A casual observer of recent Congressional action might think the road to a well informed federal HIT policy would be straight and smooth. A closer look suggests just the opposite: Congress is moving ahead with no idea of what it wants HIT to do. Couple that with the Congressional Budget Office's May 2008 paper, "Evidence on the Costs and Benefits of Health Information Technology" and you can begin to get a sense of the challenges ahead.
In the past week, the House Energy and Commerce Committee's Subcommittee on Health passed HR 6357, the Protecting Records, Optimizing Treatment, and Easing Communications Through Healthcare Technology Act of 2008 (The title of the bill meets the acronym test, it refers to itself as the PRO(TECH)T Act. Really...I'm not making this up.) (see iHealthbeat article, 6/26).
The PRO(TECH)T Act builds on legislation that has been bouncing around Congress for the past few years including the WIRED for Health Care Quality Act (S 1693) and others. The bill would expand privacy protections, codify the Office of the National Coordinator for Health IT, support the integration of HIT into clinical education and authorize funding of competitive grant programs in the amount of $115 million a year through 2013.
From where I sit, these provisions are nice, but they fail to provide any direction for HIT or, more importantly, how HIT can be used to address the tidal wave of crises confronting the nation's health care and financing systems.
But, hold it ... $115 million a year for five years, that's $575 million. That starts to sound like real money.
Hold it, again. Before you start popping corks, let's remember that this bill has a long way to go. It still has to pass the Energy and Commerce Committee, it has been referred to two other House committees that must hold hearings and take action, it has to pass the House of Representatives and then there's the Senate.
It could happen; it could happen this year. But it's not likely given the time that remains, the competition for Congressional attention from other issues (like the energy crisis, the housing crisis, the credit crisis), election year considerations and more.
But let's for a moment (or at least how long it takes you to read this column) believe that PRO(TECH)T becomes law. A fundamental part of the Congressional process is that bills like PRO(TECH)T authorize spending. Authorization of spending is necessary but not sufficient. Money doesn't flow until it has been appropriated. There's the rub.
The Appropriations Committees have simply not seen fit to meaningfully fund HIT items. The best example is that the Bush Administration's annual request for ONC funding is routinely slashed. That mindset is likely to be exacerbated by CBO's recent findings.
"By itself, the adoption of more health IT is generally not sufficient to produce significant cost savings." That conclusion by CBO is one that I cannot argue with. Indeed, for all of us who have labored to advance a digital health care system, it has been understood for some time that HIT is nothing more than a set of tools. But like any tool, its value is in its use.
So, while it's great that HR 6357 authorizes $575 million for HIT funding, the bill makes no effort to articulate an objective or strategy that can be advanced by HIT. As lawmakers and their staff digest the CBO study, I suspect they will increasingly be asking, "To what purpose will the HIT be put?" For Congressional appropriators, the question likely will be, "Is there cost without savings?"
It All Goes Back to Costs
There is a growing recognition that the health care fiscal tidal wave that threatens to swamp the health care system and the national economy as a whole is not driven by demographics, as many think. Instead, the unsustainable growth in health care expenditures is driven by the growth in the cost of health care. Again, we can turn to the CBO for insight (after all, that's what Congress will do).
"Although the aging of the population is frequently cited as the major factor contributing to the large projected increase in federal spending on Medicare and Medicaid, it accounts for only a modest fraction of the growth that CBO projects. The main factor is excess cost growth -- or the extent to which the increase in health care spending exceeds the growth of the economy. The gains from higher spending are not clear, however: Substantial evidence exists that more expensive care does not always mean higher-quality care. Consequently, embedded in the country's fiscal challenge are opportunities to reduce costs without impairing health outcomes overall."
And in that statement from CBO lies a clear objective. The country can reduce the rate of growth of federal health care spending without reducing the quality of care. The strategies to achieve that objective can only be executed through the application of HIT.
As the CBO HIT paper suggests, the evidence of this lies with integrated health systems including Kaiser Permanente, Intermountain Healthcare, Geisinger Health System, and Partners HealthCare. Each of these has implemented HIT applications -- including electronic health records, computerized physician order entry -- in an integrated and strategic approach to achieving efficiencies in care while pursing improved quality, safety and outcomes.
But you don't have to be an integrated health system. Organized physician groups, making strategic use of EHRs and other HIT, are showing they can effectively and efficiently manage chronic illnesses.
A challenge for Congress in achieving the objective of controlling cost growth while improving care quality and safety will be the low level of HIT implementation in small, dis-integrated physician practices. It is not the smallness that is the problem, it is the lack of integration. Independent practice associations, where small physician practices are clinically and digitally integrated, have demonstrated the ability to constrain cost while improving care.
It is unlikely that Congress, facing the limitation of federal financing, will simply throw money at EHR, CPOE or other HIT dissemination. CBO has clearly said such an approach shows no indication of a resulting savings. Instead, those who have pressed for the availability of HIT tools will now be called on to explain how those tools will be employed in an integrated fashion to reduce the rate of health care cost growth while improving outcomes. It can be done. It is being done.
So, therein lies the challenge: developing and executing federal public policies that can accelerate and expand the strategies to achieve that objective. Once we know where we are headed, the value of HIT tools will be demonstrable through their use.