No More Clipboards
“This kind of aid to decisions, spread across tens of thousands of decisions every day, leads to much, much lower costs with no intrusion on clinical autonomy”
– David Blumenthal, M.D., M.P.P., National Coordinator for Health Information Technology, U.S. Department of Health & Human Services, speaking at Weill-Cornell Medical College, Sept. 15, 2010
Last week I had the opportunity to hear Dr. David Blumenthal, head honcho for national health IT development, give a presentation on electronic health records (EHR), the future of health information technology (IT) and meaningful use. He spoke at a health policy colloquium at Weill-Cornell Medical College.
The points he made were clear – to begin, that health IT encompasses three areas of value:
1. Electronic Health Records (EHR)
2. Health Information Exchange (HIE)
3. Clinical Decision support (CDS)
Notes on Electronic Health Records:
“What do patients think if you ask them what’s the value of an EHR?” he half-asked the audience, a group of 250 or so, mainly physicians. He answered: “No more clipboards.”
The problem is that doctors are reluctant to take on electronic systems. Prior to the Health Information Technology for Economic and Clinical Health Act (or HITECH Act) of 2009, only 6 percent of physicians used fully-functional EHRs; only 20 percent used any EHR in their practices. Hospitals weren’t doing any better, he said. We’re running far behind our European counterparts in this arena.
“What’s the barrier?” he asked, and answered: “Money is numbers one through eight. Then logistics, technical problems and fear.”
Physicians, and hospitals, are concerned about buying into systems that will become obsolete. “And it’s a psychological issue,” he added. “That comes in whenever you’re asking people to change.”
The benefit of EHRs will be more efficient care and better health outcomes. As things stand, the quality of a nurse or doctor’s care is limited by the information they have about the patient in front of them. If providers have access to a patient’s compete record – say a cardiologist who’s evaluating a patient with notes provided by the primary care provider (PCP) – that’ll save both parties (patient and doctor) time, reduce duplication of tests and facilitate the coordination of care.
But the real value in EHR, he suggests, is in the system’s potential output of information: “Cutting down the rate of dissemination of conventional information from 17 years down to months to weeks.” What he means, as I understand it, is that by having current findings – published data and recommendations – linked to a patient’s electronic chart and diagnostic codes, the doctors will see and (hopefully) read new materials having to do with their patients’ medical conditions.
Notes on Health Information Exchange:
This component of health IT relies on having a common language. “If physicians don’t speak the same language, their computers won’t either.” He emphasized the need for standard terms using this example: there are many ways to say “high blood pressure” in English; for a health information exchange to be functional, we need to agree on one term and use it.
“Information exchange is a team sport,” he considered further. “It’s a challenge, and we’re not always good at voluntary collaboration.”
Next, he listed some HIE essentials:
– a vocabulary and statistics (I’m not sure why these were paired as he spoke);
– a way of packaging information that it can travel on the Internet;
– electronic directories, so information goes where it should;
– protocols for delivery;
– security in transit.
What will it take to get physicians on board with this kind of plan? “We need economic incentives, trust, and requirements,” he indicated. Mandates might, in the future, involve licensing boards and other accrediting agencies that would test physicians’ competency in HIT. In his view, managing electronic information is an essential skill for doctors to provide effective medical care.
Notes on Clinical Decision Support:
First, he listed the four elements – algorithms, statistics, guidelines and institutional policy – that can be incorporated into CDS to promote evidence-based practice.
Second, CDS allows for Computerized Provider Order Entry (CPOE). This is a huge benefit at several levels, but the surprise for some in the audience is that the process becomes an opportunity for continuing medical education (CME).
(The idea for doctors’ learning as they enter orders, which I think important, is this, and I’ll provide my own example here: if you’re a physician about to order a drug, like a new antibiotic for a patient who’s got liver failure, the computerized system might have a pop-up message that says “are you sure you want to order that? Antibiotic X is metabolized by the liver…” And so you’d learn that the new antibiotic X is metabolized by the liver, and you might then look over a readily-accessible table of alternative antibiotics.)
“This caught my interest because it doesn’t diminish physicians’ autonomy,” he said. It just enables them to make decisions for their patients in the context of additional, current information. “The end goal is not to adopt technology, but to improve care.”
Notes on Meaningful Use:
He listed “five pillars of meaningful use”:
1. patient and family enlightenment
2. coordinated care
3. quality, safety and efficiency
4. privacy and security
5. improved public and population health
Then the discussion turned to some big money questions – including a critical issue having to do with companies competing to develop better EHR systems and physicians’ incentives. If you’d like to read more details about meaningful use, I recommend a recent perspective in the New England Journal of Medicine and a brief in the August issue of Health Affairs, to which Blumenthal referred during his informative talk.
As for me, I’m tired of clipboards. I look forward to expanded health IT and EHRs. In the future, patients will be more informed in their decisions, and doctors will be in theirs. Maybe, sometime…