August 8, 2016

The Weeds has health IT questions, we have answers



On a recent podcast from Vox, health policy commentators wondered why U.S. health IT isn’t better. Dr. James Ralston responds.

by James Ralston, MD, MPH, Group Health Physician and Group Health Research Institute associate investigator

Vox editors Ezra Klein, Sarah Kliff, and Matt Yglesias and I have something in common: We are policy wonks. Ezra, Sarah, and Matt have a weekly podcast called The Weeds because they dive into them on policy. A friend recommended a recent episode because the podcasters raised weedy questions about health information technology (health IT), my area of research. I’m delighted to hear people talking about online health care. Here are my answers to some of the questions raised on the podcast.

Is health IT slow to develop because older people use more care and they are resistant to technology?

The health care system I work for has had an electronic health record (EHR) with secure patient access for more than 10 years. It’s true that people age 65 and older tend to access the EHR less than younger people. But we’re seeing a steady increase in users in that age group.

We’ve found that health IT innovations can be popular with older people. One study looked at OpenNotes, which is making physician notes from a primary care visit available online to patients; they were well received in all age groups. In another study, one-third of patients age 65 and older used a shared EHR for diabetes care. Some research shows that in addition to age, important barriers to health IT use are social determinants such as education level.

So what’s keeping health systems from introducing IT?

The podcasters asked why meaningful use, which is U.S. legislation encouraging health IT, hasn’t spurred more innovations. I wish I had a full answer. One barrier is normal, understandable concerns about the work and disruption of changing practice. Another is privacy: ensuring that health information is not disclosed through insecure channels. Most providers in the United States are paid only if they see you in person, so we don’t have incentives for telemedicine or other online services. Finally, a significant problem is that health care is unlike other enterprises.

In other industries, the relationship between the consumer and the product is tight: You choose an item and you pay for it directly. But in health care, the consumers of care are not the direct purchasers. A lot of care is driven by reimbursers, such as insurance companies. Even when consumers want innovations like health IT, health care systems don’t necessarily have an incentive to provide it.

As the podcasters noted from their own experiences, health IT is highly variable. Online scheduling, getting test results, and accessing an EHR are the standard of care in many but not all practices. This is because the United States has a fragmented health care system with many different financial mechanisms, practices, and cultures. Even though systematic reviews find that health IT has positive effects on care, safety, and efficiency in most studies, successful innovations occur in a specific clinical context. That hampers their dissemination.

How can health IT improve primary care, which so often is just common-sense advice about exercise, diet, and weight?

Actually, many studies show that health IT can help people with preventive care and everyday health maintenance. Some projects, including one I worked on, show that electronically communicating with providers helps people control weight, blood pressure, and other factors that contribute to heart disease.

I want to note that the podcasters have an under-65 perspective on health care. They mentioned a few health issues, but mainly they are getting episodic care. Walk-in clinics can be fine for a lot of those needs. However, if you have a chronic condition such as diabetes, high blood pressure, or depression, you particularly benefit from ongoing personal care from someone who knows you well. Health IT can support that relationship and your care, for example connecting you to services you may need outside of an office visit. People need different care at different times in their lives, and health IT can match that care to those needs.

I appreciated the podcast from Ezra, Sarah, and Matt. By raising these questions and pushing for accessible, satisfying, consistent health IT, they are part of the solution. Their demands will help drive health care systems to take up health IT innovations.

An earlier version of this article first appeared in Tincture