A long, long time ago, way back in 2007, "presidential candidates in both parties were pledging to boost health IT," writes TIME magazine reporter Michael Grunwald in his book, The New New Deal: The Hidden Story of Change in the Obama Era (Simon & Schuster). "Several bipartisan bills were floating around Congress, and Hillary and Newt Gingrich were both hailing electronic medicine as the future of healthcare."
Still, five years ago, all that talk and more or less toothless legislation had still failed to make much of an impact on what Grunwald calls "the world's least data-driven $2 trillion industry" (see the Q&A with him on page TK). "Every minute, redundant new tests were ordered because old results weren't instantly available," he writes. "Nurses and doctors wasted countless hours filling out and searching for paperwork, and atrocious paperwork still killed."
But in late 2008, in the span of just two months, the great recession brought the U.S. economy to the brink of catastrophe, and Barack Obama was elected president. Before long, the American Recovery and Reinvestment Act (ARRA) - the $800 billion stimulus whose contentious construction on Capitol Hill and nationwide legacy are the subjects of Grunwald's book - was in the works.
"Never waste a crisis," erstwhile White House Chief of Staff Rahm Emanuel was wont to say. And so, in response to the sharpest economic downturn since the Great Depression, was hundreds of billions of dollars directed toward investments in energy, education, infrastructure and much more - both for immediate "shovel-ready" stimulus and "down payment[s] on long-term goals."
A not-insignificant pillar of that omnibus bill, of course, was the Health Information Technology for Economic and Clinical Health (HITECH) Act, which earmarked some $27 billion for electronic health records (EHRs) and other health IT adoption. "Like energy efficiency, health IT was the kind of no-brainer that appealed to Obama's hyperrational side," writes Grunwald. "It seemed absurd that German doctors used laptops while American doctors used clipboards."
Sure, there had been strong (and bipartisan) support for health IT on Capitol Hill for a long time. But until the financial crisis, "a slew of competing bills had stalled over disagreements over how to protect patient privacy, how to get doctors and hospitals to go digital, and how to get computer systems to talk to each other," he writes.
ARRA - finally - helped force the issue. "People had been squabbling over the details for several years," Grunwald tells Healthcare IT News. "The prospect of $27 billion really did focus the mind."
It's hard not to wonder where we'd be if the stimulus bill - and the meaningful use program it put into motion - had never happened. Rich Hodge, senior director of congressional affairs at HIMSS, has a good idea.
"Clearly, the nation would not have made the significant progress toward electronic health records adoption and health information exchange that it has without the Medicare and Medicaid EHR Incentive Program authorized by the HITECH Act," says Hodge. "The public dialogue, open consensus-building process, standards-based approach, and phased implementation provided by the meaningful use process have been critical to bringing the country to achieve the current level of accomplishment and rapidly increasing adoption rates."
Healthcare may have eventually decided to join the 21st century and caught up with other industries in the adoption of information technology of its own accord, he adds. "But in the meantime, quality and access to care would have continued to suffer, and the nation would have continued to pay much more for healthcare than necessary."
The U.S. simply couldn't wait for a "casual, uncoordinated approach to this major national problem," says Hodge.
Almost four years later, however, despite the incontrovertible evidence of increased EHR adoption - and report after report showing a robust and highly competitive health IT job market - HITECH and the technology it champions have attracted some less than flattering attention.
A much-discussed Wall Street Journal op-ed from Harvard Medical School's Stephen Soumerai and University of Pennsylvania's Ross Koppel argued this past September that the claim that EHR adoption will lower healthcare costs is "little more than hype" from policymakers and technology vendors.
"The most rigorous studies to date contradict the widely broadcast claims that the national investment in health IT - some $1 trillion will be spent, by our estimate - will pay off in reducing medical costs. Those studies that do claim savings rarely include the full cost of installation, training and maintenance - a large chunk of that trillion dollars - for the nation's nearly 6,000 hospitals and more than 600,000 physicians...[By] the time these healthcare providers find out that the promised cost savings are an illusion, it will be too late."
Also in September, a controversial study from the Center for Public Integrity charged that EHRs make it easier for some providers to fraudulently "upcode" - billing Medicare for more extensive and expensive patient care than was actually delivered.
More recently, in October, four Republican Congressmen wrote to Health and Human Services Secretary Kathleen Sebelius, asking her to cease any further incentive payments for Stage 2 meaningful use. They charged that some $10 billion in stimulus money could have gone to waste so far because some Stage 2 rules are "insufficient" or "woefully inadequate," especially when compared with Stage 1.
With the "bar for meaningful use set so low," and "a focus instead on trying to pad participation rates," the GOP representatives urged Sebelius to "change the course of direction" of the stimulus program.
National Coordinator for Health IT Farzad Mostashari, MD, chalked up the kerfuffle to a pre-election "silly season" and expressed confidence in the incentive program.
HIMSS has similar hopes. "We are confident that when Congress carefully examines the well substantiated and significant potential of health information technology to control costs with a high return on investment, they will continue their historically bipartisan support for the meaningful use program," says Hodge.
In the meantime, the policies and regulations put in motion by HITECH continue to do their work, and checks keep getting mailed out to meaningful users - some $7 billion so far.
Other portions of ARRA had similar frameworks set up to regulate the dispersal and efficacious use of government largesse. Grunwald points, for instance, to the IT-enabled "Smart Grid" electrical infrastructure program, which had a "much more ambitious timetable" than the HITECH Act, and dealt with challenges on getting funding moving to the right recipients at the right speed.
But even as HITECH was envisioned as long-term investment, it's arguable that not too many ARRA programs have seen its immediate success - and, crucially, visibility - as meaningful use.
"In less than three years, EHR adoption rates continue to increase, and interoperability and exchange of information across systems is continuing to improve," says Hodge, and more and more eligible providers and hospitals are planning to sign onto the incentive program. Statistics from CMS, ONC, CDC and more all "support the success of HITECH and the meaningful use program."
"Change isn't always obvious," writes Grunwald in The New New Deal. "But the stimulus-funded revolution in health IT is hard to miss. We all go to the doctor, and soon just about all our doctors will use electronic health records."
The numbers don't lie. "In 2008, just 17 percent of physicians and 12 percent of hospitals used digital records; it's now 34 percent of physicians and 40 percent of hospitals," he writes. "[A]according to the Bureau of Labor Statistics, health IT is becoming America's fastest-growing occupation."
For all the faults one could find with a $27 billion federal program, most people would call that money well spent.