A Conversation with AHRQ’s P. Jon White, MD
AHRQ’s director of health care information technology looks at the federal health care IT stimulus program from the quality perspective
A year after the stimulus bill called for an investment of billions of dollars for health care information technology, and with newly defined government incentives to providers in play, it’s clear that the use of computers is going to become common in doctors’ offices and hospital rooms over the next two to three years, says P. Jon White, MD, director of health care information technology at the Agency for Healthcare Research and Quality. The change will affect health plans, which will want to connect to providers and should consider creating incentives of their own, he says. “Health plans have a great opportunity to be a positive influence on the implementation as well as the meaningful use of information systems in health care,” White says. “It comes down to setting their policies and working with providers as they get these systems installed to ensure that the outcomes their members get at the end of the day are better.” A family medicine physician, White joined the agency five years ago as a senior service fellow. He had been chief medical information officer and associate residency director at Lancaster General Hospital in Lancaster, Pa. He earned his medical degree at the University of Virginia, and he completed his residency at Lancaster General Hospital. White spoke recently with MANAGED CARE Editor John Marcille.
MANAGED CARE: How involved was the AHRQ in getting health care IT into the stimulus bill?
P. JON WHITE, MD: That bill moved very, very fast. The agency doesn’t play a role in initiating this kind of legislation, but we do play a role when the folks on the Hill have a question. For the stimulus bill, we played a small role in answering questions and providing good evidence. Since then, though, we and a lot of other federal agencies and people from the private sector have worked very closely with the Office of the National Coordinator for Health Information Technology in helping them develop their spending plans and get their programs up and running.
MC: Are we ready for billions of dollars in investment for health care IT?
WHITE: We’d better be; it’s happening. The whole point is not just to get people to adopt, but to meaningfully use health IT, which ultimately gets down to, Do you improve quality, do people suffer less, are we more efficient with how we use our health care dollar? Many people out there are ready to do this. Many have been doing it and are doing it well. Others aren’t ready, and because of the way the legislation is written, they have some time to catch up. But they are eventually going to have to be able to use these tools and systems, and they are going to have to be able to improve their quality. Within the next several years, they are going to have to be on board.
MC: Would you say, “It’s about time”?
WHITE: By and large health care has not been a place, certainly on the clinical side and to a degree on the administrative side, where information tools and systems are used effectively. We’re very good at dealing with people, we’ve very good at focusing on conditions, and we’re very good at dealing with acute care. But this has been a bare patch on the lawn for a while, and that’s a shame. A lot of people deliver good health care without IT. It can be done, but it can be better with information tools and systems. People are going to take this and run with it and do great things, and I think that over time they are going to change the conversation so that physicians are asking their peers, “Why aren’t you using these tools?”
MC: When you talk about people who aren’t eager to use these systems, are you talking about physician organizations?
WHITE: Yes, but there are a lot of people in health care: hospitals, health care systems, long-term care facilities, and ultimately, the people who use health care services. Patients need to be wired into the system, too. They need to be able to use these things. Health care comes from a lot of different places, and all of that information is valuable in getting to great health care.
MC: Where do health plans fit in?
WHITE: I have been at AHRQ for five years, and during that time, there have been sparks, some little lights going on and off, and there have been some islands of great things happening at places like Blue Cross Blue Shield plans and UnitedHealthcare. But I have been slightly puzzled that for a year now, the federal government has said we are going to be paying incentives to providers to adopt and use these things, yet we have not seen much in terms of incentives or other encouragements from health plans. The silence from private insurers is noticeable.
MC: What do you attribute that silence to?
WHITE: I understand that they may want to let the government put the money in and see what happens. The government is a big part of the health care system; it’s not the only part. In order to get us to a broadly functioning health care information system, we need to see private plans come along, too. I’m not pointing a finger at any individual group, because within these organizations, a lot of individuals are engaged. These people are not sticking their heads in the sand. But we haven’t seen that clear policy shift as we have on the federal side. In the federal agencies that pay for health care, the shift is there. It is going to take a couple of years, but the policy is clear. I haven’t seen a similar shift by health care plans.
MC: What sort of commitments or activities do you expect?
WHITE: I don’t want to set policies for health plans, but why not something similar to what the federal government said, that we are going to provide incentives for providers who are using information tools and systems up front? Whether it is meaningful use or whatever criterion they want to define. Health plans have seen some pretty clear advantages to using information systems on their business side. They are going to see that it will benefit the clinical side, too. I just haven’t seen them do it yet.
MC: Should the benefits of following that path be obvious to health plans?
WHITE: Now you are getting to the question of whether health IT improves care, and that is a good question for the government as well as health plans. When used correctly, there is absolutely no doubt in my mind that health IT improves quality of care. Using these tools in the right way means you are using your order entry system, for example, to catch harmful orders before they go in; making sure that the most effective treatments are obvious for someone who is getting ready to pick a treatment; getting patient information to where it needs to be so that we don’t waste time calling record departments; looking across populations to deliver equitable care; and incorporating people’s values into the decisions that are made about their care. That’s when quality improves. Quality doesn’t improve when people install systems because they are required to or because they think it will improve their administrative burdens, and they don’t think about the clinical use. You don’t want that grouchy old cardiologist saying to you, “You are killing my patients with your new system.” Instead, you want him to say, “Why didn’t I have this system five years ago?” That’s when people start using these systems to deliver great care. That is not obvious, and that can definitely get lost. Over the last 10 years, the percent of practices and hospitals that start to install systems and then stop has been in the double digits.
MC: Who’s to blame for the failures?
WHITE: If you look along the chain of where a product started and where it ends up, there are a lot of different reasons why things fail. Sometimes, it’s a design issue with the underlying infrastructure or the user interface. Sometimes it’s the support that an organization gets before, during, and after an installation. Sometimes that support was there, but the organization did not take advantage of it. Sometimes it’s the user’s fault. On the flip side, when things do go well, there is typically a lot of credit to share.
MC: The agency has talked a lot about usability and what you’ve called “dense data displays.” Why is that desirable?
WHITE: If a system is designed in such a way that when the doctor sits down with a patient and has to flip through 20 different screens to find the information he needs, or in a way that drives nurses bananas when they have to enter information, it’s guaranteed to fall apart. So we have to think about the clinical encounter and make the information clinicians need readily accessible. Now, that’s a lot of data, and it doesn’t mean that you have to display every bit of it on the same screen all the time. You just have to make sure providers and patients can get to the information in a timely and efficient way, in a way that makes sense. You might think of dense as thick and heavy, when really the principle behind it is to have information where you need it, when you need it. It might be a very clean display of data, not heavy at all.
MC: Are you doing research on this?
WHITE: AHRQ convened an expert panel and has created some reports. The panel found great value in the discussion because it is an issue they had been thinking about. It was a good question for us to ask, but it’s taken on a life of its own. These clinicians and technologists and other folks are continuing the conversation and recognize that it’s important and are going to try to carry it forward.
MC: Aren’t we at the mercy of the vendors of these systems on this?
WHITE: Of course we are. But we can either beat up on them and say, “You guys create bad systems” or we can try to be more thoughtful about it. There are good systems out there that clinicians like to use. But let’s try to figure out empirically, certainly not arbitrarily, who is doing a good job. This gets into the squishier, more qualitative aspects of research, such as, “Do you like it?” We need to figure out what some of the best practices are — what works and what doesn’t. Design firms across the world look at information systems and try to figure out how to make them more usable. It’s just that in health care, lives depend on it. It’s very important.
MC: Can you predict, based on the experiments you’ve seen and the projects you’ve been involved in, what is gong to happen going forward?
WHITE: We are going to see a lot of implementations, both from individual doctors and the national organizations that represent those doctors. They have been waiting for the incentives to hit, and now that they have, and they know what the regulations look like, they are going to start doing this. Over the next two or three years, people who have not seen computers in exam rooms are going to see them. It is definitely going to happen. Doctors are smart people, and they can figure out how to use these systems.
MC: Are they going to use them well?
WHITE: We are going to see a focus on this concept of meaningful use. You may not have had a chance to read the 550-page regulation, but there are a good number of digests out there. The bottom line is that providers are going to have to use these systems to measure quality and provide data on it, to electronically prescribe, and to exchange health information with each other using these systems. And I think they are going to be able to do it. I’m not saying everyone is going to get this perfect, but the majority of folks are going to wind up saying the same thing that most of their peers who have gone through it say, which is, “I would never go back to practicing medicine the old way. I don’t know how I did it without these systems.”
MC: Will we see improvements in quality of care?
WHITE: At the end of the next two or three years, we will be able to see improvements in quality in some places. Right now, we have data about the quality of care across the country, but they are largely extrapolations pulled from things like administrative data. As we get into this, we are going to discover a lot of things about quality of care based on clinical data. That’s going to be a real gut check for medicine — a time when we have to look at ourselves and ask, “Do we believe our own eyes? Do we believe our own data about the quality of care that we are providing?” In Lake Wobegon, all the women are strong, all the men are good looking, and all the children are above average. And that’s OK, but once we have some solid data, we as health care providers are going to have to say, “Now what are we going to do about this?” So over the next couple of years, we’ll see a lot of implementations, and in the end we’ll be glad we did it. Then the real game begins, which is to use this data to improve quality on a national basis.
MC: Will the provider community go along with this?
WHITE: I’ll happily point to organizations like the American Board of Internal Medicine, the American College of Physicians, the American Academy of Family Physicians, and the American College of Surgeons, who have said this is important. We are accountable to the people we serve to provide good quality care, and performance reporting is part of that. The hospitals have done it, too. The Federation of American Hospitals and the American Hospital Association have done this through things like Hospital Compare. They have made the commitment to use data not just to publicly report, but to improve the quality of what happens.
MC: Haven’t improvements in outcomes always been a part of the IT discussion?
WHITE: It was always a part of the conversation, but we were more focused on specific things, like the electronic medical record and health information exchange. Those things are important, but the newly released proposed rules on meaningful use really start to talk about reporting data on quality measures. That’s the right place to go. Everything is good when you look at yourself, but when you can look across providers, that is when people can objectively say, “I may not be doing as well as my peers, but why not? What’s going on? Do I have less well patients? Or is there something that I could be doing better?” So systematically, we are headed in a great direction. I think things like meaningful use are going to bring us forward. I really hope we get to the day where technology becomes more embedded, becomes part of the infrastructure of health care, and we can talk about that less and talk more about the outcomes.
MC: Will that be possible on a national scale?
WHITE: Nationally, we have seen some wonderful things happen with standardization, certification, and the national health information exchange, for example. Standardizing the language we speak in health care is important. When I describe a hernia and talk about how I fixed it laparoscopically, I have to be able to do it in a way that means the same whether it happens at George Washington University or UCLA. To start talking about the data and the outcomes, you need definitions. That has been a decades-long process, but we are getting to a place where the national, broader, underlying infrastructure kinds of activities have gained acceptance and are becoming part of the routine.
MC: How do we compare to other developed countries in this area?
WHITE: If we look at the breadth of technology adoption, a lot of other countries have more providers using electronic medical records. That’s true for many different reasons. If a national health care plan requires it, that will push the issue with providers quite well. That doesn’t automatically mean that providers are using those tools or that they are using them in ways that improve health care. This is an important point because it directly relates to the big surge that we are going to have in the adoption of health IT in the United States over the next few years. In some countries, people use technology to document what they are doing with patients, but the system doesn’t connect to anything. There’s no knowledge embedded in it. They can’t use it to communicate, and it can’t catch mistakes. You might as well be using Microsoft Word to capture your information. It’s slightly better in the sense that the doctor’s handwriting is no longer an issue, but it is not using these tools in the sophisticated way that you need to use them.
MC: Will our system ultimately be superior?
WHITE: Some countries have made more of an investment and are further ahead. Yet I would say places like Great Britain are on parallel with places like Kaiser and the Department of Veterans Affairs when it comes to using information tools in ways that may improve care broadly across the system of care. Have they improved outcomes? Yes. Have they had problems? Oh, yeah. Everyone around the world is on equal footing in terms of just starting to get to systems that can do the things we need them to do to improve quality.
MC: Is it essential that health plans participate?
WHITE: Health plans can play a really constructive role in this general movement. Interacting with health plans is a big part of a provider’s day. Over the next two or three years, a lot more lights are going to go on across the country in hospitals and doctors’ offices, and that has a couple of implications for health plans. The first is that these providers are going to have systems that insurers are going to want to work with. That’s going to be an issue that health plans need to stay abreast of. The second issue that is very important for health plans to understand is that for a long time, because of their great information infrastructure, insurers have been one of the few groups that have had data to look at about the quality of care, including who’s delivering what and the cost of care. So they’ve had this great resource, and as these provider systems get installed, the people installing them are going to get a new perspective on the power of data. Health plans have understood this for a long time, but soon they will not be the only ones that have data about populations of people. That’s good, but it changes the game for them.
MC: Thank you.
We have not seen much in terms of incentives or other encouragements from health plans. The silence from private insurers is noticeable.
Patients need to be wired into the system, too. They need to be able to use these things.
Over the last 10 years, the percent of practices and hospitals that start to install systems and then stop has been in the double digits.