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The HIT Productivity Paradox — It’s Gonna Be OK

February 21, 2013 DrLyle 4 Comments

The New York Times publishes another article about how spending money on EMRs is a waste since the benefits are not obvious. Like so many media cycles, they build you up (HIT is great) and then tear you down (HIT is a waste of money). 

Fair enough. Are EMR’s worth it? Was MU worth it?

I’ve said before that I don’t think I would have spent the $30-40 billion that way (remember, they use the $19 billion figure because they assume $10-20 billion in savings). I would have focused on mandating standards and trying to push for a uniform data model platform upon which vendors could then build their more external facing products.  

However, I will happily admit that MU has done its job. It has stimulated the adoption of EMRs. It won’t be the 80+ percent they were hoping, but it still got a lot of people off their asses and moving.

Next question: will EMRs provide all the great things we are hoping for?

Certainly we’ve got some issues. EMRs are still not mature, nor is our understanding on how to best use them. But no technology, from cars to computers, started out perfect.  

I’ve been reading "The Signal and the Noise." Very early on, it reminds readers of "the productivity paradox," which helped explain why the early computer age (1970s-1990s) actually saw a lower productivity as everyone was figuring out how build them well and how to use them. Sound familiar?

From Wikipedia:

The productivity paradox was analyzed and popularized in a widely-cited article by Erik Brynjolfsson, which noted the apparent contradiction between the remarkable advances in computer power and the relatively slow growth of productivity at the level of the whole economy, individual firms, and many specific applications. The concept is sometimes referred to as the Solow computer paradox in reference to Robert Solow’s 1987 quip, "You can see the computer age everywhere but in the productivity statistics." The paradox has been defined as the “discrepancy between measures of investment in information technology and measures of output at the national level.” It was widely believed that office automation was boosting labor productivity (or total factor productivity). However, the growth accounts didn’t seem to confirm the idea. From the early 1970s to the early 1990s there was a massive slow-down in growth as the machines were becoming ubiquitous. (Other variables in country’s economies were changing simultaneously; growth accounting separates out the improvement in production output using the same capital and labour resources as input by calculating growth in total factor productivity, AKA the "Solow residual.")

If and how can this best be applied to healthcare IT? It turns out that some smart authors actually addressed this exact issue in a June 2012 NEJM article entitled. “Unraveling the IT Productivity Paradox — Lessons for Health Care.” The authors explain that sure, we are seeing problems with HIT, but it is as expected, just like every other new industry has to evolve. They conclude with the following paragraph:

The resolution of the original IT productivity paradox suggests that current conclusions about the value of health IT investments may be premature. Research suggests three lessons for physicians and health care leaders: invest in creating new measures of productivity that can reveal the quality and cost gains that arise from health IT, avoid impatience or overly optimistic expectations about return on investment and focus on the delivery reengineering needed to create a productivity payoff, and pay greater attention to measuring and improving IT usability. In the meantime, avoiding broad claims about overall value that are based on limited evidence may permit a clearer focus on the best ways of optimizing IT’s use in health care.

Clearly we are not at perfection. HIT can affect efficiency and quality in both good ways and bad.  But rather than try to create some artificial polarization that it is all good or all bad, let’s continue doing our job (for the medical informatics professionals reading this) to keep making HIT better serve our providers and patients, while educating those who get freaked out every time a new stat or story comes out pointing out its imperfection. 

2-21-2013 10-49-19 PM

Lyle Berkowitz, MD is associate chief medical officer of innovation, Northwestern Memorial Hospital; chairman of healthfinch ("The Doctor Happiness Company"), author of the Change Doctor blog, and editor of the new book, Innovation with Information Technologies in Healthcare, which has a whole bunch of good stories about organizations who have succeeded with EMRs and healthcare IT by thinking innovatively about the best way to use them in their settings.

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Currently there are "4 comments" on this Article:

  1. Dr. Berkowitz–

    Well stated article about a very difficult problem. A couple of additional points:

    1. Brynjolfsson’s work focused at the national accounts level, which captures data much more readily about products (e.g., manufacturing) than about services. So out of the box we need to interpret his conclusions–striking as they are–somewhat cautiously. And to paraphrase Drucker’s famous comment, healthcare probably is the most complex industry in our economy. Another point (made by McKinsey some years ago) is that it isn’t the technology itself that makes the difference, but what we do with it–or to put it another way, technology in and of itself has no value; it is what we do with it that generates the value. One of the explanations for the discrepancy between IT investment and productivity returns is that we haven’t changed the management/clinical processes in order to take advantage of what electronic capabilities offer. Recall that it was close to 40 years after electricity was discovered before manufacturing processes were adapted to take advantage of what this at the time revolutionary technology could offer.

    2. Value measurements in the services industry, and in health care particularly, are challenging–not to mention the lag time between investment and value creation. A study at Brigham and Womens some years ago (I think David Bates was senior author) documented a period of 7 years between the initial CPOE investment and any measurable impact on the bottom line. CFOs and Boards not only too often don’t understand this, they certainly don’t like it–especially when an investment in a new MRI can generate measurable returns much more quickly.

    3. A third challenge is that commercial vendors for the most part continue to sell clinical application suites with architectures that reflect how medicine was practiced a decade ago, not how it is practiced today, nor certainly how it is likely to evolve over the next decade. In the rush to “get systems in”, product development has lagged as gaining market share seems to be the major priority. After all, once implemented, a customer is not likely to change to another system for some time.

    4. At the end of the day it really is about the productivity of our most precious and expensive resources, the clinicians, and their relationships with their patients. In the near future, we may wonder whether the literally hundreds of millions of dollars being spent in single organizations’ EMR implementations is really worth the tens of millions of federal stimulus money being paid out, and whether a more deliberative, evolutionary process–for both organizations and vendors–might have been the wiser choice.

  2. I have a simple measure of the influence of EMRs.

    It wasn’t so long ago that many docs didn’t get to go home until very late; among other things they had to clean up the messes of the day.

    To over simplify only a little, some docs now go home – have dinner with their families, put the kids to bed, and then get online to clean up the messes of the day.

    Although, anecdotally, the in-patient docs at Kaiser don’t like their EMR, the Kaiser soccer mom docs – usually outpatient docs – do like it because of the online access. They use it to communicate with one another, and with their patients, and with institutional resources – labs, medications, patient support systems, etc.

    And, as we know, Kaiser patients, at least those in the San Francisco Bay Area love their online health records. Just renewing a prescription online, and making appointments online, seem huge to the jaded public.

    None of this kind of thing gets measured, and they may be the most dramatic results – near term.

    — Mark

  3. I think the computer industry analogy is strong. Of course it’s taking us a while to figure it all out. It’s the way of innovation and the human world.

    A key to improved productivity is making sure everybody (including the patient and sometimes their family) does the right work. It is important that technology implementation does not result in routing work to providers that ancillary staff should be doing, for exmple. Team based, appropriate work allocation is the critical, and often forgotten, piece of the discussion.

    The technology itself, document storage, legible documentation, templates, automated medication order routing to pharmacies, secure messaging, etc is a no-brainer for productivity, even if we can’t measure it yet for all the noise. (And things are quite in flux right now!)

    I think criticizing the automatic messenger (EHR) is wasted breath.

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