Wednesday, November 9, 2011

Digitizing Health Reform: Not So Vast, and Not So Fast, Please!

Don’t start vast projects with half-vast ideas.

Advice of John Reece (1906-1997), to his son

Not so fast, my friend!

Lee Corso (1935 - ), ESPN Football Announcer to his broadcast partner

November 9, 2011 - American people and American physicians are reacting to the health reform law by saying, in effect, “ Not so vast, and not so fast please!”

American health care, took root in its present form in the 1940s. Back then, Congress passed legislation saying employers could deduct health benefit expenses. Innovation accelerated after World War II with vast investments in hospital construction and NIH research. Medicare and Medicaid followed in 1965. Medical technology innovations flowered. By 2010, health care comprised 1/6 of the American economy, and costs were soaring.

Two Health Reform Law Complications

On March 23, 2010, Congress passed the health reform law .

Two factors complicated it.

One: A single political party backed it, under cover of political chicanery , financial legerdemain, and last minute darkness. This made the other party resentful and determined to block it.

Two: Digitization of health care put health care reform on steroids. The digital revolution, pioneered by Steve Jobs, had turned upside down seven industries - personal computers, animated movies, music, phones, tablet computing, digital publishing, and retail stores. And it proceeded to do the same for the health care industry and American economy as a whole.

Essence of the Economic Impact

Two MIT economists, Erik Brynjolfssen and Andrew McFee, capture the essence of the economic impact in the title and subtitle of their new e-book, Race Against the Machine: How the Digital Revolution is Accelerating Innovation, Driving Productivity, and Irreversibly Transforming Employment and the Economy.

And so it has. Even the marketing of the book, as an E-Book only, costing a mere $3.99, bespeaks of radical innovation, for it undermines the entire print and publishing industry.

Why Not the Health Industry Too

So why not digitally and radically transform the health care industry too?

The government is certainly having a go at it. In 2004, President Bush signed an executive order, committing the nation to a universal interoperable electronic system by 2014. In 2009, president Obama upped the ante by promising $27 billion for IT in the stimulus bill.

And, as I write, the Obama administration proposes to reward physicians and hospitals with bonuses for meeting a slew of “meaningful criteria” for installing electronic records. The administration als o punishes those physicians who don’t sign up to meet these criteria.

Too Vast, Too Fast

For many physicians and hospitals, the reform law is simply too vast, and its implementation too fast, to swallow and digest. It is too much, too soon. The same perception holds for the public at large. The majority of Americans oppose the new law , for a variety of reasons. In this center right nation of ours, the law has Orwellian overtones. It smacks of Big Brother, perhaps I should say Big Bureaucrat, practicing medicine and calling the shots. To those on far right, it smacks of “socialized medicine” and that dreaded R word, “ Rationing.” To the left, on the other hand, it is rational, objective, and data-based.

The tool for bringing about this perceived state of objectivity is the computer and a host of radical innovations following in its wake – the Internet in all of its manifestations, dozens of new social media outlets, and thousands of new apps that will dictate how we are cared for, who will provide that care, what treatments and tests we receive, and how providers will be paid and what patients will pay.
The American Style of Innovation - More Time, More Workable

There is larger issue as well, how fast to move societal innovation, as articulated by W.W. Rostow (1916-2003) , a U.S. economist and political theorist who served a National Security Advisor to Lyndon Johnson.

In an address before Harvard alumni in 1957,”The Fallacy of the Fertile Gondola, “ Rostow had this to say about the pace of innovation in America,

Men successful operate processes by accumulating experience, feel, judgment, by sensing recurrent patterns rather than isolating clean-cut logical connections of cause and effect. This is how good captains of sailing vessels have worked, good politicians, good businessman.

This has been typical American style in operating and developing the nation’s society. Its success, however, is dependent on two conditions; first, that the problems confronted be, in their essence, relatively familiar, capable of solution by only moderately radical innovation, on the basis of existing principles or institutions; second that time be allowed for the experimental exploration of possible solutions, and the osmotic process of accepting change.

The more time permitted, the greater the workability of a technique of problem-solving by empirical experiment and the institutional change-inertia.

It is, thus, the less radical orders of innovation – in science, industry, and politics – that the nation has excelled. Or, put another way, the American style is least effective when it confronts issues which require radical innovation promptly.

It is precisely here that we are in trouble. We live in a world of extremely rapid change, where the survival of our society hinges on prompt innovation, while our intellectual style and our national institutions are accommodated to the slow and carefully balanced modifications of a successful ongoing process.

Why Physicians are Hanging Back

Why are we in trouble with the interoperable electronic revolution? After all, less half of physicians have installed or use electronic records.

Why are physicians hanging back?

I articulated some of the obstacles in an article I wrote for the Technology Review (MIT Press), “Why Physicians Don’t Like Electronic Records” (September 27, 2011), EHRs,

• are sold by so many companies—more than 100 at present—that no one knows how to separate the good from the bad and survivors from non-survivors.

• slow productivity.

• show negative investment returns.

• don't speak to one another.

• distract from patient time.

• require total reorganization of practices.

• conceal a strategy for monitoring, controlling, and dictating practice activities.

• can be misused or hacked to invade privacy, reveal sensitive information, and threaten the security of patient and doctor alike.

• raise practice costs.

A more recent publication, November 1, 2011, “Survey : Physicians See Improvement in Efficiency and Quality of Care, Yet Significant Barriers Remain (http:www,woltersskluhealth), spells the obstacles out in simpler terms. According to the survey, responding physicians cited these barriers,
• Too expensive, 40%

• Too much data and not enough actionable information 32%

• Too much to learn/too much time to learn, 27%

• Too hard to use at the point of care, 24%

The key phrase here is “not enough actionable information.” The information may be “actionable” for government, policy experts, health plans, data-mongers, and payers, but in the eyes and minds of many physicians, electronic records must become more useful, logistical, intelligible, and economical for them to take action.

Redesign of EHRs will no doubt in time correct these digitization deficiencies but we are not there yet. As Gertrude Stein might say of many current EHRs“There is no there there, “ not yet anyway.\
Tweet: Digitization is spurring medical innovation and electronic health records (EHRs), but EHR data is not yet actionable for most doctors.

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