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March 19, 2013
BOSTON, Mass. If there were as many software developers working on applications for storing and exchanging patient data as there are working on apps like Angry Birds, electronic health record systems wouldn't be so chronically outdated.
That's the mantra of experts working on a software project based here that is aimed at transforming a "monolithic and slow-to-evolve" health information technology industry into one modeled after the iPhone app developer community.
"The children of doctors should not be using better technologies in the third grade than the doctors are using in a hospital," said Dr. Ken Mandl, co-director of the SMART project, speaking Friday to a group of about 40 journalists at the Association of Health Care Journalists national conference.
Mandl said doctors are accustomed in their private lives to using iPhone apps, Google, Microsoft Office and other modern software that is constantly updated and user friendly. Then, at work, they face clunky, outmoded software systems.
"In our lives as doctors, we end up in an electronic health record where we're expected to document in text editors with no spell check, we have no search capability, the databases don't let us query and figure out what are the trends in health of our patients based on our therapies," Mandl said.
Worse, he said, electronic health records (EHRs) have been so slow to evolve that many continue to enable the sorts of errors that would be unlikely using paper records.
"For example, on paper you would never accidentally prescribe the next drug in an alphabetical list of drugs," Mandl said.
Generally, there are two obstacles holding back more dynamic development of electronic health records, he said. One is the barriers for start-up, health IT companies are steep: security and privacy considerations alone lead to lengthy procurement processes that deter all but the largest companies.
Another obstacle is the persistent lack of standardization, which hinders the ability to interface with networks and impedes development of third-party apps or plug-ins.
It's on this latter front that the SMART project is attempting to make inroads, Mandl said.
"The App Store idea is to...enable app developers to expose data the same way every time. We're defining standards in terms of what we call 'programming interfaces,'" he said.
For example, when the iPhone first came out, the geolocation function used cell tower triangulation. Later, iPhone geolocation was determined using GPS — yet the change did not suddenly break the thousands of iPhone apps that relied on geolocation.
"Software developers didn't need to know anything about what (geolocation) system was being used underneath — all Apple had to do was keep expressing longitude/latitude in the same way. So we're working this out for medication lists, problem lists, for laboratories," said Mandl, whose project is funded by the Office of the National Coordinator for Health IT.
"If you don't implement the programming interface the right way on your system, the apps don't work," he said. "This is very close to where the rubber meets the road."
Also on the conference panel, entitled "Are Electronic Health Records Finally Coming of Age?" were Stephen Soumerai, professor of population medicine at Harvard Medical School, and Farzad Mostashari, National Coordinator for Health IT.
The position of National Coordinator was created in 2004 by executive order, and legislatively mandated in 2009 by the HITECH Act, which also authorized $26 billion in incentives for doctors and hospitals to adopt electronic health records.
Soumerai said that incentive money was spent based on intuitive notions about the benefits of electronic health records, not on demonstrated value.
"The evidence does not support returns on investment — particularly the promised health care cost savings," Soumerai said.
He said independent, rigorous studies were scarce on the effect of electronic health records in reducing health care costs, increasing efficiency, or improving patient care. He said existing studies were inadequate because — among other things — they lacked baseline data gathered before implementing an EHR system.
"You cannot have an effect measured with no change. You have to have a 'before' and an 'after'," he said.
Mostashari said now was not the time to "re-litigate" whether the incentive payments were a good idea.
"The question isn't whether we should have invested," the money, Mostashari said. "The question now is: Given that we've done this investment, how do we get the most value out of it?"
He said as health care payment models change, the systems likely would be used differently than they are now and that they would be critical for demonstrating quality of care, for example.
"Context matters," Mostashari said. "If you have a fee-for-service system where you get paid based on how many elements of review-of-systems that you document, then you will use the tool (an EHR system) to more efficiently document."
Use of electronic health records could also lead to more consistency in treatments, he said.
"One of the dirty secrets of our health care system is how bad we are at doing consistently what every third-year medical student knows people need done for them. We don't have the systems to make sure we apply consistently the science we already know. Forget about learning new stuff. ... People should be up in arms with pitchforks that only half the people who should have their blood pressure controlled have their blood pressure controlled."
"I don't think people realize how bad, how broken the health care system is. You see something like the Brill article ("Why Medical Bills Are Killing Us," a recent cover story in Time), and you're like 'Wow, really?' And the people in health care are like, 'Yeah, you didn't know that?'"
Routine treatment done right isn't always glamorous, he said.
"When someone saves your life — because you have a stroke and they go in a do a heroic surgery — everyone's like 'That doctor saved my life.' But when that doctor doesn't control your blood pressure and you have that stroke, no one says 'Why didn't they give my dad the aspirin to control his blood pressure?'" Mostashari said.
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