Should Americans support President Obama's effort on electronic health records?

Will digital health data improve the quality of health care and reduce its cost?

The White House stimulus package provides $19 billion over the next two years to promote the adoption and use of health information technology.  Moreover, the President has pledged some $50 billion in all over five years.

An April 2 New York Times editorial ("Miles to Go on E-Health Records") warns, "There is a long way to go."  It cites a new study published in The New England Journal of Medicine (March 26) and led by Harvard researchers, including Dr. David Blumenthal, who has been picked by Mr. Obama to be national coordinator of health information technology.

The study reports that U.S. hospitals have been extremely slow to adopt electronic records -- just as prior studies have revealed that American physicians have been very slow to computerize their operations.

The Harvard researchers surveyed some 3,000 acute-care hospitals in 2008.  Only 1.5 percent had a comprehensive e-records system in all major clinical units that performed all 24 functions deemed important by a panel of experts.  Only 11 percent of the hospitals had even a basic e-records system in at least one major clinical unit that performed eight functions.

According to a recent New York Times story on the new research ("Doctors Raise Doubts on Digital Health Data," March 26), the study measured only the adoption of digital patient records:  "The survey did not ask whether the electronic records were used to advance the health policy goals of the federal plan, like tracking the quality of care and communicating effectively with outside specialists and clinics to coordinate a patient's care."

So-where does all that leave the debate over e-health records?

Patient privacy could be horribly compromised by computer glitches or human error and mischief, say some critics.  The real impediment is lack of money, say some advocates.

In a second article in NEJM (March 26), two experts in health information technology at Children's Hospital Boston declare that spending billions of dollars of federal funds to stimulate the adoption of existing forms of e-records system software would be a costly policy mistake.  Drs. Kenneth D. Mandl and Isaac S. Kohane say the current health record suppliers are offering pre-Internet software.  As the NY Times article (March 26) describes this software: " -- costly and wedded to proprietary technology standards that make it difficult for customers to switch vendors and for outside programmers to make upgrades and improvements."

"If the government's money goes to cement the current technology in place," Dr. Mandl was quoted in an interview, "we will have a very hard time innovating in health care reform."

The Administration's health technology plan -- part of the economic recovery package -- includes financial incentives for adopting e-health records -- more than $40,000 per physician and up to several million dollars for hospitals.  That's real money -- a big carrot to speed adoption.

But what are the e-health performance targets?

To justify spending taxpayers' money, the government plan must expand digital records beyond routine tasks, such as billing, to target "how the technology will be used to improve clinical performance," insists Herbert S. Lin, a senior scientist at the National Academy of Sciences (NY Times, March 26).

Harvard's Dr. Blumenthal, who oversaw the new study and who now has joined the Obama team, clearly thinks electronic health records are a key to reforming health care:  "The goals are quality and efficiency, instead of just putting machinery in offices," he is quoted in the same news story.  "If we encourage better performance, then physicians are going to find ways to improve performance.  And health information technology is one crucial way to do that."

With all due respect, the jury is still out on that.

And even if e-records systems are a good thing -- should the government be a cheerleader with piles of incentive money?  Or a rule-setting referee to encourage innovative new open software platforms, as Drs. Mandl and Kohane suggest?  Or stand aside and allow Yankee ingenuity and the private sector to invent optimal new market solutions?

Or all (or parts) of the above?

Certainly, various parties are weighing in on the merits and demerits of e-health technology.  The American Medical Association--noting that the collection, use and warehousing of e-medical records and claims data by third parties has become much easier--expresses physicians' concerns with payers using data sent to them for one purpose also being used to analyze their performance.  The AMA, in its November 2006 Council on Medical Service Report 6, also says that payers are using data sent to them by physicians to create a payer-based health record.

To Dr. Lin's point about e-health records needing to show they can improve clinical performance, clinical examples are indeed starting to come in.  As recently as April 7 in the NY Times "Science Times" ("Radiologist Adds a Human Touch: Photos"), a radiology resident physician discovered that placing digital patient photos on CT scan files led to more thorough, insightful reports.

Suddenly, each medical case became personal, less abstract, more unique.  When a facial digital photo was attached to a patient's file, radiologists provided longer, more meticulous reports.  They felt more connected to the patients, whom they seldom meet face to face.  Moreover, additional important clues to patients' conditions sometimes surfaced -- for example, an older man with a bruiselike hematoma around the eyes suggested a possible sign of brain injury.  Paleness or jaundice might indicate various kinds of organ problems.  In short, digital patient photos created better medicine.

This simple yet innovative use of digital technology in radiology, by Dr. Yehonatan Turner of Israel's Shaare Zedek Medical Center, also points up another fact.  According to the NY Times (April 2 editorial), a vast majority of doctors in four other industrialized nations--in contrast to the U.S.--have already adopted electronic records.

So, the questions remain:

Should Americans support President Obama's effort on electronic health records?

Will digital health data improve the quality of health care and reduce its cost?

We welcome your comments.