WASHINGTON - As Barack Obama prepares to spend billions on health information technology as part of his plan to revive the US economy, some specialists are warning against investing too heavily in existing electronic recordkeeping systems.
In a recent open letter to the president-elect, a top technology adviser to the American Academy of Family Physicians said that current systems are expensive, cumbersome to use, and cannot easily exchange information about patients' health histories and treatments among different hospitals, labs, and doctors' offices.
"If America's physician practices suddenly rushed to install the systems of their choice, it would only dramatically intensify the [tower of] Babel that already exists," wrote David Kibbe, a senior adviser to the academy and a longtime proponent of health information technology, and Bruce Klepper, a healthcare market analyst.
Kibbe and Klepper said some of the stimulus package could be spent on electronic health records, but the bulk of it should go toward simpler and cheaper technology, such as rewarding doctors for using computers to communicate with patients and for specialist referrals. The money should also help extend high-speed Internet access to doctors who don't have it, they wrote.
Obama and many health policy analysts support a large investment in electronic health records - powerful tools that contain a full account of a patient's health that can be shared with other doctors, made available to patients, and can advise doctors on the best therapies and warn them against errors - saying they will dramatically improve patient care and reduce healthcare costs. Even skeptics see them as an inevitable part of the future of medicine. But Kibbe and Klepper's letter highlights the challenges confronting Obama's proposal to digitize an enormous and fragmented healthcare system.
There is no nationwide, secure computer network on which to send information. Electronic recordkeeping systems are expensive upfront and to maintain, and doctors often lose money on the investment. Significant privacy issues are unresolved, such as conflicting state privacy laws that complicate the sharing of information. Different kinds of recordkeeping systems do not mesh easily.
"It's immensely complicated," said Melissa Goldstein, a health policy professor at The George Washington University's School of Public Health and Health Services.
But Goldstein remains optimistic about the prospects of working through those complexities to create a functioning system. Data sharing is slowly improving, she said. "Remember when Apple didn't talk to WordPerfect and
Those who set standards for electronic health records want to get as many doctors as possible using the technology and work out the kinks over time, while also investing in infrastructure to help share data.
"That there are no good products is absolutely not the problem," said Mark Leavitt, chairman of the Certification Commission for Healthcare Information Technology, a nonprofit board that certifies electronic health recordkeeping software, and that is funded partly by the companies who make it.
David Blumenthal, a Harvard Medical School professor and director of the Institute for Health Policy at Massachusetts General Hospital/Partners Healthcare System who advised the Obama campaign on the issue, said the debate over whether existing technology is good enough has only emerged recently, with the prospect of a huge national investment in electronic health records. What seems to be happening, he said, is that passionate health technology advocates fear the country could get locked into an imperfect system.
"I think this really is a question of how good does it have to be before you pull the trigger," he told the Globe in an interview. "There's no correct answer to that, but for me, the evidence tips toward acting now, not with total abandon, but making a substantial but prudent investment in health IT."
On the campaign trail, Obama pledged to spend $50 billion over five years on health information technology. He is moving quickly to include some of that money in a $700-billion-plus stimulus package, calling it an investment that will provide thousands of high-tech jobs for the people who would build and maintain the software, even as it helps improve healthcare quality.
"We will make sure that every doctor's office and hospital in this country is using cutting-edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes, and help save billions each year," Obama said in a Dec. 6 radio address outlining his stimulus plan.
Obama has said that electronic records could help save close to $80 billion a year by reducing administrative burdens, avoiding costly mistakes, and preventing duplicate tests. The Congressional Budget Office, however, questioned that number as part of a recent study that said if Medicare required doctors to use electronic records, the program could save about $34 billion over 10 years.
The healthcare industry's leading information technology organization, the Healthcare Information and Management Systems Society, has proposed spending as much as $25 billion over the next five years on electronic medical records. The group, whose members include large vendors of electronic health records systems, has recommended that all the money be spent on software that meets federal guidelines designed to ensure they can easily exchange information among different systems.
But some doctors say this would be the wrong direction. Rick Peters, an emergency room physician and technology consultant in the San Diego area who was an early entrepreneur in electronic health records software, said existing certified systems are "dinosaurs" that are not user-friendly and don't communicate well with one another. It would be better, he said, to invest in innovation - perhaps a national competition to develop a free platform for electronic prescribing, so that doctors can use a single, consistent system across the country.
"The [electronic records systems] we currently have are not ready for prime time," Peters said.
Less than 25 percent of American physicians use computers to record and track basic information about their patients. Larger practices with more money are more likely to have digitized records than practices with five or fewer doctors, which use electronic medical records about 5 percent of the time, a recent study found.
The key reason the nation's electronic health system is so far behind comes down to economics, said Blackford Middleton, chairman of the Center for Information Technology Leadership at Partners Healthcare System, a leader in health information technology.
"He who pays is not he who gains," Middleton said.
Doctors usually have to foot the bill for the computers and software, which can cost $25,000 to $45,000 per doctor, plus thousands more in yearly maintenance and the disruption during their installation. Yet if the technology does its job - fewer lab tests are unnecessarily duplicated, fewer drug mistakes are made - insurers reap almost 90 percent of the cost savings, Middleton said. Doctors get paid by the visit and procedure, not for keeping people healthy.
Middleton, who advised the Obama campaign and has provided some input to his transition team, said it may make sense to create a business case for doctors to use health information technology - by requiring them to use it to submit Medicare reimbursements, for example. A stimulus package, he said, might combine payment reforms with low-interest loans to help doctors obtain technology and also improve standards for electronic records systems.
Blumenthal agreed, saying it is critical to change the way doctors are paid to reward them for using technology well. He also said the Obama team should invest in research and development to improve the software.
"I understand the concerns, and I accept some of the concerns," he said. "However, I think this is such a golden opportunity to invest in the future - how many bridges, how many highways would prove more valuable than the down payment we could make on wiring our healthcare system?"
Lisa Wangsness can be reached at firstname.lastname@example.org.