Tuesday, December 16, 2008

e-Doubts from the Disease Management Care Blog about Health Information Technology: Caution Mr. Obama

The Disease Management Care Blog couldn't help but notice David Kibbe and Brian Klepper’s ‘open letter’ to President-Elect Obama on the topic of health IT spending. It was awfully hard to avoid after being posted simultaneously on multiple blogs including e-CareManagement, the Health Care Blog, and Health Commentary, along with subsequent mirror postings on numerous other sites.

In it, Drs. Kibbe and Kepper recognize that the Disease Management Care Blog was prescient back in 2006 and that not much has changed since then. Electronic health records (EHRs) remain expensive, not cost-saving, unwieldy, clinically unproven and not yet universally interoperable. Given the EHR’s lingering limitations, Kibbe and Kepper correctly conclude that no amount of newly printed dead presidents will overcome physicians’ widespread reluctance in letting the IT Blob and its > 100,000-person army of vendors, consultants, vice presidents, CIOs and specialists distract the docs from a) patient care and b) making a living.

Kibbe and Kepper’s considered recommendation is to step back and make far more modest investments in e-prescribing (all that’s needed is internet access), e-referrals (to promote better information exchange between primary care and specialist providers) and patient e-communications (e-mail and other forms of online information sharing between doctor and patient) along with increasing broadband connectivity.

While the DMCB agrees these areas hold a lot of potential and are a good place to start, there is no shortage of e-evidence that e-suggests we have a long way to e-go before even these e-reforms should be implemented on a large e-scale. How can the DMCB say this? Because once again it had little trouble finding a host of reports indicating that even these modest reforms are not yet ready for prime time.

e-prescribing isn’t necessarily time saving, can be unwieldy, like many other aspects of health IT can create new problems and may be used to appropriately - or inappropriately - steer physician behavior.

e-referrals should work fine in health insurance settings in which patients are assigned and have a primary care physician. What about the millions of Medicare beneficiaries who switch primary care physicians from year to year or don’t rely on PCPs at all? How about commercial PPO beneficiaries who chose that kind of insurance plan precisely because they want unfettered access to specialists? What about that inconvenient fact that in many areas of the country there aren’t enough PCPs to see patients, let alone log onto some IT e-solution and coordinate referrals?

e-communication is not a panacea either. Physician buy-in is tenuous at best because of the fear of being overwhelmed by e-mails, not to mention the possibility of a drop in income. Patients have concerns about privacy and responsiveness. What’s more, the impact on overall health care utilization and costs may not be very substantial. Last but not least, the socioeconomic digital divide may exacerbate health care disparities.

The DMCB recommends that our new President exercise a higher order of caution here. Options include letting the market work its magic at finding faster, cheaper and safer solutions. If health IT is the solution many think it is, it should have little trouble independently demonstrating value to physicians and patients alike. Alternatively, large scale pilot programs in these topic areas could be performed to better determine what is generalizable to multiple health care settings, especially smaller physician-owned practices. Alternatively, a targeted X prize could be initiated.

Last – and most importantly – e-prescribing, e-referrals and e-communication must be viewed through the prism of other health care reforms, including accountability at the primary care level for the health of populations, best-in-breed disease management programs, consumerism and physician reimbursement reform. In other words, once we work out the kinks in the e-solutions being promoted by Kibbe and Kepper, we need to recognize them for what they are: necessary but not sufficient. What President-Elect Obama's team will really need to work on is how to make them fit with all the other reforms that are necessary.


David Kibbe said...

I really appreciate the critique of the blog post Brian Klepper and I wrote earlier this week. Your points are well taken, and are entirely in line with what we are suggesting to the Obama health team and Congress about where to invest in health IT - and where not to spend.
To clarify, Brian and I are not suggesting that these incremental and Internet-using health IT solutions, such e-referral and secure patient-physician communications are in and of themselves sufficient to improve care or save a lot of unnecessarily spent health care dollars. We assume, in fact, that there will be other steps taken in the broader health care system to alter incentives to promote savings and quality improvement. In that context, however, it remains important how health IT dollars are distributed and deployed. Our modest proposal is just that.
With very kind regards,
David C. Kibbe, MD MBA

Jaan Sidorov said...

Thank you David. My past Health Affairs article was also misinterpreted as being "anti" health IT. There is only so much space in the average manuscript or blog post and your clarification helps my understanding a lot. I hope the Obama team also comes to appreciate your insights.