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Health Care Futurist Questions U.S. Health IT Strategy

Health care futurist Jeff Goldsmith says health information technology adoption has lagged in the U.S. because there’s no definable return on investment. Goldsmith, keynote speaker at the Health 2.0 conference in San Francisco earlier this month, warns that health IT adoption, combined with the current U.S. payment system and quality measurement requirements, is actually hurting productivity.

Goldsmith spoke with California Healthline about whether the federal government’s “meaningful use” incentive program will be successful in driving health IT adoption, what he would have done differently in designing such a program and which country the U.S. could learn from when it comes to health IT. Goldsmith is president of Health Futures and an associate professor of public health sciences at the University of Virginia.

The transcript of the interview follows.

California Healthline
: During your address at the Health 2.0 Conference you said health IT is actually hurting physician productivity right now. What did you mean by that and how do you think that can be overcome?

Goldsmith: It isn’t merely the tools that are the problem, but the fact that we have this micro accountability problem with the payment system and increasingly with the quality measurement process. We’re absolutely inundating caregivers on the front lines with a level of detail that’s required for them to document in their clinical workflow that is just not sustainable.

And, I honestly think that unless we can either get some kind of a truce declared and not simply keep heaping documentation requirements on people or to have a lot of that documentation occur automatically in the care process without caregivers having to take hours out of their days to key enter it all, we’re diverting a huge chunk of the clinical work force’s available time to feeding the machine. And, I just think that’s the root of the problem.

I think the tools definitely need to evolve. When I ask nursing audiences what percentage of their time do they spend with patients, it’s never more than half, it’s more like 40%. And, a lot of them will admit privately to having to take their work home, which is technically a violation of HIPAA, in order to complete the documentation. So I just think we’re in a place where we haven’t done a decent accounting of how we’re using the information that we’re sucking out of their work hours.

California Healthline:
 Why do you think IT adoption has been so slow in health care, compared with other industries?

Goldsmith: I think there’s an easy answer to that question, which is that there’s no definable [return on investment] to the investor. It’s interesting. [In] the one study that everybody cites — the RAND Corporation study that was financed by the vendors — a huge fraction of the savings that were supposed to accrue from a digital care system were from eliminating duplicative testing. Well as anyone [who] has actually worked in the care system knows, testing is the incremental income to providers. It’s how they’ve made up for the loss of fee-based income by essentially billing for imaging and lab tests. So the idea that that goes away when you’ve completely wired up the health system I think is just ludicrous. At the level of individual institutions, it isn’t a huge victory to lay off the billing clerks and coders but have to hire $100,000-a-year database managers to keep the system up and running. That’s not a big win for the institution or the society.

California Healthline:
 The federal stimulus package allocated billions of dollars for the “meaningful use” of electronic health records. Do you think that the promise of Medicaid and Medicare incentive payments, and ultimately financial penalties, will help drive health IT adoption?

Goldsmith: Well, it’s certainly scared a lot of people. Whether it’s going to improve the rate of adoption remains to be seen. I guess I would have done it differently. I would have given meaningful users of clinical IT who actually followed the embedded care guidelines … a malpractice shelter. That would have been the approach I would have taken is to carve out some kind of exception and reduce their malpractice expense. That would have much more directly connected with providers than a potential bonus two to three years out.

California Healthline:
 What are your predictions as to whether the meaningful use program will ultimately be successful?

Goldsmith: What’s been going on at the same time as all this is that physician practices are being acquired by hospitals by the tens of thousands. … The structure of medical practices is changing dramatically at the very same time that those incentives are in place, so I think most of the new owners of the practices absolutely are going to make sure that they’re wired and not just because of the incentives, but because it’s the only way they can maybe begin to get the doctors in their systems to work with one another and talk to one another electronically. So I think that actually the movement toward salaried employment by health systems is more likely to have an impact on the rate of adoption than the incentives themselves.

California Healthline:
 As baby boomer physicians retire, do you think younger physicians will be more willing to use health IT in their practices?

Goldsmith: I think part of the problem that’s going to slow down the adoption is that if you’re three years away from ending your practice, what do you care if your wired or not. So I was always of the view that a couple hundred thousand paper-based boomer docs were never going to be affected by anything you did in the way of incentives.

But I think the problem with younger docs is that they’ve been online a good portion of their lives, and … compared [with] the ease of use of search [engines], the iPhone, you know you name it, the IT they’re being asked to use in the clinical setting is incredibly difficult. So you’re going to have a different problem with the Gen Y docs, which is they’re going to expect IT to be easy to use, and they’re going to really bridle against the huge time demands that a lot of these obsolete user interfaces are going to make on them.

California Healthline:
 What kind of role do you think consumers and patients play in both health IT adoption and health IT use by providers?

Goldsmith: Nearly zero. There’s been good evidence for years that people wanted to e-mail with their physicians; they can do that without the docs having EHRs. It’s questionable whether people saying, “Please send this information to my personal health record” is going to make that much of a difference because it’s not clear that the PHR is really something that people are demanding. I think what consumers want is better communication with their docs, and to the extent that better IT can provide that, I think there’s going to be a favorable consumer reception.

I mean I can tell you that I bridle being handed that clipboard when I enter the doctor’s office, and I’m like, “Look, why didn’t you just send me an e-mail and ask me if any of my information has changed instead of asking me to fill this stupid form out over and over again?” And, I think you know enough people get angry about the absurd paper requests, and you know maybe it’ll embarrass people into automating, but I don’t think there’s a tremendous amount of consumer pressure right now.

California Healthline:
 Do you think the U.S. can learn from other countries when it comes to health IT adoption? If so, which ones?

Goldsmith: You know if you look at France with the carte vitale, and you kind of wonder, why didn’t we do something like that? I mean the answer is that we have multiple payers in our system, not one. But the idea that we want to have this incredibly complex, high-level interoperability you really don’t need if the patient carries the record around with them and it’s simply updated as they have clinical encounters. So I think the French experience certainly begs the question of why we haven’t done something like that.

You could put most of the relevant information about me on my thumb drive, and I could attach that to my keys. But [you would need] get to the point where you can agree on what ought to be on the thumb drive and have the minimal level of interoperability that you could read it anywhere and write to it anywhere. I think there was a much simpler way to do what we’re trying to do than to create some kind of every system talks to every other system in the cloud structure that appears to be where we’re heading.

California Healthline:
 You are an adviser and/or investor in several health-IT related companies, such as Eliza and onFocus Healthcare. How do you decide what companies to work with and how do you think those companies differ from the general health IT or health 2.0 marketplace right now?

Goldsmith: They’re both tools-based companies. They’re not in the mainstream of clinical process. I think both of them strike to the heart of trying to improve communication. In the case of Eliza, a remarkable ability to both communicate with and listen to subscribers by the millions. In the case of onFocus, an ability to get an entire management team singing off the same sheet of music — to put all of the performance information that you need about an organization on a really simple and easy to use dashboard. You know I’ve served on enterprise software boards before. I was on the Cerner board for six years and that was an incredible experience. But I really I think at this point the meaningful changes are going to come from the margins not from the core vendors.

California Healthline readers: Do you agree or disagree with Goldsmith’s take on health IT adoption? Use the comment section below to share your views. 

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