The Development and Future of Health IT: A Conversation with Dr. David Blumenthal

Interview by David An

David An (DA): Thank you very much for agreeing to this interview. Let’s jump right in. The first question that I wanted to get your thoughts on, is, can you tell me a little bit about your research career? And what made you become invested in the goal of broadening the use of health information technology?

Dr. David Blumenthal (DB): Well, I have done a lot of different things. Research is one aspect of my career, but not the only one. After working as a manager at the Brigham Women's Hospital, I went back to Massachusetts General Hospital and started a research group, and I managed to attract funding to study the adoption and use of electronic health records. It wasn't an area of great focus for me before that. I'm not technologically sophisticated—I'm not a technologist. But I took it as an example of a technology that was interesting, useful, and underused. And so, it was more of a policy question for me, rather than a technology question. As a result of our funding, we published a series of articles in well-known medical journals like the New-England Journal of Medicine, the Journal of the American Medical Association, and others, about what was inhibiting the adoption of electronic health records. During that period, I began working on the campaign of Barack Obama while he was Senator and stayed with the campaign through the primaries and through the general election. Then after the election, his team offered me a job as the National Coordinator for Health Information Technology. And, again, I was not particularly working on health information technology; I was doing research on multiple other areas, so at first, I refused. But after the piece of legislation called the HITECH Act was passed, I saw an opportunity to make a large impact. Though I would have preferred to work on coverage and insurance issues, there was no guarantee that President Obama would continue to work on those issues after he was inaugurated. And so, I thought, well, I've got a crack at making an impact in a narrower area, but one that I know the opportunity exists, or I can hold out and try to find something else, but not really be sure about what's going to happen. So, I took the National Coordinator job and started in March of 2009.

DA: As you mentioned, you worked in other areas other than health IT before then. What do you think made your work with the HITECH Act a necessity at the time? I mean, it was part of the huge Recovery Act package after the Great Recession. So, what kind of challenges did you face with that? And how did you overcome them?

DB: Well, the big challenge that faces the adoption of electronic health information systems in the US and every country is that it requires that clinicians, doctors, nurses, others, change the way they do their work. And information management is the absolute central element in health care. Without information, clinicians are paralyzed. With good information, they can make good decisions. So, improving the flow of information within the healthcare enterprise is a hugely powerful opportunity to improve the practice of medicine, the practice of care, the health of the population, and all the things that health policy seeks to accomplish. But the other side of the coin from it being so important was that it required significant changes on the part of doctors, hospitals, clinics, all over the United States. Changing the behavior of professionals is a challenging thing. Changing the behavior of large, multimillion or multi-billion dollar institutions is even more so. Health IT is expensive to acquire, and the technology to implement it is too. It’s a major disruption to the daily workflow of clinicians and organizations. So, the big challenge was to cultivate that change. Like getting smokers to quit smoking or getting people to choose different specialties. It was about getting into people's heads and getting them to change the way they act. To me that was the fascinating and challenging part of it.

DA: I see. By the time you left the position in 2011, by many counts, you succeeded in that goal. But it sounds like it was a greatly challenging problem. How did you go about trying to change the lifestyle of every physician in those hospitals?

DB: Well, it was a series of decisions, some quite obvious and intuitive, and others less so. First of all, I had the huge advantage of Congress having put a lot of money behind the adoption process. So, there were big financial incentives to do it if clinicians wanted to. I don't think that it would have happened without those incentives. But I also knew that sometimes you can't pay people enough to get them to change what you want them to change. This was all voluntary; there was nothing mandatory about adopting records.

The other thing in addition to implementing the incentives was defining what was then called meaningful use, which is essentially a standard they had to meet in order to qualify for the incentive payments. We had to design those requirements to be achievable; not so daunting that physicians would say, “I'd like to do it, but there's just no way I can do it,” or hospitals would say, “We'd like to do it, but my God it is going to be so expensive and so disruptive that we'll just wait and see what happens.”

I knew that we needed to build momentum quickly, have early successes, and to create a way to change that was both sufficiently ambitious, but not overwhelming. So, one of the important things we did was to implement the program in well-defined stages. We outlined three stages for implementation, the first was pretty straightforward, and basically only required recording information in the electronic record. Then the second involved adopting decision support, which was a more advanced technology that coached physicians on decisions. And then the third would look at outcomes; whether the electronic health record was achieving improvements in outcomes in terms of the care of patients. Those steps, together with the incentives, were critical. And then we focused on communication–telling a story about why people should change. And the story we told was, “It is going to happen.” It's inconceivable that 30 years from now, you're still going to be using paper to manage your patient information. I think most physicians knew that eventually, they would have to either quit or adopt electronic records. And so, our point was they can either do it now with federal money, or do it later with their own money.

DA: I see. Because as the rest of the world is being digitized, it's unlikely that it won’t affect health care at all. But at the same time, from my own experiences talking with physicians, some of them regard electronic health records kind of in a negative light, because they feel that it has a greater focus on ease of billing than ease of administering care to patients. Do you think that conflict exists? And what are your thoughts on the controversial topic in general?

DB: I think that's a fair critique. The records were not developed to optimize care. They were developed to make the users happy. And the first priority of many users, especially the hospitals and healthcare organizations, was billing. So there was, I think, a failure in design that wasn't fully recognized until the deployment occurred. On the other hand, there was no way to change that until the deployment occurred. Because the problem was not apparent prior to the widespread use of the technology. Another thing that remains a problem is that the records were designed to meet the financial incentives in the payment system—not the law that I was implementing, but the payment system. And that payment system valued coding and billing but didn't reward quality or cost control. So, in effect, the records were a creature of the prevailing value system in healthcare.

The EHRs are blamed for problems that extend way beyond the technology. Every technology has potential for positive and negative use. How they're used depends on how humans want to use them. And the humans that designed them and the humans who paid for them, for the most part, wanted to make sure they collected the revenues that were available. And those revenues were not conditioned on performance in terms of quality, cost or physician satisfaction.

Also, when we looked at whether we could regulate electronic health records for usability, we went out to the National Institute of Standards and Technology of the Department of Commerce and we probed to see whether usability was a well-established scientific field that you could measure with reliability and validity such that it would withstand legal challenge if we created regulations. And we found that the state of the art was insufficient. So there was another gap in society's preparation with this change that we could not remedy without funding a lot of work that we didn't have the jurisdiction nor the support to fund.

Overall, I think they are getting better. And some of what's happening now is that physicians are learning to use them. So, there was a generational issue here as well that I think is now behind us.

DA: That makes sense. A little bit of a shift here for after your work with health IT. So, I read one of your pieces published in the Harvard Business Review, about the neglected and struggling field of primary care nowadays. How do you think the field of primary care has changed, if at all, since when you were a practicing primary care physician? And then you also listed three possible avenues that corporations could take as solutions to this problem. Do you think you can share a bit more about how future policymakers can motivate the private sector to pursue at least one of those solutions?

DB: Well, let me backup a bit and say that the problem with primary care in the United States is that it's undercompensated and undervalued. And that is true more in this country than in virtually any other high-income country. It is a product of our infatuation with technology and our collective willingness to reward specialties much more favorably than primary care.

So, I think there is a deep under appreciation that is now reinforced by the politics of payment. The conclusion that policymakers, especially congressional policymakers, have arrived at is that in order to increase payment for primary care, they have to decrease payment for other physicians, because it's a zero-sum game. And the other specialties are very powerful. They are better compensated. They have better lobbyists. They tend to attract a lot of support. Every male congressman is of an age where they're likely to have a urologist, maybe a cardiologist, and they likely had surgery at some point. And so, they're very sympathetic to specialists. And it just has become almost impossible to change the compensation model.

So that's one important thing. And the other related thing is that those highly compensated specialties are now major sources of funding in medical school through clinical practice revenues. Every medical school has as a faculty group practice that includes cardiac surgeons, orthopedic surgeons, neurosurgeons, cardiologists, and other proceduralists, whose income and payment are multiples of that of primary care, and they therefore have a lot of influence in the governance of training programs. So it's all wired into this complex, highly specialized, excessively costly healthcare system that we've created.

So all that is by way of background. I think that the problem largely stems from investor-owned companies. The reason why investor-owned organizations have entered primary care is that it is such a wasteland and the traditional healthcare system has not found a way to make it viable. And they have perceived a value to primary care that the traditional system has not. Some of it, I think, is misperception; a number of them are going to be unpleasantly surprised at how hard it is to make primary care a financially feasible enterprise without making all the problems of primary care worse, or without basically turning it into a service that is offered by non-physicians: nurse practitioners or physician assistants who are less expensive.

So, for the three strategies that I proposed not as recommendations but as possible routes for investor-owned companies to take, one was to use primary care as a loss leader. If you're a CVS or Walgreens and you can get people to come in to get primary care, you'll have more traffic in the front part of the organization, and you'll sell more of other goods. And that's where the real money will be. You might lose some money back in the Minute Clinic. But you'll more than make it up in the front-end part of the store. And I think that's one strategy that some organizations are going to pursue. I am skeptical of that being successful because I think that loss leaders in organizations are on thin ice and as soon as budgets are tight, they undergo really intense scrutiny.

The second strategy was to make primary care profitable by running up prices and running up the volume. Running up prices is not very promising. Primary care payment has been very limited, and insurance and Medicare/Medicaid do not pay well. And running up the volume just makes the problem of primary care burnout worse and will result in the loss of practitioners.

The third strategy is the most promising but the hardest to implement. It is to accept the risk for the entirety of the costs of care and give primary care the opportunity to manage those costs. And cut downstream specialty care by augmenting upstream primary care. Organizations such as One Medical, which Amazon just bought, are based on that model of capturing the downstream value by eliminating waste and reducing unnecessary elements. But it requires a lot of sophisticated reengineering of healthcare practice and a lot of upfront capital investment in primary care to give them better information systems that help them pick good specialists and give them direction on lower cost yet high-quality ways to manage common problems such as preventing chronic illness from getting worse.

There are a lot of things in this third area that could be done, and have been done in the past, but are very hard to do in a community setting. So that third route is still an opportunity and there are some groups that are doing it. I just think it's really hard and it won't produce short term, quick impacts. You're going to have to absorb losses.

DA: Thank you so much for taking the time to talk with me.