Dr. Blumenthal Went To Washington

http://www.youtube.com/watch?v=EaN1uxHZqSI

For the last two years, Dr. David Blumenthal was the czar of Health Information Technology for the Obama administration, overseeing its monumental efforts to push the country toward electronic medical records. This is his first week back at his Harvard home. In case you missed it yesterday, CommonHealth featured him in the above brief video, on what we should all be asking of our doctors, electronically speaking. Today, we continue our debriefing, lightly edited:

Q: You’re just back from two years in Washington, DC. What will you do now?

To be absolutely frank, I’m exploring lots of different options. It’s virtually impossible to plan your next step while you’re in government, because of all the potential conflicts of interest. I’m back as a professor at Harvard and I’m sure I’ll be doing some writing, and probably some academic work, and a lot of speaking and guest-lecturing. I also have acquired something of a taste for having an impact on the real world — I spent two years trying to do that in Washington — so I’m looking for opportunities to affect health care delivery, and I’m not sure what form that will take.

I’ve become a convert to the idea that information really is power, in health care just as in everything else. The information platforms that systems work with are vital to their success, and getting those better-integrated into the day-to-day delivery of care is important for patients, doctors, nurses, hospitals — everybody. I don’t see a pathway to accomplishing everything we want to accomplish, in the commonwealth or nationally, until we have much more powerful information systems.

You can make big changes in the delivery of health care just by giving people better information. Most health care professionals go to work every day wanting to do a good job, and when they fall short, it’s often because they don’t have the information they need.

Q: Could you share a telling example of the power of information in health care?

I’ve often told the story of myself as a doctor using a radiology software program they have here at Partners. What it does is two things:

When you write an order for a high-cost imaging request — MRI or CAT scan, or an ultrasound, or a stress test with complicated imaging — it asks you to put in the indications and then it compares your test order to the American College of Radiology’s guidelines, in real time. It gives you a red, yellow or green signal.

If it’s red — which does happen, it happened to me many times — it’s often because you’re getting an MRI when a CAT scan would be better, or you’ve ordered an MRI without contrast when you should have added contrast, or you’re ordering a stress test with imaging of the heart when you need to order it without.

So people change, and it prevents waste. And you can override it. I suspect if you’re an outlier on overriding, you might hear from the chief medical officer or something like that, but there’s no penalty. I did override it; most commonly when I had a patient insisting. I’d say, 'Your back hasn’t been hurting long enough, the guidelines don’t suggest you need an MRI for your back pain,’ and they’d say, ‘If you don’t do it I’ll find someone else who will.’

The other thing it did was in some ways even more powerful: It would scan through the record and find out if something similar had been ordered in the previous three months.

One woman came in with what I thought might be kidney disease, and I wanted to image her kidneys. I put in the order and up came the feedback that something similar had been ordered in the last three months. So I went looking for the test, and found another physician had ordered a lung CAT scan, but it so happens that when people do CAT scans of the lung, they often go below the diaphragm. Her kidneys had been imaged on that test and they had been normal.

[module align="right" width="half" type="pull-quote"]

To me, that symbolizes the way forward. The doctor is a better doctor, the patient is less inconvenienced, and we’ve saved a whole bunch of money.

[/module]So it avoided the money and it avoided her inconvenience, it was a total win. To me, that symbolizes the way forward. The doctor is a better doctor, the patient is less inconvenienced, and we’ve saved a whole bunch of money. I thought to myself, if that could happen tens of thousands of times a day all through our health care system, it would be a dramatic change, and without any controversy.

One of the reasons I think the work we were doing in Washington is so potentially important is that we were creating incentives for people to put in place this kind of software and the capability to use it.

Q: So you actually think this kind of change can come without controversy? Hasn’t there been a great deal of pushback against electronic medical records?

It’s a constant theme. We understood that this was about winning hearts and minds, of mostly the small practices and small hospitals. Among the large practices and hospitals, it’s absolutely unquestioned. That’s been a big psychological change.

It’s hard to adopt electronic health records, that’s very clear. It takes a lot of extra time and effort. The cost question is less clear. When I got to Washington, I was pretty much convinced that there was not much of a return on investment for small practices, but that you could get to break-even.

[module align="left" width="half" type="pull-quote"]We understood that this was about winning hearts and minds, of mostly the small practices and small hospitals.[/module]

But there’s been increasing information demonstrating that in fact, there are pretty dramatic cost savings possible, and revenue gains — even in small practices — from electronic medical records. They have to do with elimination of personnel from filing, easier systems to make appointments, less requirements for nurse follow-up of lab testing, all those kinds of things — and needing less space as you get rid of all those paper files. And also more thorough, accurate billing. The Medical Group Management Association, which represents groups of five physicians or larger, did a study that showed that among their members, groups with electronic health records — compared to groups without — netted over $40,000 more per physician per year.

I think this will be especially true as the systems improve, and one of the elements of improvement is cloud-based software.

Q: You’d said initially your commitment was only for two years, but still, why did you decide to leave Washington?

I think that at the margin, my contribution was diminishing. There are still some big problems to solve but the task was much more an implementation task than a policy development task now, so I thought there were other people who could do that just as well as I could.

Q: Some people say you’re leaving just as the really hard part starts...

The first two years weren’t without their controversy but I think we have a good grounding. And if Information Technology were my lifelong passion it might also have made a difference, but I’m much more about delivering health care services more efficiently.

Q: What surprised you there?

A number of things, both positively and negatively.

One of the positive things was the enormous outpouring of support and time commitment that we got from volunteers on our advisory committee. I calculated that we had probably had 15 or 20,000 volunteer uncompensated hours from experts, the best people in the country who either sat on the phone or met in meetings open to the public and discussed the key issues.

That was the upside. The downside: I was surprised at the level of skepticism about the whole premise. I expected people to say, ‘It’s going to be hard.’ I expected people to say, ‘I don’t trust the software.’ I expected people to say, ‘It’s going to reduce my productivity.’ I was a little more suprised by a theme that was kind of a conspiracy theory, that this was an industry project, that in the IT industry there were some big donors, big democratic donors, big information technology companies that had basically captured the process.

The fortunate thing about it is that there was absolutely no truth to the story so it went away. I was the poster person for this initiative, and I’ve been on the masthead of the New England Journal of Medicine, and the New England Journal has very, very tight conflict rules: I couldn’t accept honoraria for speaking, I did no consulting for industry, no speaking. I was really completely clean. And not only that, I had no involvement in information technology before I got there. I didn’t know these people. Evenutally, they just couldn’t make the case.

Then it took another shape. The Huffington Post had a couple of investigative reporters who were tackling us for quite a while and their argument explicitly was that electronic health records were unsafe for patients, because they made errors — software bugs and failures and unusable equipment could lead to errors.

Q: And are there errors?

The response we made was that net-net, people are safer with electronic health records, but any technology, no matter how beneficial, creates potential errors, that’s why we regulate vaccines, drugs and devices. We need to look carefully at information technology from the same perspective. So we actually asked the Insitute of Medicine to do a study of how to improve the safety of electronic health records, and they’re in the process of doing it. They’re going to report in the fall, and there are a number of options we were actively looking at, including that they could be considered devices under FDA regulation. We also have a certification process that didn’t exist before, that could involve some safety assessment.

Q: Was the president supportive enough?

Yes, I felt we got support from the president. I had fewer surprises than there might otherwise have been. This is a bipartisan issue. The administration was strongly committed to it; it was a priority for them to get it launched successfully. When we really needed them to help us meet our deadlines for getting regulations out the door and meeting legislative deadlines, they got the job done for us. Nothing ever is completely as you expect, or completely uncontroversial, but on the whole I got the support I needed. Even the Ryan proposal does not take aim at electronic health records. I think it’s because people like Newt Gingrich have been big supporters of health information technology. One of the early bills on health information technology was jointly sponsored by Hillary Clinton and Newt Gingrich.

Q: You say we can’t proceed with health reform without better technology...

You can’t be accountable for care if you don’t know what care you’re delivering. You can’t be accountable for cost if you don’t know cost. You can’t be accountable for quality you can’t measure. We don’t have a way for doing things better absent better information