Medscape One-on-One: Rapidly Unfolding Health Information Technology

Eli Y. Adashi, MD; Ashish Jha, MD, MPH

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December 02, 2009

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Eli Y. Adashi, MD: Hello. My name is Eli Adashi, Professor of Medical Science and former Dean of Medicine in Biological Sciences at Brown University [Providence, Rhode Island]. Welcome to Medscape One-on-One.

Today's topic is the rapidly unfolding edge of health information technology and what it actually means to the inpatient and outpatient physician. With me here today is Ashish Jha, an expert physician-scientist and an Associate Professor of Medicine of Health Policy and Management with the Harvard School of Public Health [Boston, Massachusetts]. Dr. Jha's latest contribution to this area, a seminal paper that was published in The New England Journal of Medicine earlier this year, caused a significant stir, given the finding that only 1.5% of US hospitals have implemented a comprehensive electronic records system. Welcome, Dr. Jha. It's wonderful to have you.

Ashish Jha, MD, MPH: Thank you, Dr. Adashi. It's my pleasure to be here.

Dr. Adashi: What a shocking finding in that paper. Many of us have assumed this system would be much further along. Tell us a little bit about how this all came about and how you put it together.

Dr. Jha: It is a surprising number, and let me provide some background. When we first began looking into how many hospitals are using electronic record systems, we found that the prior survey suggested that the rate of adoption was somewhere between 5% and 57%. Now that's a pretty broad number, and it suggests that we didn't have a good sense of what was happening. That's because the previous surveys either hadn't defined electronic records very carefully or they hadn't used a good national sample, and so we set out to try to do this well. We didn't ask hospitals whether they used an electronic record system. Again, there is no consensus on what that means.

Dr. Adashi: Right.

Dr. Jha: Instead, we asked hospitals about functions. We asked questions like: Do physicians prescribe electronically in your hospital? Do they write notes electronically? Do they look at laboratory results electronically?

Then, we convened an expert panel to help us think about what functions constitute a comprehensive electronic record, sort of the ideal vision of where we're trying to go, and also a basic record, because we knew that very few hospitals would be able to meet the comprehensive definition.

The expert panel told us that there are 24 functions that go into a comprehensive electronic record system. That accounts for the 1.5%. They also said that there is a list of about 10 functions that are important for a basic electronic record, and of those 10 functions, about 7.5% of hospitals meet the necessary requirements.

The total comes out to about 9%-10%, which is still a pretty dismal number. One last point: It is not to suggest that the other 90% have nothing. A lot of hospitals have laboratory results that are electronic and some aspects of decision support, but the key things that really are holding hospitals back are clinical documentation -- doctors and nurses writing notes -- and order entry, physicians ordering electronically. Those are the real challenges.

Dr. Adashi: Clearly a lot of work remains to be done, but one piece that I was particularly curious about concerned the outpatient setting. Could we conceivably be doing better in the outpatient setting as opposed to the inpatient context, which is primarily, but not exclusively what you looked at?

Dr. Jha: Right. We had another survey published about a year ago in early 2008, which looked just at the outpatient setting. In that survey, we found that 4% of doctors have a comprehensive electronic health record and an additional 13% have a basic record. Sure enough, the outpatient setting is better, but 80% of doctors still don't meet either the basic or the comprehensive definition. No matter how you slice it, the bottom line is that we have a long way to go.

Dr. Adashi: I completely agree, and I would say not surprisingly and perhaps fortunately in February of this year the government stepped in and took upon itself to really lead the change, which we badly needed for a long time.

Dr. Jha: Yes.

Dr. Adashi: Tell us a little bit about the so-called stimulus bill, what it offers to the practicing physician inpatient or outpatient in terms of electronic medical records.

Dr. Jha: Sure. I think the current administration was keenly aware of these numbers. There has been broad consensus that we have to transition toward an electronic record system for the good of the country, for the good of the healthcare system. Our healthcare system right now is incredibly inefficient. There is a lot of waste; care is suboptimal; and we all believe that electronic record systems should help. They're part of a broader solution.

The government, as part of the stimulus bill, put in about $30 billion in financial incentives for doctors and hospitals. Sometimes you'll hear the number 19.5 billion. The real number is about 30 billion; 30 billion is about how much the government is going to be cutting checks for. The notion is that if they do it well and if doctors and hospitals really adopt, there will be some savings to be had from Medicare and Medicaid, which is how we come out with 19.5 as the net.

Let's talk about what those incentives are and what it means for the average physician on the street, sort of the practicing doc. What does it mean? There is about $44,000 for every ambulatory care physician. Every physician in the ambulatory care setting gets about $44,000 starting in 2011, and the incentives run out in 2014. For that 4-year time period they get about $44,000. The question might be: Is that enough?

Dr. Adashi: What do they have to do to be eligible for the $44,000?

Dr. Jha: Right, great question to which we don't have a definitive answer yet. Let me explain a little more. Congress said that they wanted to give the incentives not just for buying a record system and implementing it, but for using it in a meaningful way. Of course, everybody says, "what do you mean use it in a meaningful way?" The answer is that it is not yet defined, but we have some contours of what it's going to look like. David Blumenthal, who is leading this effort on behalf of the federal government, has put together several panels of expert clinicians, policy people who have been leading the charge on defining "meaningful use."

At the end of the day, it's a decision that the administration makes, but if you look at the work of the panel, what becomes very clear is that they're using this to get people to engage in quality much more -- to use tools that are going to reduce errors. They're going to have to show that they can prescribe electronically, that they're using decision support, and that they're able to measure quality through their electronic system.

This is much more ambitious than what people have been able to do in the past, and it's going to set the bar high eventually for doctors and hospitals to get the incentives.

Dr. Adashi: Suppose for a moment that I failed to achieve the goals you just delineated and/or in fact chose not to pursue them? Are there any downstream consequences? Are there any penalties I need to be thinking about as a physician practicing?

Dr. Jha: The answer is yes there are. From 2011 to 2014, there will be incentives for you to adopt records systems in a meaningful way. Starting in 2015 the penalties will kick in. Medicare and Medicaid payments are going to actually get cut, but specifically Medicare payments are going to get cut from physicians who don't meet meaningful use. There is the carrot up front, but a stick that follows that says ultimately it's optional, but it's not that optional.

Dr. Adashi: It's fair to say that this time around we really mean business, and second, I would say the magnitude of the budget is truly historic and could in principle transform the way we practice medicine in the United States.

Where in the process would you say we are today? In other words, what have we accomplished in the timeline toward 2015 and beyond? Granted, much of this is time driven.

Dr. Jha: It is time driven. If someone were to ask me where we are in 2009 on this topic, I think the answer is we're really in the first stages. We're in the first inning of a baseball game. First of all, we've talked about the adoption numbers, right? Less than 20% in the physician's outpatient setting, less than 10% in the inpatient setting, and the definitions of meaningful use are still coming into play. My sense is that over the last 6 months to a year, adoption has been sort of frozen for 2 reasons. For hospitals it has been hard to access the capital markets because of the financial meltdown that we had, and everybody trying to figure out what meaningful use will be before making the big investments.

My sense is that we're in the first inning, but the game is going to pick up very, very quickly, and people have to be ready to be up and running in a very short timeline. As I mentioned, the incentives are from 2011 to 2014, but they're front-loaded and much of the incentives will come in 2011 and 2012, and if you miss that window, it's going to be hard for you to make it up later. For doctors and hospitals, you're not going to have a lot of time to get up and running on electronic record systems.

Dr. Adashi: If I were a practicing physician today in an outpatient context, what would you suggest that I do, if anything, at this time and/or in early 2010? What kind of advice could you offer to the practicing physician in terms of preparing for the inevitable in many ways?

Dr. Jha: Yes. It's a great question and I have a few thoughts. First of all, I think paying attention to where this topic is going, where meaningful use is going, is going to be very important, especially if you're a physician in a small practice. This is going to be challenging. This is going to be disruptive to your practice. There's nothing easy about adopting and effectively using an electronic record system. One of the reasons the numbers are so low is because physicians are very aware of how hard this is.

If I were starting to prepare, I would really look at my practice; I would look at my workflow; I'd look at how it is that I do things on a day-to-day basis and start planning out what I'd like it to look like once I have electronic record systems. How am I going to do record management? How am I going to manage patient flow? Those are all the really hard things that you can begin preparing for now as you do this.

The other hard part for a lot of physicians is vendor selection. Who do I go with? How do I make this choice? I don't have any easy advice and certainly don't have any specific recommendations. I think there are a lot of good vendors out there, but I think it's going to be important to team up with other colleagues and look to your medical society. A lot of medical societies are starting to work on trying to help physicians get ready for electronic record systems.

Understand that this change is coming, and if you want to meet meaningful use definitions, 2010 is going to be your big year because you're going to have to do most of the work in 2010 in order to meet the incentives in 2011.

Dr. Adashi: As of today, for example, you would argue or suggest that there are no forms I need to fill out. There is no registration I need to go through. I just need to be tuned to the information that comes from the US Department of Health & Human Services, specifically from the Office of the National Coordinator, and then do what is expected to be done. Is that a fair statement?

Dr. Jha: That's a fair statement, and there is going to be some help here. It's not going to be simply that they will declare here's meaningful use and then everybody's going to go out and do it on their own. The Office of National Coordinator and US Department of Health & Human Services are funding a series of regional extension centers. These things have still not gotten funded. We don't know all of the details of what they're going to look like, but the notion here is that these entities funded by the government are going to be in charge of helping doctors and hospitals adopt.

Dr. Adashi: These are resource notes.

Dr. Jha: These are resource notes.

Dr. Adashi: Think of them as Apple stores throughout the nation.

Dr. Jha: Exactly. Those Apple stores, these regional extension centers, are going to be absolutely critical. Another thing that physicians certainly can start doing is figure out who your regional extension center is. Start making connections with people who are going to be there. They are going to get up and running over the next few months.

This is a very quickly moving field, and doctors really do have to pay a little bit of attention to what's happening. There will be help for them. This is not going to be a "you're left on your own to figure this out on your own."

Dr. Adashi: Keep your ears up, and help is on the way.

Dr. Jha: I think so.

Dr. Adashi: Given your background in this arena and the time you have spent thinking about it, if you were to give us a prognostication of the likelihood of us becoming a connected medical nation by 2015, which is 5 years away effectively, what kind of prognosis would you predict for this national patient of yours?

Dr. Jha: Right. The president has said that he wants to have 90% of patients in America get their care through electronic records by 2014. This is an extremely ambitious goal, given where we are today.

Dr. Adashi: We have to go from 1.5%, ideally to 100%.

Dr. Jha: Right. That is not an easy path. I think that we're going to see a lot of movement. It's hard for me to imagine that we're going to get to 90% or 100% by 2014 or 2015, but I hope we can get a majority of physicians and a majority of hospitals using electronic record systems. That would be terrific if we could get to there.

The part that I worry about even more than whether we can adopt these systems is whether we're going to be able to use them in ways that are really going to lead to greater efficiencies and higher quality. That is much, much harder. It's interesting because people think about adoption being hard and adoption is hard, but adoption in some ways is the easier part of this because we all know in some ways how to do adoption. What is really challenging is once you've adopted, once you're using this, how do you make sure that you really use this tool effectively to both improve the care you provide and to improve the efficiency with which you provide that care? We're still early in our knowledge of how to do that, and that's the part that I worry more about in terms of our ability to achieve that.

Dr. Adashi: Another element I would like for you to deliberate and give some consideration is the notion of connectivity to the rest of the system. Say I practice in the Boston area. I would at a minimum want to be connected to any and all hospitals I assume in the region. With us really thinking of a national grid, would I not want to be connected to a hospital in San Francisco, California? If so, how are we thinking about all of this coming to pass?

Dr. Jha: It's a good question, and it underlines the fact that when I mentioned the 10% of hospitals or 20% of doctors, none of that included connectivity. Those were sort of silos. Those were electronic record systems in your institution. The reality is that as of today, as of 2009, relatively few doctors and hospitals are exchanging clinical data with each other. It's happening in a handful of communities, and even there it's pretty limited.

Dr. Adashi: Yet we all agree that without getting there we are missing the point.

Dr. Jha: Absolutely. Most of the evidence that suggests that our system can ring out a lot of inefficiencies requires us to be able to do clinical data exchange.

Dr. Adashi: To minimize redundancies, not to order tests twice or thrice, we should have the information at our fingertips as opposed to having to chase it down?

Dr. Jha: That's right. Anybody who's practiced in an emergency room -- and I certainly have experienced this over and over again -- you see the patient who comes in and you have almost no information about them. At this point, you're making guesses about what's going on and you're practicing medicine in a way. Really you're practicing medicine with your hands tied behind your back.

Dr. Adashi: You're always starting from scratch.

Dr. Jha: You're always starting from scratch.

Dr. Adashi: As if there was no history.

Dr. Jha: That's right. It's not only inefficient, not only wasteful, but it's also not good care. There is broad consensus that clinical data exchange absolutely has to be a key part of this. A couple of thoughts about where I think that's going. First of all, there is a small set of money, about $300 million that's set aside in the stimulus bill specifically for clinical data exchange, specifically to promote this.

The second issue is that in the meaningful use definitions -- and again, it's still being worked out, so I don't have any crystal ball into what it will look like -- but in the early sketches of the meaningful use definition, the ability to share data and to demonstrate that you can share clinical data are in there, and I think that's gong to be really important.

There is, I think, a major issue that has not been addressed by policy makers around this, and that has to do with issues around competitiveness. As much as we all like to believe that we're not competitive with each other, of course the reality is that hospitals compete with hospitals; certain doctor groups compete with other doctor groups; and there is early evidence beginning to emerge that some of the biggest barriers to clinical data exchange are not the technical stuff. It's not financial issues; it's competitiveness issues.

Dr. Adashi: It's the willingness to share.

Dr. Jha: It's the willingness to share. A colleague of mine, who's a professor at a business school, always says it's sort of like asking Amazon.com to share its customer list with Walmart.com. It's not going to happen. Now in healthcare we'd like to believe we're a little bit more collaborative. There are patients' lives at stake here, but the reality is that there are underlying market pressures that are going to hold people back, and that to me is the big unanswered issue that no one is taking on.

Dr. Adashi: To your knowledge, are some of the committees that are currently advising the national coordinator addressing this or related issues?

Dr. Jha: I think the committees are addressing a lot of the other issues that are on the table. They're addressing privacy and security concerns, and that's always been a big issue, especially for consumers who are worried about how clinical data will flow. That's being addressed pretty effectively. Another big issue has been standards, the fact that electronic records systems can't talk to each other; a lot of that has to do with the fact that we have no national standards. There has been terrific work in that area.

Obviously, financial barriers are being addressed with the stimulus money. I think most of the issues have been addressed, but no one has taken on the competitiveness stuff because I don't think we have a clear path for how you do that.

Dr. Adashi: A loose end that still fairly needs to be dealt with.

Dr. Jha: Yes.

Dr. Adashi: We have focused mostly on the physicians it seems, and clearly a big piece of all of this would be adoption by hospitals. What types of incentives and/or penalties do hospitals look at for the next presumably same 4 or 5 years?

Dr. Jha: I think hospitals are going to have a harder time at this. Here's why. I mentioned earlier that we had about $44,000 for every physician. The financial estimate suggests that it costs a typical doctor between $40,000 and $60,000 to put in an electronic record system. From soup to nuts that's the bill. Well, $44,000 goes a long way to paying for that. Most or all of it can get paid for with the stimulus money.

The dollars for hospitals are much harder to wrap your arms around because it varies dramatically based on size, based on prior legacy systems that hospitals have. The numbers for hospitals run in the tens of millions. There are hospital systems that easily spend $50, $100, or $200 million on electronic record systems. The stimulus money isn't going to come close to covering that.

Dr. Adashi: What would you say is the best-case scenario for a midsized hospital in terms of the dollar figures they could count on as an incentive, just to give the listener a sense?

Dr. Jha: Sure. The number that's often quoted for the average hospital -- whatever that average hospital might be -- is about $11 million. While $11 million is nothing to sneeze at, for the average hospital it's probably not going to be close to enough, and that's a big challenge.

Dr. Adashi: Do we have any sense or notion that the much larger bills that characterize the vendors up until now might be coming down? Is this going to be like any other technology wherein over time the price simply seems to come down? It always seems rather puzzling that figures like $50 to $75 million were floated as required to digitize a hospital, if you will. Is it likely that over time we're going to approach the $10- to $15-million range?

Dr. Jha: I wish it were so, and let me tell you why I'm worried that it's not. First, when you hear numbers like $50 or $75 million, a lot of people ask, "how could it possibly cost that much? The computers don't cost that much. The software doesn't cost that much. How is it that it costs that kind of money?" Surely the computer and software costs can come down over time as we get more economies of scale. The problem is that for a hospital, hospitals have lots of legacy systems. They have a pharmacy system, a laboratory system, a radiology system, etc. An electronic record has to be able to talk to all of it, hold data from all of it, and that requires a lot of interface building and requires a lot of human information technology expert time that's hard too upscale, and it's hard to reduce the cost just by improving the technology, as it were. That's going to be a major challenge.

The second part that makes it so expensive is the training that goes into getting doctors and nurses to use it effectively. One of the most effective ways of ruining your implementation is not spending enough time and effort on training, and training is expensive. Some hospitals try to do it on the cheap by making people get training on their own time, and that leads to disgruntled staff, or you can pay the nurses and physicians for their time, which makes it expensive. Either way, you have to do good training, and there is a cost there. I'm not sure that comes down if you have lots of people doing it.

There will be some efficiencies as we scale up, but my sense is that the majority of the costs are probably not so easy to scale.

Dr. Adashi: Perhaps we can look forward to the entry of other vendors into the arena, improve competition, and perhaps more affordable creation of infrastructure as we go forward.

I wanted to thank you for a very thoughtful and very complete coverage of an unfolding edge. On behalf of the listeners and behalf of myself, I really want to express my appreciation.

Thanks to our guest, Dr. Ashish Jha, and to our viewers, for listening to this inaugural edition of Medscape One-on-One.

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