Spencer S. Jones

Despite rapid growth in the rate of adoption of health information technology (HIT), and in the volume of evaluation studies, the existing knowledge base for the value of HIT is not advancing at a similar rate. Most evaluation articles are limited in that they use incomplete measures of value and fail to report the important contextual and implementation characteristics that would allow for an adequate understanding of how the study results were achieved. To address these deficiencies, we present a conceptual framework for measuring HIT value and we propose a checklist of characteristics that should be considered in HIT evaluation studies. The framework consists of 3 key principles: 1) value includes both costs and benefits; 2) value accrues over time; and 3) value depends on which stakeholder's perspective is used. Through examples, we show how these principles can be used to guide and improve HIT evaluation studies. The checklist includes a list of contextual and implementation characteristics that are important for interpretation of results. These improvements will make future studies more useful for policy makers and more relevant to the current needs of the healthcare system.

Background: Incentives offered by the U.S. government have spurred marked increases in use of health information technology (IT). Purpose: To update previous reviews and examine recent evidence that relates health IT functionalities prescribed in meaningful use regulations to key aspects of health care. Data Sources: English-language articles in PubMed from January 2010 to August 2013. Study Selection: 236 studies, including pre–post and time-series designs and clinical trials that related the use of health IT to quality, safety, or efficiency. Data Extraction: Two independent reviewers extracted data on functionality, study outcomes, and context. Data Synthesis: Fifty-seven percent of the 236 studies evaluated clinical decision support and computerized provider order entry, whereas other meaningful use functionalities were rarely evaluated. Fifty-six percent of studies reported uniformly positive results, and an additional 21% reported mixed-positive effects. Reporting of context and implementation details was poor, and 61% of studies did not report any contextual details beyond basic information. Limitation: Potential for publication bias, and evaluated health IT systems and outcomes were heterogeneous and incompletely described. Conclusion: Strong evidence supports the use of clinical decision support and computerized provider order entry. However, insufficient reporting of implementation and context of use makes it impossible to determine why some health IT implementations are successful and others are not. The most important improvement that can be made in health IT evaluations is increased reporting of the effects of implementation and context. Primary Funding Source: Office of the National Coordinator.

Efforts to close the primary care workforce gap typically employ one of three basic strategies: train more primary care physicians; boost the supply of nurse practitioners or physician assistants, or both; or use community health workers to extend the reach of primary care physicians. In this article we briefly review each strategy and the barriers to its success. We then propose a new approach adapted from the widely accepted model of emergency medical services. Translating this model to primary care and leveraging the capabilities of modern health information technology, it should be possible to create primary care technicians who can dramatically expand the impact and reach of patient-centered medical homes by providing basic preventive, minor illness, and stable chronic disease care in rural and resource-deprived communities.

A team of RAND Corporation researchers projected in 2005 that rapid adoption of health information technology (IT) could save the United States more than $81 billion annually. Seven years later the empirical data on the technology’s impact on health care efficiency and safety are mixed, and annual health care expenditures in the United States have grown by $800 billion. In our view, the disappointing performance of health IT to date can be largely attributed to several factors: sluggish adoption of health IT systems, coupled with the choice of systems that are neither interoperable nor easy to use; and the failure of health care providers and institutions to reengineer care processes to reap the full benefits of health IT. We believe that the original promise of health IT can be met if the systems are redesigned to address these flaws by creating more-standardized systems that are easier to use, are truly interoperable, and afford patients more access to and control over their health data. Providers must do their part by reengineering care processes to take full advantage of efficiencies offered by health IT, in the context of redesigned payment models that favor value over volume.

There is ongoing debate about the wisdom of the $27 billion federal investment driving the adoption of health information technology (IT) under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. Proponents expect IT to catalyze the transformation of health care delivery in the United States from a fragmented cottage industry plagued by poor quality and high costs to a highly organized, integrated system that delivers high-quality care efficiently. Skeptics suggest that the productivity benefits of health IT have been overstated, arguing that it may create safety problems and could even increase costs.

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 offers significant financial incentives to hospitals that can demonstrate "meaningful use" of EHRs. Reduced hospital readmissions are an expected outcome of improved care coordination. Increased use of HIT, and in particular participation in HIE are touted as ways to improve coordination of care. In a 2007 national sample of US hospitals, we evaluated the association between hospitals' HIE and HIT use and 30-day risk adjusted readmission rates for acute myocardial infarction (AMI), heart failure, and pneumonia. We found that hospital participation in HIE was not associated with lower hospital readmission rates; however, high levels of electronic documentation (an aspect of HIT use) were associated with modest reductions in readmission for heart failure (24.6% vs. 24.1%, P=.02) and pneumonia (18.4% vs. 17.9%, P=.003). More detailed data on participation in HIE are necessary to conduct more robust assessment of the relationship between HIE and hospital readmission rates.

The federal government is currently offering bonus payments through Medicare and Medicaid to hospitals, physicians, and other eligible health professionals who meet new standards for “meaningful use” of health information technology. Whether these incentives will improve care, reduce errors, and improve patient safety as intended remains uncertain. We sought to partially fill this knowledge gap by evaluating the relationship between the use of electronic medication order entry and hospital mortality. Our results suggest that the initial meaningful-use threshold for hospitals—which requires using electronic orders for at least 30 percent of eligible patients—is probably too low to have a significant impact on deaths from heart failure and heart attack among hospitalized Medicare beneficiaries. However, the proposed threshold for the next stage of the program—using the orders for at least 60 percent of patients, a rate some stakeholders have said is too high—is more consistently associated with lower mortality. Our results suggest that the higher standard that will probably follow in the second stage of meaningful-use regulations would be more likely than the first-stage standard to produce the improved patient outcomes at the heart of the federal health information technology initiative.