- Electronic health records remain a barrier instead of a helpful tool for increasing population health management capabilities, clinical analytics, health information exchange, and patient care coordination, say physicians and other stakeholders interviewed in a new study from the Journal of the American Medical Informatics Association (JAMIA).
While the healthcare industry generally applauds the concept of using health IT to improve care and is doing its best to make use of available infrastructure, organizations are still plagued by poor EHR usability, a lack of interoperability, and insufficient financial incentive to invest heavily in innovative technologies.
Researchers from Harvard University and Brigham and Women’s Hospital undertook 47 interviews with healthcare professionals working across the industry, including policymakers, practicing physicians, vendor executives, academics, legal experts, and payer representatives.
While the general consensus among participants was that the HITECH Act has been a meaningful and positive catalyst for health IT adoption, the specifics of the EHR Incentive Programs – and the technologies they have spawned – prompted less enthusiasm.
In 2009, EHRs were simply not ripe enough for the tasks set out for providers, several respondents said. The majority of health IT systems were developed in response to billing problems, and were not oriented for the clinical quality improvements and population health management tasks that meaningful use demanded.
“I think the lever was placed at the wrong place with meaningful use,” one survey participant said. “We started with a very immature technology. The lever was placed on physicians to use electronic health records as if they were already mature.”
“Existing EHRs are optimized for simple transactions,” another interviewee added. “They are not optimized…to support re-engineering care.”
The healthcare industry has always suffered with a patchwork of technologies developed in fits and starts, from pioneering organizations in the 1970s and 1980s that saw the future of computing in the industry to modern startups attempting to make these legacy systems, some in use for decades, communicate with innovative, internet-based data standards. The resulting hodgepodge of infrastructure, along with financial pressures that have rewarded providers who keep data to themselves, have made health information exchange and interoperability a nightmare.
“We have done just a God awful job doing clinical data exchange—health information exchange,” a participant said. “So it is just maddening to hear all of these ‘success stories’ about health information exchange when we are really doing a really bad job of it globally or nationally at least…many of the health information exchanges will cease to exist because they don’t have a sustainable business model.”
A string of high-profile failures in the state HIE arena have somewhat overshadowed the efforts of smaller, regional health information exchange organizations that provide the foundation for population health management on a community or local level. Started by integrated health systems or coalitions of providers and accelerated by the growth of the accountable care organization (ACO) movement, health information exchange is happening – yet it has largely failed to make a measurable dent in the larger scheme of things. Despite the possibilities, patient data continues to lag behind those who seek care, and preventable medical errors and unnecessarily repeated tests remain critical cost and care coordination concerns.
“We have not had strong enough policies. I think we largely have tried to leave HIE to the market,” opined one interviewee. “And I just think that it is a public good in a lot of ways. So I think continuing to pursue it as something that healthcare delivery organizations are going to do on their own … there are just multiple market failures that end up playing into it.”
“It's not clear that any given organization has a strong incentive to share their data and I think we haven't really put much pressure on the vendors to really make their systems interoperable,” she continued. “And I think the combination of those two, which is not good technical solutions and not very strong drive from the potential customers … It just sort of feels like a hopeless situation and I feel like everyone I talk to about where we are with HIT today, it’s the number one thing … We’re just not close.”
Rulemakers, providers, and vendors must change their perspective on the implementation of health IT, eschewing the idea that the academic medical center should be the primary focus for designing a data-driven healthcare system. Finding a way to better integrate smaller physician groups, specialists, and supporting providers without touching off a sudden rush for consolidation will be crucial for making EHR adoption, data exchange, clinical analytics, and interoperability into attractive business competencies.
And will start with population health management, many participants said. “Let me understand my population better in terms of their behavioral propensity,” pleaded a physician. “So of all my patients, who is the one who is most likely to fail this therapy? Who's the one most likely to end up in the emergency room? Who’s most likely to have the adverse effect? Who’s most likely to not pick up their medications? Who’s most likely to fall? So anticipating, going from retrospective to concurrent to prospective to predictive analytics, that’s kind of the next frontier as it were for health IT.”
The responsibility for helping healthcare organizations reach that point lies with the ONC and other rulemaking bodies, the participants largely concurred, and regulatory mandates like meaningful use and even HIPAA would need to be revised and rethought in order to encourage providers to make real efforts to improve clinical care quality, exchange data, and focus on population health.
Retooling the financial environment to embrace value-based reimbursement, bundled payments, and other accountable care strategies would be a good first step towards incenting organizations to leverage health IT in an effective way, especially as the need for ongoing chronic disease management begins to supplant the episodic structure upon which the system has always been built. As policymakers, payers, and physicians begin to embrace the idea of paying for outcomes and care quality, population health management will become even more central to financial sustainability and organizational success.
“To me, the future is going to be based on how we can better manage population health,” said one executive. “We are really doing very poorly when it comes to population health management and the basic things like managing of chronic conditions and managing certain risks … it’s really being able to expand the use of the tools to support better population health management.”