President Obama’s plan (published here) (the “Plan”) describes a multi-part approach to expanding the amount of health insurance available to those without insurance while attempting to reduce the costs of providing health care to Americans. A portion of this plan involves the expansion of health information technology to help reduce the costs of administering health care. On page 9 of the Plan, paper medical records are identified as a health care expense which can be reduced through records computerization. The Plan cites a study by the RAND group (published here) (“RAND”) that indicates that the processing of paper claims costs twice as much as processing electronic claims.
Estimated Savings and Quality Improvements by Adoption of Health IT
The RAND group suggests that fully implemented health IT would save the nation approximately $42 billion annually, and would cost the nation’s health care system approximately $7.6 billion to implement. RAND at 3. According to their review of the literature on health IT adoption, approximately 20% of providers in 2005 had adopted an information system (which may have several meanings from patient reminder systems to clinical decision support). RAND at 20-21. Full implementation of health IT would require a substantial number of providers to convert to regular use in order for the total savings identified by RAND to be realized. RAND estimated that in 2005 there were approximately 442,000 providers in the U.S.; this suggests that about 353,000 providers would need to convert from paper to electronic systems before the full savings to the health system would be realized. RAND at 20.
Areas of savings in the outpatient setting noted include: transcription, chart pulls, laboratory tests, drug utilization, and radiology. RAND at 21. Areas of savings in the inpatient setting noted include: reduction of unproductive nursing time, laboratory testing, drug utilization, chart pulls and paper chart maintenance, and reduction of length of stay in the hospital. RAND at 36. Savings on the inpatient side account for approximately 2/3rds of the total savings, and the largest area of annual savings is tied to the reduction in the length of stay of patients as a result of the adoption of health IT. Id. This overall cost savings is based on adoption of health records by virtually all health care providers in a 15 year period; the total savings to the health system during that time would total about $627 billion. Id.
The Plan also discusses increasing the quality of health care delivered to all patients through the implementation of disease management programs (which are driven by health data of individual patients to monitor progress and outcomes), and the “realignment” of provider reimbursement with quality outcomes. Plan at 7. Realignment typically occurs when health insurance plans pay not for the total visits billed by a provider, but based on some kind of quality measure that tracks how well patients are doing in managing their health condition. This is also driven by the availability of reliable health outcomes data (for example, the hemoglobin a1c test results of patients with diabetes over time, and the percentage that report a result under the “normal” or expected value).
The Trouble with Adoption of Health IT
Adopting health IT systems, however, is no small feat. Systems have been available to the health care infrastructure for a substantial period of time (Centricity, a health information system now owned by General Electric, was originally developed by Medicalogic in the mid-80’s and became popular in the 1990s). See Article. In 2000, Medicalogic had penetrated the practices of about 12,000 physicians in the U.S., or around 3% of the total market, and was described then as the market leader in electronic medical records (which perhaps a total of 10% of the market had adopted a system by that time). Using RAND’s analysis, five years passed and 20% of physicians had adopted some form of health IT.
If market penetration is to double every five years, by 2010, 40% of physicians should be using a health IT system, and by 2015, 80% should have adopted such a system. (Admittedly, this assertion is weak because there is not sufficient data in this article to support this assertion. In addition, adoption rates tend to follow a parabolic rather than a linear pattern, so that larger numbers of adopters join the crowd as time progresses. But, dear reader, please feel free to comment with specifics to help improve the quality of this article!)
The New England Journal of Medicine, with a likely more restrictive definition of health IT, found that less than 13% had adopted such a system as of 2008, based on their sample of 2,758 physicians. Article here. An article in the Journal of Evaluation of Clinical practice reported that about 18% of the practices it surveyed (847 in total) had an electronic health record in use in 2008. Article here. (“JECP”) As RAND had pointed out in its own literature search conducted in 2005, the definitions of health IT vary widely across the empirical surveys conducted, so an accurate estimate of market penetration is hard to come by. However, it does appear that the number of practices that have adopted general health IT is not significantly higher than in 2005.
An interesting article suggested that some of the problem with health IT adoption may be regional – that some regions of the country tend to have a slower adoption rate of technology in general, which would tend to slow down the adoption of health IT in those areas. Article here. The JECP survey also indicated that specialty practices and smaller practices tend to be slower to adopt health IT as compared to their primary care provider counterparts. Access to adequate capital to fund health IT purchases is an obvious reason for not implementing such systems. Id. I would also posit that the adoption of health IT does not generally distinguish health care providers in the market of health care delivery (physicians don’t advertise that they have a health record system). It would be interesting if patients could receive information on average health outcomes by physician when researching who they want to use for medical services (only possible if health IT is widely adopted and there is general consent to the publication of such data, which today is putting the cart before the horse).
There is, therefore, a market failure in that, if we accept that health IT reduces medical costs or improves outcomes over time, the market has not made a concerted effort to adopt this technology. The Plan puts forward capital to help implement records and has an incentives component that rewards improved health outcomes. Time will tell if these investments and market changes will actually reduce health care costs in the U.S.
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