Some other countries were introducing more clinically-based IT into their health care systems over the 1990s, and they tended to place it where their systems were focused - which tended to mean in primary care. The three Ns (Norway, Netherlands, New Zealand) along with the Danes & the Brits were close to 100% EMR use in office based primary care by the early 2000s. The UK was able to use this to actually track what its primary care docs were doing, and started paying them bonuses for doing the “right thing” in terms of prevention and evidence based medicine. But note that the IT was shoe-horned into a system which was by and large doing that already. It did not change the core way care was delivered. In fact in the UK the links between primary care (GPs) and specialty care (hospitals) are still by and large absent - despite a huge budgeted (and not fully spent) investment in Healthcare IT that exceeds what’s in the current US stimulus package for a country 1/5th the population! The astute observer will also notice that several countries that don’t have EMRs in universal use among physicians, notably France and Germany, also have pretty well regarded health care systems.
So it’s a pretty fair assumption that IT use in health care will reflect the system it’s put into, rather than transform it to something completely different.
So why all the aggro? Since the Obama win and the recession made the stimulus a certainty and health care IT’s inclusion in it a reality, THCB has been the venue for a series of articles in the form of Open Letters to the Obama Administration by David Kibbe & Brian Klepper, a defense of the proposed spending by John Halamka, an analysis of the perversion of administrative simplification under HIPAA by interested parties (clearinghouses) from Rick Peters, all culminating in a declaration that Health IT is in fact ready, just add $20 billion, by Mark Leavitt yesterday. This argument has by no means been confined to THCB, and in fact this latest discussion was started mostly in a series in Health Affairs, in which Carol Diamond and Clay Shirky accused the current health IT establishment of “magical thinking”, while somewhat surprisingly Microsoft - which sells a lot more in copies of Windows and Office to hospitals than health care tools to consumers or small practices - in the person of its health care leader Peter Neupert suggested that we should take a pause before hitting the “buy” key, and spend money on outcomes not on technology for its own sake. And enfant terrible Jonathan Bush is warning anyone who’ll listen that we’ll be locking in place outmoded technology.
Essentially the argument comes down to two things (Warning - gross generalizations ahead!). I liken this to the common truism that dogs attach themselves to people while cats attach themselves to places
Outcomes vs. technology: The Kibbe/Klepper/Peters/Neupert/Bush faction (the dogs)assumes that we need to change the incentives in the system, and then IT will naturally follow - and the current embryonic decision support systems will flourish quickly. But that current clinical systems aren’t good enough to invest in mostly because current results from EMR installations are very disappointing.
Although they discuss incentives (and most of the $20 billion will probably be aligned with some P4P measures), the cats’ (Leavitt/Halamka/Kolodner view is closer to the thought that if you get the appropriate clinical technology (essentially in-patient and outpatient EMRs) into the hands of clinicians, then they’ll figure out what to do with it, and eventually the government can pay them according to how well they do it. (Halamka is a bit more open about this also being an IT public works scheme).
Patients vs. facilities: There’s also a more philosophical bias which harkens back to the difference between American and European health care systems, but not in the way you might think. The dog faction is in general primarily in favor of light-weight tools (and standards) that allow for innovation and service of the consumer patient by primary care teams (that’s the European part). The recent emergence of Web-based tools and patient communities that allow patients to apply self-service techniques and easy communication with teams of providers (yes, yes, that’s Health 2.0) are for them the keys to enabling better care. These tools are relatively cheap (and flexible) and mirror the SaaS trends in the rest of technology. (Think Gmail vs Outlook).
