When it comes to information technology, the health care industry is “clearly lagging behind,” according to Ashish Jha, Harvard T.H. Chan School of Public Health’s K.T. Li Professor of International Health.
We live in an era when anyone with a smartphone can host a business meeting, deposit a check, and navigate the quickest route home through rush hour traffic, all with a few swipes of the index finger. Not so when it comes to health care – at the doctor’s office people still fax things, noted Tejal Gandhi, CEO of the National Patient Safety Foundation, who also teaches at Harvard Chan School.
Not too long ago, in 2008 – the same year Barack Obama ran the first “Facebook Election” – Jha and colleagues discovered that “about 17 percent of doctors were using electronic records, and only about 9 percent of hospitals had one.” He called these “abysmally low rates.”
When it comes to information technology, the health care industry is “clearly lagging behind.”
Since then, the health care industry has played a lot of catch-up, but “it’s slow,” said Mary Finlay, a Simmons School of Management professor who teaches Leadership Strategies for Information Technology in Health Care at Harvard Chan School. “People in health care ask, why can I go online and order a pair of boots and have a conversation with my sales person, but I can’t go in and schedule my own appointment with my physician?”
Now, though, technology is changing the way doctors and providers do business. In 2014, Finlay had to schedule doctor’s appointments via telephone, she said; now she uses a patient portal. As with her provider, most large health care organizations have by now crossed the digital divide and embraced things like electronic health records and patient portals. Some smaller providers find this transition more challenging due to budget constraints.
Those managing tight budgets are keenly aware that adopting and maintaining IT systems costs sizeable amounts of money. Compounding this challenge is the worry by some that digital strategies in health care have a long way to go in terms of improving outcomes for both patients and institutions.
To frame it another way: let’s say your organization just spent many millions of dollars on IT. Now what? How do you get the most out of it? Those are questions still being answered. With large organizations and smaller providers grappling with how to best implement and use robust health IT systems, the benefits can remain murky, and some may even wonder if major investments in HIT are worth it.
Health IT is expensive
Health care IT isn’t a small investment, not by a long stretch.
A few years ago, Kaiser Permanente, one of the nation’s largest not-for-profit health plans, spent $4 billion on a huge organization-wide implementation of IT systems and electronic health records, according to Jon Glaser, CEO of Siemens Health Services, which is now part of Cerner.
On the other end of the spectrum, a community hospital with about 200 beds might spend $20 million. These dollar figures make more sense when put into context. “If you go back five years or so, a hospital would spend about 15 to 20 percent of its capital on IT,” Glaser said. The rest went toward things like new medical equipment and refurbishing buildings. “Now that number [spent on IT] is closer to 40 percent, so it’s doubled or more than doubled.”
“What that means, if you keep your capital level flat,” he said, “is that other things are not getting done. You’re not making investments in the new MRI or the new outpatient wing.” Those are tough decisions to make for those who hold the purse strings at hospitals.
The size of the investment required and the organization-spanning impact of health care information technology have made health IT a strategic priority. CEOs now need to develop a deeper understanding of how information technology functions, while CIOs need to better understand – and engage in – corporate strategy.
“That’s one of the biggest challenges,” said Finlay, “and you hear this from executives. It costs a lot. It costs a lot to keep up. They don’t really understand the bits and the bytes of it all, if you will, and so the question we’re always getting asked is, ‘what are we getting in return from the investment with this technology?’ And I think that challenge has only increased.”
Jha outlined the difficult choices in a similar manner: “The average American hospital has about a one to two percent operating margin. If you’re a 300- to 400-bed hospital and you have a revenue of $300 million, that means your margins are $3 million to $4 million a year, and it’s really hard to justify making a $20 million investment and improving patient safety, because that’s five years of margin.”
Meanwhile, doctors and nurses – many of them at least – are often frustrated with the electronic health record systems currently in place. They can be cumbersome. For instance, when prescribing a medicine electronically, a “pop-up” window on the computer screen might alert the doctor to important information, such as the patient’s allergy to the drug. “Those types of pop-ups can be extremely helpful,” said Gandhi, but, “there can be too many pop-ups. If you’re trying to order a medicine and you get five pop-ups, it can, A, drive you crazy and, B, you might just start ignoring them.”
Technology is changing the way doctors and providers do business.
Information technology was supposed to translate into better care and lower costs, Jha said, “yet the early evidence so far is it’s not happening. We have not seen information technology pay off” in terms of dollars. When a bank or retailer cuts costs and streamlines services through IT, the dollars shows up on the bottom line. That’s proven more elusive in health care.
Wait! There are noticeable benefits
Instead, the benefits of things like electronic health records make themselves known in other areas.
Marjorie Bessel, vice president of clinical integration at Banner Health, considered a high-performing organization when it comes to using IT, said, “[Health care IT] makes it easier to take a look at outcomes and processes, and then it makes it easier for us to do the continuous process improvements that are necessary for clinical care delivery.”
She listed some specific areas where IT has driven improved outcomes: in treating pediatric appendicitis, in elective deliveries in obstetrics, and in care delivery in the ICU, to name a few.
Having a fully integrated system on one platform is important. “The less variation we have in all our processes, clinical or otherwise, the better we believe we perform, which helps us deliver on our bottom line,” she said, adding, “Having a single electronic tool as an investment helps us work on some of those other clinical realms to improve overall quality for patients.”
CIOs now need to better understand – and engage in – corporate strategy.
Patient safety is a major area where electronic health records are improving outcomes in health care, though some, including Jha, argue there’s more work to be done in this area.
Finlay pointed to medication safety. Electronic health records track patients’ drugs, dosages, schedules, allergies, and other relevant information.
Said Gandhi: “Things like bar code technology can really reduce administration errors” by making sure “you’re getting the right [medicine] at the right time with the right patient and the right dose.” Implementing this technology has been tied to a 50 percent reduction in administration errors, she said.
It’s an example of what Finlay called “decision support: business intelligence that they’ve been able to embed behind systems to ensure the care you’re getting is the right care.”
In a more general way, electronic records improve health care processes and make them more efficient, Finlay said. She used readmissions as an example. EHRs are helping answer questions like: how often do patients come back to the hospital within 48 hours of being discharged? How much is known about these patients? Can the hospital make improvements, such as explaining discharge instructions better, to make sure patients are getting better care and don’t need to come back so soon?
‘It’s like the plane that doesn’t crash’
Sometimes it’s hard for patients to see these improvements, said Glaser, noting that doctors and nurses are able to make better decisions with electronic health records because they have a full set of data at their fingertips. What the patient doesn’t see is “the decision that would have been made otherwise,” he said.
“[It’s] sort of like the plane that doesn’t crash,” he elaborated. “Every time you land safely, you took that for granted. But it actually took some engineering to make that occur.” It’s the same with an effective health care IT system. It leads to better decisions, safer care, more efficient care, and less expensive care, but you don’t necessarily see those things in the same way you see a package that arrives from Amazon.
Measuring the right things
Federal funding has, over the past five years, driven more widespread adoption of electronic health records, according to Gandhi. The funding stems from the American Recovery and Reinvestment Act of 2009, which provided incentive payments, tied to Medicare and Medicaid, for health care organizations that demonstrate meaningful use with electronic health record systems. Organizations are assessed by their ability to meet core objectives, such as implementing computerized physician order entry (the ability to prescribe drugs electronically), recording the smoking habits of patients, and providing patients with the ability to view their information online.
Jha called these metrics “a step in the right direction but not anywhere near adequate.”
“You can create incentives and you can create metrics, but if the metrics are not really meaningful and the incentives are not well aligned, you’re not necessarily going to get where you want to go,” he said, adding, “this is an area of some debate.”
Metrics around issues like readmissions and efficiency are fine, but patients are more concerned with death and complications arising from their care, he argued. “The way we’re doing it is just not quite right. It’s not totally off. It’s not terrible, but it’s not quite right in my mind,” he said.
Moving on from version 1.0
That said, Jha pointed to the banking industry, where, “for the first three to five years after ATMs were put in, banks weren’t convinced it was a good idea,” he said, adding, “It’s sort of ironic now to think of it 20 years later, that somehow we would rip the ATMs out and go back to the old teller approach, but some banks were actually thinking about that.” Likewise, he noted, it was difficult, at the time, to measure the productivity gains derived, in the 1990s, from the PC revolution, but looking back they were clearly there.
Health IT leads to better decisions, safer care, more efficient care, and less expensive care.
Gains from health care IT will come from the ability to crunch large amounts of data, to see patterns and trends, coupled with the ability to target and better serve individuals. For instance, Bessel’s organization, Banner Health, has expanded into population health management – the “coordination of care delivery across a population to improve clinical and financial outcomes.” Bessel said her organization’s information technology systems improve their ability to handle and analyze large and diverse collections of data – what some call Big Data – and to use this data to improve care.
“Big Data becomes a little easier when you’re on a single, integrated platform from which to extract the data … so you can do the analytics on it, so you can make good decisions from a population health perspective,” she said.
We’re still at the beginning of this process.
“I like to say we spent the last ten years convincing people to do it” – adopt robust IT systems – “and now we need to spend the next ten years figuring out how to do it well,” said Gandhi.
Said Jha: “I think we’re in version 1.0 right now in information technology in health care. I think the pressure amounting in the marketplace, the frustrations doctors and nurses have, is pushing organizations so they know how to do this much better … I think 10 years from now, these systems are going to be much better.”
“We’re going to get there,” he said, “it’s just going to take a bunch of work.”