Jan 21, 2009 
“…we must also ensure that our hospitals are connected to each other through the internet. That is why the economic recovery plan I’m proposing will help modernize our health care system – and that won’t just save jobs, it will save lives. We will make sure that every doctor’s office and hospital in this country is using cutting edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes, and help save billions of dollars each year.”
-President-elect Barack Obama, Weekly Address: The Economy December 6 2008
“…the way most large organizations actually process information…reveals a looking-glass world, where everything is in fact the opposite of what one might expect…a variegated patchwork of systems, containing 50 or more databases and hundreds of separate software programs installed over decades and interconnected by idiosyncratic, Byzantine and poorly documented customized processes.”
-Cynthia Rettig, “The Trouble with Enterprise Software” MIT Sloan Management Review Fall 2007
No, we are not trying to rain on the parade of hope that yesterday wended its way down Pennsylvania Avenue towards house number 1600. The US healthcare system is dysfunctional in so many ways, and the idea that healthcare technology should assert itself as a key plank in what is shaping up to be a multi-trillion dollar economic recovery effort is heartening indeed. A House Appropriations Committee draft currently making the rounds makes note of the figure $20 billion as planned Congressional spending on healthcare IT in connection with the larger economic stimulus package President Obama seeks to have on his desk by the Presidents’ Day holiday in February. That same document also details $2 billion for the Office of the National Coordinator for Health Information Technology. Observers are optimistic that something not too far from that $20 billion will emerge at the other end of the legislative sausage-making still to take place in the House and Senate.
Let a thousand flowers bloom – preferably in the form of innovative cooperation between the many public and private sector actors on the health care stage and preferably in the form of programs that will actually work. Electronic medical records (EMR) technology is undoubtedly something of which we need more – after all practically every corner of our $14.4 trillion GDP uses some form or other of technology to work better, and given the massive size of the healthcare industry it would be entirely sensible to bring medical records processing into the 21st century. Of course in so doing we are only bringing our own system closer to what is already standard practice elsewhere in the world – medical records in Denmark, for example, have long been 100% electronic, whereas by most estimates we are somewhere closer to 25% here.
Here’s the note of caution, though – we hope that “cutting edge technology” will turn out to be a phrase employed in a broad sense – grounded in the intent of a well thought-through strategy –rather than primarily in the more narrow-cast meaning of simply automating health records in hospitals and doctors’ offices. The driving problem we have is not the level technology per se, it is the high cost of waste and less than optimal administration of health services that result in our spending more per person for lower quality outcomes when compared with health systems in other countries. Technology can and should be seen as a potential enabler of lower administrative costs. But technology creates its own costs, and those unfamiliar with the tales of woe that permeate the landscape of system integration projects in large institutions would be well-advised to heed the lessons therein.
The purpose of citing Cynthia Rettig – whose Sloan MIT Review article caused a great deal of commotion and harrumphing among the corporate enterprise software set when it came out a little over a year ago – is that it neatly encapsulates the problems arising when, as all too often happens, we regard technology through the rose-colored lens of hope and deliverance from all ills rather than through the considerably more sober eyepiece of a posteriori knowledge – the history of ill-fated integrations of hundreds of thousands of lines of code on disparate, outdated platforms that collectively suck out any potential efficiencies gained from the technology itself. Technology is a tremendous enabler – it gives us power to accomplish much that would not be possible without it, but ultimately the gains we reap from technology in the form of enhanced productivity and task effectiveness derive from the intelligence of the strategies we devise and employ. There’s a lot of money out there in the public discourse, but the problems we as a country face in healthcare and overall public infrastructure demand that we leverage every dollar of it with intelligent thinking and effective execution.
So it seems a fairly good bet that quite a bit of funds are going to be made available in the very near future – but how are they going to be spent?
The Commonwealth Fund, noted in a report released on January 9 that technology-driven streamlining of administration and purchasing could actually reduce overall healthcare costs while at the same time providing healthcare insurance for uninsured Americans – in other words we accomplish two overriding goals of health care policy at the same time. The operative word there is “could” – for “could” to become “will” requires intelligence and care both in intent and in execution. In a recent article for Healthcare IT News Dr. Edgar Staren and Chad Eckes note that “[i]t is tempting for both administrative and clinical groups to view conversion from paper to electronic records as an information technology (IT) project. In fact, the optimal approach recognizes the integral role played by IT but recognizes such activity as an operations effort supported by IT and lead by Project Management. ”
One other voice may be helpful to add to the healthcare IT debate: that of the patient. In a recent New England Journal of Medicine article Dr. Abram Verghese issues a cautionary note:
The patient is still at the center, but more as an icon for another entity clothed in binary garments: the “iPatient”…the iPatient’s blood counts and emanations are tracked and trended like a Dow Jones index, and pop-up flags remind caregivers to feed or bleed. iPatients are handily discussed (or “card-flipped”) in the bunker, while the real patients keep the beds warm and ensure that the folders bearing their names stay alive on the computer.
All the technology in the world cannot substitute for the insights and judgments of experienced doctors at their patients’ bedsides, making those micro-level decisions that will add up in the aggregate to money well-spent or not as the case may be. What technology can do, though, is help to facilitate these decisions in a more effective manner throughout the system and leverage the administrative cost of providing the resulting health care services. As President Obama moves into the White House today we join our voices in the hope that this is where the road will lead.
