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Health Information Technology Comes of Age: Comment on “Achieving Meaningful Use of Health Information Technology”

Health Information Technology Comes of Age: Comment on “Achieving Meaningful Use of Health... Just over 3 years ago, President Obama signed the Health Information Technology for Economic and Clinical Health (HITECH) Act, an unprecedented intervention by federal policymakers to change the way physicians and hospitals deliver health care. The motivation to move clinicians toward adoption of electronic health records (EHRs) was born of a clear need: it was time for the US health care system to transition from a 20th century, paper-based cottage industry into a technology-driven, efficient, 21st century system. The Act is complex, and many physicians likely remain confused about what HITECH is trying to accomplish and how it affects them. In this issue of Archives, Marcotte and colleagues1 offer a very useful guide. The authors, from the Office of the National Coordinator (the federal agency overseeing implementation of the Act) and the Centers for Medicare & and Medicaid Services (the federal agency distributing the financial incentives), provide a detailed map of what HITECH might mean for practicing physicians. They lay out who is eligible for the incentives, what physicians have to do meet meaningful use criteria for receiving incentive payments, and the mechanics of signing up for the program. Three points of the guide are worth highlighting. First, because Medicare incentives are front-loaded, physicians who do not sign up by 2012 will not receive the full financial support. Second, the payments are more generous for physicians who care for a large proportion of Medicaid patients, partly to offset their greater difficulty accessing capital to invest in health information technology (IT). And third, HITECH carries penalties via reduced Medicare payments for those who stay with paper-based records past 2016. This incentives structure, front-loaded support with future penalties, should motivate physicians to begin their journey toward adoption of an EHR system. Do we have evidence that the Act is having this effect? We do. In 2008, just before HITECH was enacted, fewer than 20% of US physicians used EHRs.2 The adoption rate was increasing at a dismal pace of 3% to 4% per year, suggesting that it might take decades to achieve the goal of universal adoption articulated by both Presidents Bush and Obama. Under HITECH, the rate of adoption has increased dramatically: In 2011 alone, nearly 10% of US physicians adopted an EHR system, bringing the total to 35%.3 Physicians are now asking when and how best to adopt EHRs, not whether they should adopt. Given the challenges of delivering safe, effective, and efficient care using paper-based records, this is a welcome change. The Act is a timely reminder of the power of policy interventions when they are focused, targeted, and backed by substantial incentives. While the increase in EHR adoption is good news, the biggest challenges to achieving the goals of HITECH remain ahead. Many of the gains in EHR adoption appear to be happening among large practices, widening preexisting gaps. Because a sizeable proportion of health care is delivered in small practices of 1 or 2 physicians,2 many patients will not reap the benefits of EHR adoption unless small practices come on board. While Marcotte and colleagues1 mention the critical role of Regional Extension Centers (RECs) in helping these underresourced providers adopt EHRs, we have little information about how effective RECs have been, and slower adoption among small practices is cause for concern. The Office of the National Coordinator should report adoption and meaningful use data stratified by practice size and require that RECs demonstrate (through targets) that they are helping an adequate number of small practices to achieve these goals. A second major challenge is ensuring that EHRs are used effectively. Electronic health records change the way physicians practice medicine, sometimes in ways that can be helpful, and other times not. The EHR in the examination room can be a powerful tool for physicians to educate patients, but if used ineffectively, it distracts from the patient-physician relationship. An EHR allows members of the care team to function more effectively together by providing timely access to critical information, but in some instances, work previously done by ancillary staff shifts to the physician, worsening clinical efficiency. Finally, while EHRs can reduce medical errors,4 it can be harmful to clinical care through disruptions in workflow.5 We have almost no evidence about which strategies ensure that EHRs lead to better care and do not cause unintended negative effects. We need to build this evidence base immediately to help the hundreds of thousands of clinicians who are switching now from paper to EHRs. Failure to generate this knowledge will substantially increase the likelihood that the federal investment in health IT will fall short of its intended goals. Finally, even if physicians begin to use these systems effectively, there are substantial challenges to achieving the full benefits of EHR adoption. There are 2 areas that require particular attention. The first is ensuring that clinical data flow seamlessly between delivery settings. Most systems today do not support this, and there are technical challenges as well as organizational and cultural ones that hinder progress.6 Second, most systems are not equipped to automatically generate and report quality data. Federal policymakers would be most effective if they could identify a small set of very high priority quality measures and ensure that all EHR systems can generate them as a condition for meaningful use. Given our slow progress in patient safety,7 tools that measure and report on unsafe care would be an excellent start.8 Three years after the passage of HITECH, we can confidently say that we have started down the road toward 21st century medicine. The progress is heartening, but substantial challenges remain. Will we create a new digital divide where some providers use the latest electronic systems while many are stuck with an anachronistic, paper-based system? Will we learn how to use EHRs to enhance the quality and efficiency of clinical care while avoiding unintended harm? Will we seamlessly share clinical information in ways that improve patient care and population health? And finally, will we use EHRs to generate high-priority clinical quality measures to drive improvements in care? The answers to these questions, many of which will become apparent in the next 3 to 5 years, will signal whether the public's investment in health IT was worth it. Back to top Article Information Correspondence: Dr Jha, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115 (ajha@hsph.harvard.edu). Financial Disclosure: Dr Jha has served as a consultant on evaluations of programs funded by the Office of the National Coordinator for Health Information Technology. Additional Contributions: I am grateful to Julia Adler-Milstein, PhD, for her helpful comments on an earlier version of the manuscript. References 1. Marcotte L, Seidman J, Trudel K, et al. Achieving meaningful use of health information technology: a guide for physicians to the EHR incentive programs. Arch Intern Med. 2012;172(9):isa120006731-736Google Scholar 2. DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care: a national survey of physicians. N Engl J Med. 2008;359(1):50-6018565855PubMedGoogle ScholarCrossref 3. Hsiao C-J, Hing E, Socey TC, Cai B. Electronic medical record/electronic health record systems of office-based physicians: United States, 2009 and preliminary 2010 state estimates. http://www.cdc.gov/nchs/data/hestat/emr_ehr_09/emr_ehr_09.htm. Accessed March 15, 2012 4. Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc. 1999;6(4):313-32110428004PubMedGoogle ScholarCrossref 5. Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116(6):1506-151216322178PubMedGoogle ScholarCrossref 6. Adler-Milstein J, Bates DW, Jha AK. U.S. Regional health information organizations: progress and challenges. Health Aff (Millwood). 2009;28(2):483-49219276008PubMedGoogle ScholarCrossref 7. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363(22):2124-213421105794PubMedGoogle ScholarCrossref 8. Jha AK, Classen DC. Getting moving on patient safety—harnessing electronic data for safer care. N Engl J Med. 2011;365(19):1756-175822070474PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Health Information Technology Comes of Age: Comment on “Achieving Meaningful Use of Health Information Technology”

Archives of Internal Medicine , Volume 172 (9) – May 14, 2012

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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2012.1538
Publisher site
See Article on Publisher Site

Abstract

Just over 3 years ago, President Obama signed the Health Information Technology for Economic and Clinical Health (HITECH) Act, an unprecedented intervention by federal policymakers to change the way physicians and hospitals deliver health care. The motivation to move clinicians toward adoption of electronic health records (EHRs) was born of a clear need: it was time for the US health care system to transition from a 20th century, paper-based cottage industry into a technology-driven, efficient, 21st century system. The Act is complex, and many physicians likely remain confused about what HITECH is trying to accomplish and how it affects them. In this issue of Archives, Marcotte and colleagues1 offer a very useful guide. The authors, from the Office of the National Coordinator (the federal agency overseeing implementation of the Act) and the Centers for Medicare & and Medicaid Services (the federal agency distributing the financial incentives), provide a detailed map of what HITECH might mean for practicing physicians. They lay out who is eligible for the incentives, what physicians have to do meet meaningful use criteria for receiving incentive payments, and the mechanics of signing up for the program. Three points of the guide are worth highlighting. First, because Medicare incentives are front-loaded, physicians who do not sign up by 2012 will not receive the full financial support. Second, the payments are more generous for physicians who care for a large proportion of Medicaid patients, partly to offset their greater difficulty accessing capital to invest in health information technology (IT). And third, HITECH carries penalties via reduced Medicare payments for those who stay with paper-based records past 2016. This incentives structure, front-loaded support with future penalties, should motivate physicians to begin their journey toward adoption of an EHR system. Do we have evidence that the Act is having this effect? We do. In 2008, just before HITECH was enacted, fewer than 20% of US physicians used EHRs.2 The adoption rate was increasing at a dismal pace of 3% to 4% per year, suggesting that it might take decades to achieve the goal of universal adoption articulated by both Presidents Bush and Obama. Under HITECH, the rate of adoption has increased dramatically: In 2011 alone, nearly 10% of US physicians adopted an EHR system, bringing the total to 35%.3 Physicians are now asking when and how best to adopt EHRs, not whether they should adopt. Given the challenges of delivering safe, effective, and efficient care using paper-based records, this is a welcome change. The Act is a timely reminder of the power of policy interventions when they are focused, targeted, and backed by substantial incentives. While the increase in EHR adoption is good news, the biggest challenges to achieving the goals of HITECH remain ahead. Many of the gains in EHR adoption appear to be happening among large practices, widening preexisting gaps. Because a sizeable proportion of health care is delivered in small practices of 1 or 2 physicians,2 many patients will not reap the benefits of EHR adoption unless small practices come on board. While Marcotte and colleagues1 mention the critical role of Regional Extension Centers (RECs) in helping these underresourced providers adopt EHRs, we have little information about how effective RECs have been, and slower adoption among small practices is cause for concern. The Office of the National Coordinator should report adoption and meaningful use data stratified by practice size and require that RECs demonstrate (through targets) that they are helping an adequate number of small practices to achieve these goals. A second major challenge is ensuring that EHRs are used effectively. Electronic health records change the way physicians practice medicine, sometimes in ways that can be helpful, and other times not. The EHR in the examination room can be a powerful tool for physicians to educate patients, but if used ineffectively, it distracts from the patient-physician relationship. An EHR allows members of the care team to function more effectively together by providing timely access to critical information, but in some instances, work previously done by ancillary staff shifts to the physician, worsening clinical efficiency. Finally, while EHRs can reduce medical errors,4 it can be harmful to clinical care through disruptions in workflow.5 We have almost no evidence about which strategies ensure that EHRs lead to better care and do not cause unintended negative effects. We need to build this evidence base immediately to help the hundreds of thousands of clinicians who are switching now from paper to EHRs. Failure to generate this knowledge will substantially increase the likelihood that the federal investment in health IT will fall short of its intended goals. Finally, even if physicians begin to use these systems effectively, there are substantial challenges to achieving the full benefits of EHR adoption. There are 2 areas that require particular attention. The first is ensuring that clinical data flow seamlessly between delivery settings. Most systems today do not support this, and there are technical challenges as well as organizational and cultural ones that hinder progress.6 Second, most systems are not equipped to automatically generate and report quality data. Federal policymakers would be most effective if they could identify a small set of very high priority quality measures and ensure that all EHR systems can generate them as a condition for meaningful use. Given our slow progress in patient safety,7 tools that measure and report on unsafe care would be an excellent start.8 Three years after the passage of HITECH, we can confidently say that we have started down the road toward 21st century medicine. The progress is heartening, but substantial challenges remain. Will we create a new digital divide where some providers use the latest electronic systems while many are stuck with an anachronistic, paper-based system? Will we learn how to use EHRs to enhance the quality and efficiency of clinical care while avoiding unintended harm? Will we seamlessly share clinical information in ways that improve patient care and population health? And finally, will we use EHRs to generate high-priority clinical quality measures to drive improvements in care? The answers to these questions, many of which will become apparent in the next 3 to 5 years, will signal whether the public's investment in health IT was worth it. Back to top Article Information Correspondence: Dr Jha, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115 (ajha@hsph.harvard.edu). Financial Disclosure: Dr Jha has served as a consultant on evaluations of programs funded by the Office of the National Coordinator for Health Information Technology. Additional Contributions: I am grateful to Julia Adler-Milstein, PhD, for her helpful comments on an earlier version of the manuscript. References 1. Marcotte L, Seidman J, Trudel K, et al. Achieving meaningful use of health information technology: a guide for physicians to the EHR incentive programs. Arch Intern Med. 2012;172(9):isa120006731-736Google Scholar 2. DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care: a national survey of physicians. N Engl J Med. 2008;359(1):50-6018565855PubMedGoogle ScholarCrossref 3. Hsiao C-J, Hing E, Socey TC, Cai B. Electronic medical record/electronic health record systems of office-based physicians: United States, 2009 and preliminary 2010 state estimates. http://www.cdc.gov/nchs/data/hestat/emr_ehr_09/emr_ehr_09.htm. Accessed March 15, 2012 4. Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc. 1999;6(4):313-32110428004PubMedGoogle ScholarCrossref 5. Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116(6):1506-151216322178PubMedGoogle ScholarCrossref 6. Adler-Milstein J, Bates DW, Jha AK. U.S. Regional health information organizations: progress and challenges. Health Aff (Millwood). 2009;28(2):483-49219276008PubMedGoogle ScholarCrossref 7. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363(22):2124-213421105794PubMedGoogle ScholarCrossref 8. Jha AK, Classen DC. Getting moving on patient safety—harnessing electronic data for safer care. N Engl J Med. 2011;365(19):1756-175822070474PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: May 14, 2012

Keywords: health information technology

References