Sunday, March 10, 2013

The HIT Productivity Paradox - It's Gonna Be OK!

The NY Times published another article recently with a negative vibe about EMRs... implying that spending money on EMRs is a waste since the benefits are not obvious, and questioning the ethics of EMR vendors for asking the government to help subsidize these systems.

Really?  It seems like that is incredibly backward thinking which was also likely used against the stethoscope, anti-sepsis, penicillin, cars, planes, TVs, computers and the Internet when they first started out. I get it, change is hard and technical progress is slow - but let's not throw the baby out with the bathwater, let's give it a chance to grow up!  And, of course, what is even more interesting is that like so many media cycles, the media happily built up how great healthcare IT would be, and then gladly tear it down when it does not happen right away.

Glen Tullman (HIT entrepreneur and former Allscripts CEO) had some great thoughts on this issue in a recent Forbes Editorial he wrote Why Haven't Electronic Health Records Made Us Healthier?  He essentially said that we are a lot further along than when we started, but certainly still have far to go.  I especially liked that he reminded us of Amara’s Law: “We tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run.”

SIDE NOTE:  I did a little research to find out that Roy Amara was a Stanford Systems Engineering PhD who was President of the Institute for the Future.  I also found that his law was one of Four Geeky Laws that Rule Our World, the four together are:
  • Amara's Law:  "We tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run."
  • Brooks' Law:  "Adding manpower to a late software project makes it later."
  • Thackara's Laws:  "If you put smart technology into a pointless product, the result will be a stupid product."
  • Reed's Law:  "The Value of a Network Increases Dramatically When People Form Subgroups for Collaborations and Sharing."

So I wrote a little reply to the NY Times article as well and the wonderful folks at HISTalk published my piece at: 
I actually received a lot of positive feedback on this - so here it is: 

Fair enough - are EMR's worth it, was MU worth it?
I've said before that I don't think I would have spent the $30-40 billion that way (remember, they use the $19 billion figure because they assume $10-20 billion in savings).  I would have focused on mandating standards and trying to push for a uniform data model platform upon which vendors could then build their more external facing products.  However, I will happily admit that MU has done it's job - it has stimulated the adoption of EMRs… it won't be the 80+% they were hoping, but it's still got a lot of people off their asses and moving.

So next question - Will they provide all the great things we are hoping for?   
Certainly we've got some issues - EMRs are still not mature, nor is our understanding on how to best use them. But no technology, from cars to computers, started out perfect.  I've been reading "The Signal and the Noise" - and very early on it reminds readers of "The productivity paradox" which helped explain why the early computer age (1970s-1990s) actually saw a LOWER productivity as everyone was figuring out how to build them well and how to use them!  Sound familiar?

From WikipediaThe productivity paradox was analyzed and popularized in a widely-cited article[1] by Erik Brynjolfsson, which noted the apparent contradiction between the remarkable advances in computer power and the relatively slow growth of productivity at the level of the whole economy, individual firms and many specific applications. The concept is sometimes referred to as the Solow computer paradox in reference to Robert Solow's 1987 quip, "You can see the computer age everywhere but in the productivity statistics."[2] The paradox has been defined as the “discrepancy between measures of investment in information technology and measures of output at the national level.”[3] It was widely believed that office automation was boosting labor productivity (or total factor productivity). However, the growth accounts didn't seem to confirm the idea. From the early 1970s to the early 1990s there was a massive slow-down in growth as the machines were becoming ubiquitous. (Other variables in country's economies were changing simultaneously; growth accounting separates out the improvement in production output using the same capital and labour resources as input by calculating growth in total factor productivity, AKA the "Solow residual".)

So if and how can this best be applied to healthcare IT?  
Well, it turns out that some smart authors actually addressed this exact issue in a June, 2012 NEJM article entitled: Unraveling the IT Productivity Paradox — Lessons for Health Care.   In this article, they explain that sure, we are seeing problems with HIT… but it is as expected - just like every other new industry has to evolve.  They conclude with the following paragraph:
The resolution of the original IT productivity paradox suggests that current conclusions about the value of health IT investments may be premature. Research suggests three lessons for physicians and health care leaders: invest in creating new measures of productivity that can reveal the quality and cost gains that arise from health IT, avoid impatience or overly optimistic expectations about return on investment and focus on the delivery reengineering needed to create a productivity payoff, and pay greater attention to measuring and improving IT usability. In the meantime, avoiding broad claims about overall value that are based on limited evidence may permit a clearer focus on the best ways of optimizing IT's use in health care. 

Clearly we are not at perfection - HIT can affect efficiency and quality in both good ways and bad.  But rather than try to create some artificial polarization that it is all good or all bad… let's continue doing our job (for the medical informatics professionals reading this) to keep making HIT better serve our providers and patients, while educating those who get freaked out every time a new stat or story comes out pointing out its imperfection.

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