By Stephen B. Soumerai and Sumit R. Majumdar
Tuesday, March 17, 2009
President Obama's proposed health-care reforms include investing $50 billion over five years to promote health information technology. Most notably, paper medical records would be replaced with linked electronic records to try to improve quality of care and lower medical costs. The recently enacted stimulus package included $20 billion for health IT, and, indeed, the $50 billion the administration initially earmarked is almost twice the annual budget of the National Institutes of Health. Yet while this sort of reform has popular support, there is little evidence that currently available computerized systems will improve care. In short, it's the wrong investment to make at this time.
The assumption underlying the proposed investment in health IT is that more and better clinical information will improve care and save money. It is true that computerized records in some settings might improve care, such as by preventing duplicative prescriptions, medical errors caused by illegible handwriting and even inappropriate treatments. But the benefits of health IT have been greatly exaggerated. Large, randomized controlled studies -- the "gold standard" of evidence -- in this country and Britain have found that electronic records with computerized decision support did not result in a single improvement in any measure of quality of care for patients with chronic conditions including heart disease and asthma. While computerized systems seek to reduce the overapplication or misuse of care, they do little to prompt greater and more widespread health-care practices that are known to be effective. Health IT has not been proven to save money. Moreover, personal financial ties have been found between some researchers and the companies that produce these systems, and as far back as 2005 studies have shown that health IT developers are about three times more likely to report "success" than evaluators who had no part in system development.
What's more, evidence suggests that adoption of some computerized systems has not helped but harmed patients. After the Children's Hospital of Pittsburgh added automated prescribing recommendations to a commercial electronic records system, the institution documented a more than threefold increase in the death rate among child patients. Another leading system contributed to more than 20 different types of medical errors.
There are thousands of small groups of physicians in the United States, the majority of which are not ready for this sea change of interconnected health information. The latest national survey, published in the New England Journal of Medicine, shows that only 4 percent of doctors have fully functional electronic records that can provide any kind of clinical recommendations. Health information technology is expensive, and government subsidies may not be sufficient to persuade doctors to use them. Studies in U.S. hospitals suggest that these systems can add a half-hour or more to a day for tasks such as electronic ordering, and the false alerts that systems sometimes send can desensitize doctors to legitimate clinical recommendations. Yet, as things stand, doctors who rightly worry about these problems and delay adoption of certain types of health IT solutions beyond 2014 will be penalized through lower Medicare reimbursements. No one benefits, and reform is likely to stall, or worse, if doctors are forced to adopt flawed or unproven health IT systems.
There are, of course, places where advances in health information technology may have modestly reduced medical errors. But most such improvements came under the very large, integrated systems such as those used by Kaiser Permanente and the Veterans Administration, or the national health plans in countries such as Denmark, Britain and Israel. In those countries, physicians are required and trained to use the national systems. That isn't standard in the United States, where such large systems cover only a small fraction of patients.
In the near term, health IT systems are an expensive and still unproven technology for most physicians in the United States. Before moving ahead, the administration should first consider conducting well-controlled research on the cost-effectiveness of health IT in office practices, which are the bulk of the U.S. medical system. It should base any investments of taxpayer funds on solid evidence of benefit and safety. Finally, it should invest in proven but underused health programs that do not bankrupt the budget, such as physician and nurse-practitioner teams that help homebound elderly people avoid hospitalization and institutionalization.
For many chronically ill and vulnerable patients, it does not matter much whether their health records are digital or their prescriptions typed. Without patient access to clinicians and adequate health insurance that includes affordable drug coverage, a $50 billion investment in health information technology won't do much for many Americans. These funds are needed elsewhere.
Stephen B. Soumerai is a professor of ambulatory care and prevention at Harvard Medical School. Sumit R. Majumdar is an associate professor at the University of Alberta's Department of Medicine.