Digitizing health care: Karen Bell, director of the Office of Health IT Adoption at the U.S. Department of Health and Human Services.
Courtesy Office of Health Information Technology And Adoption
The director of the U.S. Office of Health IT Adoption explains why it's so hard to get doctors to go digital.
The average baby boomer with multiple health concerns likely has a slew of doctors--a primary-care physician to manage day-to-day issues, a cardiologist to monitor a blocked artery, a rheumatologist to manage arthritis pain, and an orthopedist to treat a trick knee. But chances are that these physicians aren't in regular contact and that the patient's fragmented medical records are isolated in different databases and paper files.
That problem could be solved, or at least drastically reduced, by electronic health records, which allow data to be easily shared among physicians, pharmacies, and hospitals. Such systems help coordinate a patient's care, eliminating duplicate testing and conflicting prescriptions, and ultimately cutting costs.
But despite the benefits, only 15 to 18 percent of U.S. physicians have adopted electronic health records. Karen Bell, director of the Office of Health IT Adoption at the U.S. Department of Health and Human Services, spoke with Technology Review's biomedical editor Emily Singer about the hurdles to digitizing health care.
Technology Review: What have been the biggest hurdles in getting physicians to adopt electronic health-care records?
Karen Bell: We still lack a compelling business case in terms of purchasing, upkeep, and decreased productivity. Physicians have to shell out considerable upfront costs and lose about 20 percent productivity in the first few months as personnel get used to the system. And the average primary-care physician doesn't have time to research different systems and learn how to use them: every minute they are not seeing patients, they are not getting paid.
The places you do see high rates of adoption are large physician groups. Thirty percent of those have already established electronic health records. That's because the group can negotiate a great price and can provide lots of support.
TR: Who has done this well?
KB: Denmark. They gave physicians a choice of electronic health-record systems at reasonable cost and then provided extensive consulting services. They also established a pay differential, so that physicians who adopted EHRs were paid more.
TR: Have the health-care systems that have adopted electronic record-keeping seen beneficial changes?
KB: The Rand Corporation has looked at Kaiser, Partners, and other large systems. You certainly see that they perform better on quality-of-care measures [such as whether patients with uncontrolled high cholesterol are prescribed statins]. But we don't know how that will translate into small offices. And because there is no standard way to calculate cost savings, it is hard to measure returns. We all believe that benefit is there; we just have to find a way to measure it.
TR: What about the public-health benefits? Systems that house large quantities of patient data could enable new types of research studies.
KB: Absolutely, that's something I get really excited about. It will totally break open our knowledge base. For example, I have been diagnosed with low-pressure glaucoma, which is fairly unusual. No one knows what causes it. I would love to be able to search the system for anyone with this form of glaucoma and start to look for similarities.
TR: When do you think that kind of study would be possible?
KB: We would need large numbers of people with patient-controlled health records, but the numbers are still very low. The number [of practices] with fully functional electronic health records--meaning information can be easily shared between systems--is only about 4 percent.
For more on electronic health records, watch a webcast of Bell and others speaking at Technology Review's Emerging Technology Conference this week.
The federal government is about to spend big on health-care IT. Too bad the medical industry has a vested interest in inefficiency.
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This is one of those subjects that I am always in two minds about - my main concern is the insurance industry, who seem to be out to ensure that those who actually NEED the health insurance are blocked from every getting it. Identity theft has never been that high on my list of fears on this particular subject.
The part I like about it - it can be very hard to even GET the doctors to let you have your records, let alone share them with others. Most people start their medical career when they are ..oh... about 1 month old. It is impossible to get copies fo those records, and while it probably doesn't mean much - those measles you had when you were 6 months might have caused something later.
Mainly, I like to have my records, I like to take them to the doctor with me (the doctor never seems to be intersted in the acutal history, regardless of what they say, but htey do like to have hte records) - an electronic file wehre I can record the doctors, their addresses at the time, my patient number (if findable), actually being able to enter hte tests, drs notes, and SEARCH the whole thing.
It should not be that difficult to either write or leanr to use such a record - but of course, in our culutre everybody's idea is "you must use my software, and my peripheries, I am not going to make my system so you can mix and match components and modules from various companies to meet your own needs".
Will be intersting to see where this technology goes in the future, and if I will ever be able to access it without paying an arm and a leg for life.
Guest (Curiosity)
Who is going to pay for this? As a physician, why should I pay $25,000 plus $500 a month for this system. Where is the return? The companies promote a savings of employees, but my friends tell me that is not true. The companies suggest that a higher level of billing can be done, but that exploits the system. Then there is the learning curve trying to figure the thing out. Finally, there is no computer system that can replace holding a chart in your hands and flipping back and forth between old studies and new and finding the changes that have taken place over time. If you are looking for specific information, computers are much faster. If you are looking for patterns and gestalt, the chart beats a computer hands down.
The ROI comes in the form of fewer medical errors (medication overdoses, inappropriate medications being prescribed) and fewer lawsuits due to negligence. The cost of few lawsuits can more than equal the cost of an electronic medical record system for a physician.
It's also good practice to ensure cross-communications among all physicians treating a patient to ensure continuity of care. For many physicians that doesn't happen (I know from personal experience) and what they don't know can kill you.
The situation cries out for a "central-payor" universal healthcare system. The observation that most providers are small and therefore results hard to measure (re collecting data) is damning. The bottleneck is the insurance industry. They provide virtually zero added-value (except that as a gate keeper). The US may never accept largely public delivery of healthcare, so providers may stay as private entities. Canada uses a government payor - private (mostly) provider model. Empirically, its better & cheaper.
Despite the fact that only 75% of Americans have health insurance, tax payers pay more per-capita than any other nation (nearly all of which have a national health care plan that covers every citizen).
25% of our health care costs goes to paperwork, so really, this paper vs digital thing is more of the same thing... its a broken system!
If we were really interested in reform, whether its social security, energy conservation, health, whatever, it would happen.
Unfortunately, it only happens after there is a massive public outcry (usually after a disaster).. otherwise, lobbyist, which is really just legalized bribery, will keep the status quo.
Need for user-centered design and focus on usability.
I don't think that many developers know much about user-centered design, participatory design, or usability testing. If they did, health care applications would not take the user much time to learn. This is the case in the education sector as well. For example, the web-based data system I'm required to use doesn't have a feature that will allow me to import student evaluation data files from test scoring applications that I use on my laptop.
I must enter the data manually, which is not the most efficient use of a busy school psychologist's time!
Does anyone know how the VA's system rates?
http://www1.va.gov/cprsdemo/
The VA's been using computerized records for about 20 years, and from the little I've heard, their current system is quite good. Why can't they lease it out or (better yet, since their system really belongs to the people of the US) give it to doctors. Even if they leased it, it ought to be cheaper than the commercial alternatives. Even if it's not as good as some of the commercial ones, something is better than nothing, right?
1. It's won major awards (http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1152)
2. It's already open-source (http://www1.va.gov/VHA_OI/page.cfm?pg=37, http://www1.va.gov/VHA_OI/page.cfm?pg=37 , http://www.hardhats.org)
3. There's a whole community working on Open Source medical software (http://linuxmednews.com/ , http://josmc.org/ )
Dentists are not on board, Ms. Bell
I would like to ask Karen Bell how well she thinks electronic health records are being accepted in the dental profession. As a dentist who is watching from the sidelines (I am not a HIPAA covered entity by choice), it is obvious that HIPAA is rapidly becoming a national embarrassment, and the Rule long ago irretrievably failed in dentistry.
I hope Ms. Bell can find the courage to respond to my concerns because the American Dental Association no longer discusses HIPAA with members. The leadership is in too deep. They cannot back out of their commitments, regardless of the harm that they cause my professional organization, and in turn, my profession.
Far too many ADA employees invested their careers, along with members’ dues, in a bad idea. That is my opinion. Darrell K. Pruitt DDS
Re: Dentists are not on board, Ms. Bell
I'll mail a check for close to $3.65 if anyone can persuade Karen Bell, director of the Office of Health IT Adoption at the U.S. Department of Health and Human Services, to respond to my challenging comment. Darrell K. Pruitt DDS
Re: Dentists are not on board, Ms. Bell
Why do you think Karen Bell, an employee of the US Department of Health and Human Services, has not responded to my direct question about HIPAA and dentistry? What could possibly be her excuse? Do you think it is because she has been too busy and must move on to other things? Or is it because she never noticed my comment? Either way, her bad manners is an insult to all dentists.
Shouldn’t a government employee be responsible enough to respond to a citizen’s question? I read somewhere that Obama promises web access to all cabinet secretaries. I wonder if he has been talked out of that idea for the “common good.”
Transparency means accountability. Without accountability, dental patients’ interests will never be recognized.
Where are you, Karen Bell, director of the Office of Health IT Adoption at the U.S. Department of Health and Human Services?
Don’t get me started. Darrell K. Pruitt DDS
Re: Dentists are not on board, Ms. Bell
OK, already. You got me started.
Since I suspect that Karen Bell, director of the Office of Health IT Adoption at HHS, is still quietly reading the comments I post here, I would like to suggest that she follow an unprecedented open conversation about HIPAA and dentistry that I am enjoying on the PennWell forum.
http://community.pennwelldentalgroup.com/forum/topic/show?id=2013420%3ATopic%3A14126
Since she is obviously naïve about her subject of expertise, she could learn something and possibly avoid embarrassing herself and HHS Secretary Michael Leavitt again.
The title of the thread is “Findley for our Future” - as in Dr. John S. Findley, soon to be the president of the American Dental Association. Darrell K. Pruitt DDS
Re: Dentists are not on board, Ms. Bell
Why does Karen Bell, director of the Office of Health IT Adoption, not respond to my perfectly reasonable and important question to her? Does she not care that dentists are not on board with HHS plans? Or is she just too important for conversation with dentists?
Or is it my unprofessional attitude that keeps her quiet? Darrell K. Pruitt DDS
Re: Dentists are not on board, Ms. Bell
Dentists in the audience need to remember the name Karen Bell, director of the Office of Health IT Adoption at the U.S. Department of Health and Human Services.
She cannot be trusted because she will not respond to my questions. Darrell K. Pruitt DDS
Re: Dentists are not on board, Ms. Bell
Karen Bell’s boss, Secretary of HHS Michael Leavitt, opened an unprecedented US government weblog that invites conversation with American citizens.
Karen Bell refuses to talk to a dentist about the adoption of electronic dental records on an open forum.
What is she afraid of? It would appear that she does not have confidence in her product. Should Michael Leavitt have confidence in Karen Bell? Darrell K. Pruitt DDS
Re: Dentists are not on board, Ms. Bell
There's a new sheriff in town. He doesn't like HHS employees much.
http://community.pennwelldentalgroup.com/forum/topic/show?id=2013420%3ATopic%3A14454
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3 Comments
There are a number of things which come to mind after reading this article...
1) Time. The fact that the comment was made - "It takes several months to get used to the system", should be, in my opinion a red flag that says "why". Why are the developers of this making it so difficult to be included in existing practices? Why not have the "developers" spend the extra months making their product integrate into the practice's systems easier?
2) The "easy" one - Security. With credit card, banking information, etc., being lost on a daily basis, the sense of any such system being able to be "secure" is obviously right up there. HIPA (or whatever the acronym is) does not care about the "who, what, or where" a breach ocurred, if you can not prove that your system was 100% secure, you are at fault. A piece of paper, locked in a file cabinet, with two people have the key, is easier for most smaller practices to control, than an accessable computer system in their office.
3) Patient information security... Similar to above (obviously), but with the comment made that this individual would like to "look through the records" to research her condition and compare it to other's who may have the same / similar condition is scary. Assurances that associated "personal" information would not be available, except by "authorized" personnel, is not going to cut it. The Veteran's Administration had the same implemented, yet the information got out, our banks have it, yet it get's out, and on and on and on.
4) Denmark is NOT the US. Denmark is about the size of Rhode Island, has far, far, far fewer different systems in place (or had), prior to going to an integrated system. Far fewer people, far fewer infastructure interconnections, etc., than we have. Not to mention, a culture that is far less divergent than ours. To equate the two is almost silly, rediculously simplistic, from any point of view.
The "concept" of an integrated medical records system and the benefits that could come from it, is, without a doubt, a wonderful thing. Implementing, in the US, such a system is not simple, should not be touted as being simple and proponents of such systems, whether they be in the government (as in this case), or in the thousands of practices out there who over-simplify and ignore the negatives are NOT helping the process move forward.
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