Today I read a post that said we have now spent $34.7 billion on the Meaningful Use effort. The author noted that it was admirable that there was such transparency in the reporting of spending, but expressed dismay over the lack of good data on the expected savings (recall that when the law was enacted the spending on the program was supposed to net out to $20 billion, with projected savings).
That got me to thinking – what is the best way to consider the money spent on stimulating the purchase, deployment and use of health care medical record technology? Should we look at it like we do other government infrastructure spending – where it offers broad benefits to many users (think interstate highway system) or should we look at from the perspective of individual practice and whether it really offers a good return on capital? Or is there another way to think about it altogether?
Let’s look at HITECH and Meaningful Use from the public infrastructure perspective. According to the Department of Transportation, the United States federal government spent about $119 billion to pay for the construction costs of building the highways across the country. Now this spend, much like the funds offered under HITECH, was not the only money invested – in many cases it was matched by local and state governments – yet most of the money to create the road system came from the feds (90 percent) because it was deemed to be “vitally important to national goals.” Today, the federal government does not own the interstate highway system – states do. Similarly, the federal government does not own EMRs – practices and hospitals do – and they also now own the obligation of maintaining and using these systems.
Under this model, the idea is that there is a vital and critical need for our nation to improve its critical health care infrastructure. Thus there is a need to take action where there is individual gridlock and lack of investment. During the 5-year period from 2010 to 2015, EMR adoption rates rose substantially. This has opened up the opportunity to apply programmatic efforts to the data – doing clinical decision support to identify missing preventive care, guide appropriate care and signal potential drug interactions.
Now, on the other hand, if you look at this from a practice or hospital perspective – this has not been a Yellow Brick Road. It has disrupted workflows, consumed countless hours and ushered in the role of “scribe” – a person who a provider has input information into the computer while they talk to the patient. The American Health Information Management Association (AHIMA) notes, “One of the major obstacles provider organizations face in EHR adoption is an unclear understanding of the return on investment (ROI). Even though the “meaningful use” program within ARRA provides billions of dollars to help offset the significant costs, organizations are less likely to invest in EHRs without a clear ROI….For organizational stakeholders to embrace EHR adoption, they need assurance that adopting an EHR system would positively impact business performance.”
Studies of ROI at the practice level have been mixed. Rural critical access hospitals have struggled to carve out the funds in a declining reimbursement environment and they lack the scale and talent that is present in larger urban and suburban settings. A study of solo and small group practices showed a payback of just under three years and then positive cash flows thereafter.
What if the answer to the question of value was somewhere in the middle, or perhaps viewed from a different angle? I argue that the real value in all of this spend is yet to be achieved. On the one hand, the U.S. now has a very different level of IT adoption in health care than a decade ago. We can begin to see the opportunities for computing and analytics that have really only been seen to date in retail or other service industries. But what we have is incomplete – it is an interstate highway system that hasn’t connected to the local roads. True interoperability and exchange of information is lagging. Sure, computing is great inside the walls – but it is poor across the community. Until we finish the connections, both the value of the overall national infrastructure investment and that of individual practices are be diminished.
The true value of this investment is more like that of a network – the first buyer of the first fax machine was a fool. It may have looked great, but it could only make sounds and spit out thermal paper copies. The initial EMRs are a nicer version of fax machine – they capture information, will do local computing, but their true value is locked up until it is connected across their community among all the other users.
Let’s finish the paving – let’s get the real value out of this investment – both for the country and for the providers.