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Achieving Health IT Momentum: "Do's" and "Don'ts"


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Carolyn M. Clancy, M.D., Director of the Agency for Healthcare Research and Quality (AHRQ)

eHealth Initiative HIT Summit, San Francisco, CA, March 7, 2005


I appreciate the opportunity to open this Summit on Health Information Technology. You have an ambitious agenda. Or, I should say, we all have an ambitious agenda as we look at the great range of tasks ahead of us.

When we look at the challenges facing our health care system in the years and decades ahead, there is no job more important than getting health information technology (Health IT) into place, and getting it right. Good quality care... patient-centric care... cost-effective care—all of these issues, which present themselves as shortcomings in our health care system today, look more like opportunities in the light of health information technology.

No, Health IT is not a silver bullet that will transform our system on its own. But it is difficult to think how transformation could possibly take place without the capacities of Health IT. We have a fundamental problem of fractured health care delivery, that results in needless waste of resources. Health IT can bind this system together, even as it preserves the strengths of our system's diversity.

I think we all share this sense of potential. I think we also share a sense of awe at the size and complexity of the tasks ahead of us:

  • Not just electronic health records for all Americans, but interoperable networks and shared formats.
  • Not just availability of information whenever and wherever needed, but information that is secure and private, and guided by the patient's wishes.
  • Not just evidence-based information for better quality care, but information that's truly accessible and usable—at the point of care.
  • Not just quality in the patient's care, but quality measurements for the consumer.
  • And in the end, a system not imposed by edict or mandate, but adopted and used because it works.

How many hundreds of tasks have we scooped up with that short list? And how many different players have we called upon? The task is daunting, but the commitment is also great. I think we are prepared to do a generation of development in half a generation's time. The keys to success will be cooperation, communication and openness.

That's why conferences like this one are so important. That's also why we welcome the eHealth Initiative as one of our partners in developing AHRQ's National Resource Center on Health Information Technology—because it will be so important to share what we learn, even as we are learning it.

Let me start with one thing that's certain—our new Secretary of HHS, Mike Leavitt, is a long-time friend of Health IT. He has background and a track record on this subject. While he was governor, Utah built a base that makes it one of the Nation's leaders in health information connectivity.

Secretary Leavitt's first full day on the job was spent on Health IT. He joined the President at the Cleveland Clinic in January as part of a public conversation about the importance of health information technology. That event helped move the discussion by making it clear to Americans that we need not only electronic health records, but also an interoperable system of health information exchange. In the President's words, "a medical internet."

Interoperability is key to achieving the ultimate goal: to get the right information, for the right person, at the right time and place. That's a long way from where we are today. And as we all know, that lack of information can often spell more than inconvenience—it can result in injury and even death when medical decisions are made based on insufficient information.

Our National Coordinator for Information Technology, David Brailer, published a call for information last fall just to make sure we have the right pieces in view for health information exchange—before we even consider how to organize them.

The issue of interoperability is at the top of his "to-do" list, and you can expect to see increased Federal investment in regional collaborations and networks.

Of course, the work we are contemplating today is built on a deeper foundation. An important part of that foundation has been constructed with support from my agency and its predecessors, over a period stretching back some 30 years, when our investments in medical informatics were just beginning. In recent years, organizations like the eHealth Initiative have brought rapid acceleration of the issues. And today, I think we can see many long-term trends and investments converging to put Health IT near the "tipping point:"

First, of course, is the success of information technology itself. The triumph of the internet and the dramatic changes in banking and other industries make it clear that information technology can do more than enhance—it can transform.

Second, there is a new realization that "infomedicine" is a necessary partner of biomedicine, if biomedicine is to deliver fully on its promise.

Think for a moment about what is happening in health care settings around the country. Millions of decisions are being made about a myriad of issues:

  • Should a patient take an over-the-counter pain reliever for a headache, or is a prescription medication required?
  • Is chemotherapy the best treatment for a patient with breast cancer, or should she be treated with radiation and chemotherapy?
  • What type of screening for a particular cancer should be covered?

Patients and consumers struggle with even more basic decisions: Which provider to see? When to seek care? Which treatment option is best for their needs?

Many of these decisions are difficult even in the most ideal circumstances, when there is sufficient time to assess good, reliable information. But as we all know, these decisions frequently must be made at times and places where information is not available, and time is of the essence. In addition, we often know that the information before us isn't reliable, or that reliable information isn't readily accessible in real time.

This point was brought home to me by a personal experience. My 14-year-old niece is an elite, competitive gymnast. At a recent competition away from home, she fell and fractured both of the bones in her forearm. Decisions had to be made quickly about finding the right physician and hospital to treat her in the absence of easily accessible, reliable information.

My niece had an advantage over other patients in this situation—me and my contacts. My medical school roommate is an orthopedist who was able to step in and direct her care. With health IT resources, we need to make that kind of information available to the majority of patients who don't have such connections.

Our Health IT opportunities also build on a crucial area where AHRQ has been a leader—the area of evidence-based medicine. Choices between treatment options need to be based on strong scientific evidence. And Health IT promises to bring that evidence to the point of care—in formats that are directly applicable to the patient being treated.

To me, the Medicare Modernization Act, passed just over a year ago, marks a turning point in our Nation's understanding of evidence-based medicine. This legislation calls on AHRQ to conduct research on the comparative effectiveness of health care interventions and services for the most significant medical conditions affecting the Medicare, Medicaid and SCHIP programs. Of course, this information will also be vital for the health care community as a whole.

This marks a realization by the Congress of the fundamental role that evidence-based research can play. More than that, it marks a new understanding that quality care and cost-effectiveness are not opposed.

To the contrary, evidence-based understanding of good quality care is crucial to cost-effectiveness in medicine. When good care is given, and errors are avoided, then we can be confident that our health care dollars are being spent effectively.

Health IT will provide an important means for delivering this information to clinicians and patients. Equally important, as we assemble clinical data in electronic forms, we will have exponential growth in the information we need to produce more and stronger evidence-based comparisons for future decisionmaking.

Today our researchers are more like hunters, seeking out information on therapies that is often sparse. In the future, a ubiquitous system of electronic records will virtually "grow" the data we need. We will be able to learn more, faster and with greater certainty. This can be especially important in detecting adverse drug reactions, so that unexpected hazards can be identified rapidly.

At the same time, this new wealth of information will enable better measurement of the quality of care being delivered by providers. This will give patients much better information for making choices about their care—and it will certainly give providers the incentive to measure up on quality.

In a word, Health IT promises to enable system-wide transformation. So what do we need to do—and NOT do—to reach such a sweeping goal?

At AHRQ, as you know, we are providing $139 million over three years to help communities plan or implement Health IT systems, and to help develop statewide systems in five states. We focused our grants especially in rural and underserved areas, in order to help Health IT get a foothold in some of these areas.

But the most important aspect of these projects is not merely as seed money. More important, these are opportunities to measure Health IT in action. Each of these projects will undergo systematic evaluation. They constitute a real-world laboratory, where we'll be able to observe different Health IT applications, how they work in real clinical life, the value they add, and the challenges they may pose. This will help us build a business case based on practical experience, not just theory. It will help bring about refinement of Health IT applications. And the information will be shared through our new AHRQ National Resource Center.

By examining Health IT applications in working settings, these projects will help show us something about the human side of health information technology—the impact on providers and patients. These days, the "T" in Health IT gets much of the public attention. But the "H"—better health care and better health outcomes—is what Health IT is really about. We're building a technical foundation... but the technology is not an end in itself.

Our goal is to support decisionmaking in situations that are deeply personal and often intensely emotional. In those moments, Health IT needs to make the human interaction more effective, not more difficult. It needs to give clinicians more time to interact with the patient, not less. It needs to provide more information output than it requires in input. Wherever possible, it needs to anticipate the patient's needs, with reminders or other information keyed to that particular patient's situation.

So at the same time that we're establishing our technical protocols and standards, we also need to be developing products that facilitate the human interaction between provider and patient—along with products that empower health care consumers themselves.

I hope we won't wait to give as much attention to the human effectiveness of Health IT as we give to its technical effectiveness. That means developing prototypes now and testing them.

We also need to think more about the "I" in Health IT—especially, getting information into usable formats. We need to find ways to provide evidence-based medical information quickly and succinctly for clinicians. At its best, Health IT should be capable of providing decision support at any point where it's needed—whether that's an office desktop computer or a bedside handheld device.

Health IT is an information delivery system—but delivery alone isn't enough, if the information isn't usable where it's needed. New forms of information packaging and presentation will be important in helping Health IT reach its full potential.

Only a year ago, few Americans had thought about the potential for information technology in health care. One survey showed that many Americans assumed electronic health records were already in place. Today, Health IT is truly on the national marquee. Americans are quickly coming to understand how much we have to gain from Health IT. And one thing about Americans—we don't like to wait.

With Health IT now at center-stage, I think there are a few potential hazards that we should be alert to:

  • First is the simple danger of impatience. We need a sense of urgency, of course—but we also need to resist the temptation to take counter-productive short-cuts. Once the benefits are known, people are bound to ask: Why not a Manhattan Project? Why not just require physicians and others to invest now? There will be temptations to use government resources and mandates to accelerate the process. But mandates that may look efficient today are too likely to become the institutionalized dead-weight of tomorrow.
  • Our Nation faces enormous health care challenges in the years ahead, and Health IT is an important part of the solution. But "instant" solutions won't work. There is no substitute for a cooperative, evolutionary process in creating and improving the products... agreeing to the standards... and integrating these systems productively into clinical workflows.
  • We also need to be closely attuned to the public's high sensitivity to issues of privacy and security. One recent poll showed a near tie between Americans who believed the benefits of Health IT would outweigh privacy concerns—and those who believed the privacy risks are simply too high. The HIPAA [Health Insurance Portability and Accountability Act] provisions represent a beginning toward resolving privacy issues, but not the end. With 50 States and 50 sets of State law affecting privacy, there is still ground-level work to be done—and this is work that is crucial to the success of Health IT.
  • Finally, if Health IT may seem to be taking hold more slowly than we'd hope, there may be the temptation to blame—especially, to blame physicians for not moving faster to invest in Health IT products. Whatever their limitations as computer experts, physicians know their practices. We should offer help with their computer needs. But if they're reluctant to invest, we need to listen and learn why. We need to understand the barriers, and we need to know what kinds of products and features will truly "connect" with their practices.

All of these are good problems to have. They are the problems of a technology that's ready to take off. The tasks are being defined, and the demand is growing. And don't underestimate the importance of consumer expectations. We talk about empowering patients through Health IT—their first taste of power may come when they demand that their own providers get wired.

There is no shortage of work ahead. For government, that means addressing legal and regulatory questions that have been raised by Health IT. It means convening public and private sector participants and helping settle common standards. It means continuing to lead by example—including a better job of presenting our own health information on the web. It means demonstration funding for small practices and solo providers—and more support for regional collaborations. It also means assessing the need for incentives for Health IT investment, especially for smaller practices.

At the same time, we need to remember there is no substitute for the private market in developing complex and cutting-edge systems. We want to be able to move rapidly toward new opportunities. We want continuing experimentation and willingness to take risks. Ultimately we want ever-improving products that our medical professionals will seek out and use. All of that means we need the give-and-take of the marketplace.

When we talk about Health IT, it's tempting to say that health care has been a laggard industry in adopting information technology. Perhaps that's true. But I also think technology has now reached a level of sophistication that can make it truly useful for the full range of health care uses. Health care is not an ATM or a ticket service. It is subtle, and complex, and personal in a way that comparing airfares just isn't. Banks have the benefit of an elegant system of 10 Arabic numerals. SNOMED® [the Systematized Nomenclature of Human and Veterinary Medicine] has 357,000 concepts.

When we achieve interoperable networks that deliver sophisticated, patient-specific information whenever and wherever needed, securely and privately, we will have accomplished something new. Technology will have taken a step, just as health care will.

I welcome the challenge, as I know you do. At AHRQ, we look forward to working with all of you to make the potential of health information technology a reality for Americans.

Current as of March 2005

 

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