from office files for patients' visits (and then put them back where they belong),

3) prompt providers to prescribe generic medicines instead of more costly brand-name drugs, and

4) reduce duplicative diagnostic tests.

We take CBO's point, that the adoption of IT in health care (by properly using EHRs, focusing on the coordination of care, managing complex chronic conditions) will actually lead to an increase of care and costs—but our goals include improving the quality of health care in America, so we're OK with that. We think the cost of improving the health of Americans will come back to us in spades—and more than just to the health care sector. We believe that it will help improve the productiveness of the workforce too. Health IT is worth it—and we think the CBO believes this too, it just wants it done right. And then savings will follow.

Another report issued two days ago was from The National Alliance for Health Information Technology (Alliance), under the guidance of BearingPoint, Inc., a management and technology consulting firm, which offered definitions to certain Health IT terms:

1) electronic medical record (EMR),

2) electronic health record (EHR),

3) personal health record (PHR),

4) health information exchange (HIE),

5) health information organization (HIO) and

6) regional health information organization (RHIO).

These definitions should go a long way to eliminate confusion about these concepts as legislation and private initiatives move forward, especially for the purposes of standard contract terms between health IT vendors and their customers. For instance, an EMR is an electronic health record that is created and consulted by providers in one health care organization. EHRs are the same thing, but are equipped with "interoperability standards" so an EHR can be easily shared with providers in more than one health care organization (ie. a cardiologist at one hospital, an internist at a second hospital, and an emergency room at a third hospital could all access the patient's full record with medical history, imaging studies, prescription drugs etc) . PHRs are easily shareable too, and the sources of information mostly come from providers, but are managed by the patient. This is a rapidly changing field—it's already different than when the senators began drafting the Wired Act a few years ago—so it will help if we all can agree on and understand terms as we try to bring our health care technology infrastructure into the 21st century, and use it to keep people safer and healthier.