Chip Kahn sees successes, missed opportunities in health IT

President Barack Obama's January 2009 pledge to “computerize the nation's health records in five years” largely has come to fruition. More than 4,000 hospitals and nearly 300,000 “eligible professionals” have received Medicare and/or Medicaid incentive payments for investing in certified electronic health records and meeting “meaningful use” functional requirements in the 5½ years since the passage of the Health Information Technology for Economic and Clinical Health Act.

Taken on their own, these EHR adoption statistics make a strong case for the success of the program. That's one side of the story. The other side of the story is that HITECH was bigger than the meaningful use and the EHR incentive programs. The law envisioned building a nationwide interoperable information superhighway, ensuring patient information gets to the right place at the right time to enable better decisionmaking at the point of care.

Instead, more than five years and hundreds of millions of dollars in grants and seed money later, we have little more to show than the equivalent of a few disconnected interstates and county roads and a health IT landscape shaped by certain missed opportunities.

This problem is the failure to achieve “macro” interoperability—the movement of patient information outside the walls of a facility. Macro-interoperability is happening in pockets of the country, but certainly not on the scale Congress envisioned when it passed HITECH.

The law's initial vision was dependent on three factors: technology, aligned incentives and a culture that enables information to flow. Yet instead of enabling these factors to flourish, we allowed them to atrophy, due largely to what ultimately is a cultural problem—a fundamental distrust of external information among providers and clinicians—that supersedes any policy lever the law created.

The barriers that have stood in the way of macro-interoperability are well-documented. During the frenzy to get products to market to meet regulatory deadlines, we failed to address interoperability among certified products.

We also failed to prevent business practices running contrary to the spirit of HITECH, such as closed vendor networks and costly transaction fees to move information. The bottom line: We have not aligned vendor incentives with provider requirements.

Further, meaningful use's myopic focus on EHRs means that national-level discussions about interoperability effectively ignore the multitude of medical technologies within a facility that generate critical patient data, including devices, modules and other digital instruments. When you ask hospital chief information officers what matters to them, they talk about these technologies and their lack of plug-and-play connectivity with EHRs, even though this problem of “micro-interoperability” continues to be omitted from the growing number of frameworks and roadmaps focusing on how to achieve a connected healthcare system.

Despite our EHR successes, most hospitals are a “Tower of Babble,” with numerous modules and devices unable to talk to each other without costly interfaces, overlays, or, in many cases, a nurse or other healthcare professional serving as a translator, manually transferring or transcribing data from one system to another.

It is sobering to realize that hundreds of millions of dollars were spent experimenting on how to get patient X's information from Ohio to Florida, yet we cannot convey data from a digital blood pressure cuff into an EHR three feet away without some type of work-around. This reflects yet another missed opportunity to invest in solving a concrete connectivity problem that adds cost, reduces efficiency and diverts the focus of clinical staff away from patient care.

We are at a critical juncture in the automation of our healthcare system. The window to earn incentive payments for EHR adoption is closing, and the financial penalties for noncompliance are real. In these tight fiscal times, it is difficult to imagine where the funding will come from to robustly address any one of these missed opportunities, absent the private sector rising to the occasion.

HITECH's stated goals in 2009 of reducing errors, bringing down costs, ensuring privacy and saving lives are still the right goals for patients, providers and the healthcare system as a whole. Yet, absent interoperability, macro or micro, their prospects seem shaky at best.

As we look to the future—to Stage 3 meaningful use and eventually a post-HITECH world, it is critically important to continue striving to realize the law's larger vision for health information technology. At the same time, one “lesson learned” should be never to underestimate the value of taking a concrete step, such as moving information from a digital blood pressure cuff into an EHR a few feet away.