Great Expectations: What happens when once-promising healthcare technologies and ideas don't deliver?

MDNG Psychiatry, July 2008, Volume 8, Issue 7

Stop us if you’ve heard this one before: A new technology is developed. Its creators promise the moon, claiming their idea will solve everything. Initial studies and testimonials appear promising, setting off a frenzy of speculative media coverage. As more attention and publicity is focused on the technology, a few early success stories cause expectations to inflate exponentially, overshadowing reports of disappointing or failed applications. Wider adoption exposes serious flaws in the technology and its applications, bursting the hype bubble and causing industry observers to move on to alternate options and ideas.

Replacing the revolution with incremental change and modest goals, the remaining proponents of the technology settle down to the long, hard work of refi ning practical applications that find their niche in the marketplace. The pattern has repeated itself so frequently that information technology research and consulting leader Gartner, Inc., came up with a catchy name for it: The Hype Cycle. Nearly every technology-dependent industry has experienced hype cycles on scales both large and small, from e-commerce and finance to communications and media. Healthcare certainly hasn’t been immune, especially when it comes

to information technology.

Although many of the hot-topic technologies and applications that are at the center of the debate have been around in one form or another for many years, it seems as if the hype surrounding their use in healthcare has grown in intensity in the last few years. From increased federal support for projects that study and promote the use of various IT applications in healthcare, to the burgeoning EHR industry, to dozens of other projects, initiatives, industry partnerships, and organizations, never has so much activity and attention been focused on healthcare technology—much of it driven by hype and promises of a healthcare landscape transformed.

Exciting times, yes, but much of the initial rush of optimism has been replaced by the sober realization that successfully implementing and applying information technology solutions that effect truly meaningful changes in the healthcare industry is going to be a complex and diffi cult process. One reason for this emerging pragmatism has been the failure of many emblematic health IT applications to live up to the lofty expectations that accompanied their initial adoption. Whether due to insuffi ciently mature technical capabilities, flawed business models, faulty interpretations of the underlying challenges they were supposed to solve, unsustainable financial requirements, or any of a dozen other reasons, the technologies and ideas profiled on the following pages have fallen short of the mark.

EHRs: The alpha and omega of healthcare hype

Perhaps the one application that best represents the tangled drama of potential, hype, disappointment, and redemption that has characterized the drive toward widespread health IT adoption, EHRs remain something of a paradox. They have demonstrated value for practitioners (less so for patients, at least directly) and are supported by a fairly robust and developed product market; but they are also prohibitively expensive, they accrue their benefi ts mostly to payers and insurers, they create extra work for practices that implement them, and they are still not very user friendly.

EHRs are supposed to help physicians streamline the process of maintaining a patient’s medical record from start to fi nish. Physicians were told of the many benefi ts of installing an EHR in their practice, including how it can reduce costs, decrease medical errors, and improve quality of care. To date, though, too many physicians have experienced too many problems—system malfunctions, issues with accuracy and user interface design, and high costs. MDNG Physician Editor-in-Chief Jonathan Bertman, MD, says, “Bringing technology into one’s practice has been hampered by greedy corporations charging thousands of dollars for software that is overly complex, poorly designed, and all too frequently unusable.” Little wonder then that the adoption of EHRs has been slow in the United States.

Does this mean EHRs will not one day be as successful as everyone had originally hoped? Not so fast. Recently introduced EHRs are more functional and cost less, and the future is even brighter. “For EHRs to live up to the hype, physicians have to demand transparent pricing, an ability to try the products before they buy, and head-to-head comparison of products where vendors can show how they document a standardized patient,” says Bertman.

Blame it on RHIO?

Google the term “RHIO” and you’ll retrieve thousands of articles that talk about the potential usefulness of creating regional data networks that allow physicians and other providers in different health systems to seamlessly transmit and share medical records and other data. Although you’d think that solving the thorny technical problem of interoperability among disparate systems would be difficult enough to doom many of these projects, you’d also find that sooner or later, most of those articles get around to mentioning the real reason that many RHIO projects have failed: the unsustainable business model upon which many of them are based.

Federal grants provided seed money for many RHIO projects—grants which proved in many cases to be non-renewing. Once those funds dried up, RHIO executives and organizers were forced to confront a variety of challenges, including reconciling the problem of misaligned fi nancial incentives among stakeholders (a classic business quandary in which benefi ts that accrue from capital outlay and other investments by one participant are not shared among all participants), and convincing all stakeholders to incur equal financial risks.

The poster child for this outcome is probably the Santa Barbara RHIO that closed shop at the end of 2006. Much has been written about the causes of its demise, but perhaps the best summary is provided in a “lessons learned” report from the California Healthcare Foundation, the authors of which identifi ed “lack of a compelling business case, distorted economic incentives, passive leadership among participants, vendor limitations, software delays, and privacy and security issues” among the primary causes of failure. For more on the challenges RHIOs face, see Dr. Barry Chaiken’s piece in the March/April issue of Patient Safety and Quality Healthcare.

It’s the Internet’s fault

Clearly, the Internet has replaced money as the root of all evil. Most misunderstandings can be traced back to the online knowledge source Wikipedia, online fi rst-person gaming is undoubtedly responsible for the spawning of at least a few homicidal maniacs each year, and don’t even get us started on the worldwide epidemic that is repetitive strain injuries. While we’re here, let’s make the Internet the fall guy for all that’s wrong with healthcare.

That may be overdoing it just a bit, but the Internet is far from blameless in the search for what ails healthcare. Take, for instance, the patient Googlers! In all seriousness, it’s impossible to ignore the profound impact the Internet could have on making patient records easily accessible, and consequently, speed the delivery of care by healthcare professionals. Think about how streamlined medical care would be if doctors’ offices, hospitals, and pharmacies could easily access the same information from their respective locations. Unfortunately, there are still a few roadblocks—namely security—that we have to overcome before we make this a reality. So, knowing the potential of the Internet, and realizing that it cannot yet be achieved, equals an HIT idea that has failed to deliver, yet still might pay off . But whether it’s this Internet or the next one that pays off remains to be seen.

Patient portals offer a window into modern medical practice

Patient Portals, which can be thought of as “a gateway or door (in the form of a Web interface) to related sets of data, content, and Web services,” have been touted as an excellent way to open the lines of communication between patients and providers by allowing users to request appointments, check lab results, examine statements, request prescription refi lls, and complete healthcare forms. Earlier this year, the Journal of General Internal Medicine published a study titled “Interest in the Use of Computerized Patient Portals: Role of the Provider—Patient Relationship.” The study found that “interest in the portal was linked to dissatisfaction with the provider–patient relationship, including dissatisfaction with provider communication/responsiveness, the inability to obtain medical information, and logistical problems with the office.” Further, the study authors found that “disinterest in the portal was linked to satisfaction with the provider—patient relationship, including provider communication/ responsiveness, difficulty in using the portal, and fear of losing relationships and e-mail contact with the provider.” Much like EHRs, patient portals have the potential to transform the way healthcare is delivered. However, at the moment, the obstacles loom large.

Planting a seed of doubt about RFID

RFID, at least in the form of implantable microchips that enable patients to

take their medical information with them wherever they go and make it available even if they are unconscious or unresponsive, certainly seems like a no-brainer. That’s why in April 2002, Applied Digital Solutions began production and sales of its implantable ID microchip. Fast forward to December 2007 and you’ll fi nd that only 500 people nationwide are enrolled in the company’s system that uses the chips, and barely 200 US hospitals deploy the RFID readers needed to access the information stored on the chip. A 2007 survey of 119 CIOs who are members of the College of Healthcare Information Management Executives found that 76% did not have RFID at their organization and had no plans to adopt it. Further, just 4% said their organizations use RFID systems, with only 4.5% in the process of adopting a system.

Why the reluctance? For starters, the 16-digit patient identifi er housed on the chip “is not protected by [HIPAA], and there are no laws that regulate how and by whom it can be read,” said Ben Adida, research scientist, Children’s Hospital, Boston, MA. “Th eir unique identifi er is available to any reader in exactly the same way.” Further, the databases that store patients’ information “are not yet uniform in the sense of using the same data [and] the same defi nitions… so having access to one database does not give easily transferable information,” added Mark Levine, chair, council of ethical and judicial aff airs for the AMA. A June 2007 AMA report that stated “Though [RFID implants] are removable, their small size allows them to migrate under the skin, making them potentially diffi cult to extract,” certainly hasn’t helped increase adoption. The report also presented concerns regarding electromagnetic interference with electrosurgical devices and defi brillators, the implants’ possible eff ects on medication effi cacy, and information security.

Little personal interest in PHRs?

There are a variety of reasons why personal health records (PHRs) have been slow to catch on: wide variations in quality among the hundreds of products on the market; little-to-no support from physicians (who also worry about their legal responsibilities regarding the data stored in PHRs); limited compatibility with existing electronic record systems; uncertainty among the public regarding what exactly a PHR is for and how it is used; no financial incentives from payers; privacy concerns; and consumer inertia.

Does anyone really want one of these things (saying “yes” to hypothetical questions on a survey doesn’t count)? What capabilities and features are consumers looking for in a PHR? We’re not alone in wondering this. Patricia Flately Brennan, RN, PhD, National Program Director of Project HealthDesign, a program designed to support the creation of a new generation of PHR systems, wrote an article in Healthcare IT News earlier this year that asked “How can we make [PHRs] useful to consumers?” She claimed that “it’s simply not enough to create a [PHR] and then assume patients will use it.” If we want to “truly capitalize on the potential of PHRs and develop tools that can motivate individuals to better manage their health and coordinate their care, we must start by understanding what consumers need,” noted Brennan.

CPOE: Replacing one problem with anotherThe number one reason for the development of computerized physician order entry (CPOE) was to decrease the number of medication errors. In fact, research has shown that should this technology be implemented in all US urban hospitals, approximately “907,600 serious medication errors could be avoided each year.” As with EHRs, expectations were high for CPOE and its benefi ts for patients and physicians. The problem, in a nutshell, is that almost no one seems to be using CPOE. Concerns regarding system and training costs, implementation time, and unanticipated technical shortcomings (eg, physicians’ ability to override the safety alerts designed to make sure the information entered into the system is correct) are to blame. “You can’t just take a CPOE system off the shelf and plug it in,” says Leah Binder, CEO of Th e Leapfrog Group, a powerful coalition of healthcare purchasers. “It takes commitment and leadership from clinicians to make it eff ective in reducing errors.” As long as physicians are willing to take the time to carefully enter treatment instructions into CPOE, prescription errors will decrease. “CPOE is a technology that’s been slow in up-take, but certainly not for lack of evidence of its usefulness in terms of the number of lives and dollars saved from its implementation,” says Binder. Between all of the headaches associated with CPOE, it still does more good than harm if it is used properly… or at all.

Exam room computers don’t mean to intrude

A September article in Health Care Management Science reads “Few clinicians in the United States use computers during patient encounters, and many still worry that computers will depersonalize their interactions with patients.” A decade later, exam room computers have been touted as improving access to information at the point of care, and allowing for better note-taking, among other performanceenhancing benefits. But it’s difficult to argue that much progress has been made.

A 2006 study sponsored by the Office of the National Coordinator for Health IT found that only 24% of physicians used any form of a computerized record system. The most commonly cited reason for not using computers in the exam room is the effect they have on patient—physician communication. Research results published in July 2005 stated that physicians who had poor communication skills tended to get lost in the computer, communicating with it instead of the patient.

The study’s lead author, Richard Frankel, PhD, explained “You may have a great diagnosis, but if you can’t communicate it to the patient, he or she may not follow-up appropriately... If the computer is poorly positioned, it either gives you a really sore neck from turning around if you want to engage your patient or you wind up with the back of your head to the patient.” Early last year, a study found that patients “more often agree that exam room computers decreased the amount of interpersonal contact.” Frankel’s article sums up the issues best, explaining that computers present more tasks to complete, with attention to the patient often suffering.

Personalized medicine: Is hype in our genes?

Your patients have been promised maps of their individual genomes, drugs that are tailored to work perfectly for them without those pesky side effects, and advanced warning about disease risks based on a study of their DNA. So far, however, the personalized medicine craze has been a substantial letdown. Yes, there have been advancements regarding how individuals will

metabolize some pharmaceuticals. But as for widespread applicability, it’s been an exercise in hype, fueled in part by an overzealous media. The Personalized Medicine Coalition—non-profi t advocacy group that “works to advance the understanding and adoption of personalized medicine for the ultimate benefi t of patients” and counts among its members several dozen biotech, consumer diagnostics, and genetic testing services companies (so you know where they’re coming from on this)—sounds the proper note of cautious optimism in its report “The Case for Personalized Medicine,” written to “shed light” on the “demonstrated benefits and limitations” of personalized medicine. Another antidote to infl ated expectations can be found at the Gene Sherpa blog, written not by Mr. Eugene Sherpa, but by Yale University Clinical Genetics Fellow Steve Murphy, MD. Murphy, whose sensible optimism about this fi eld is tempered by an awareness of the challenges that lie ahead, likens the pursuit of personalized medicine to a “perilous path… Much like the route through the Himalayas, it has punished the naive and self-reliant.” Now that’s cutting through the hype.