In 2018, the phrase “learning curve” is used so frequently that it’s essentially part of the English lexicon with little need for definitions and etymologies.
In the late nineteenth century, however, both phrase and concept were yet to be invented. German psychologist Hermann Ebbinghaus described what we know as the learning curve in the late 1800s, and the term itself was first used in a 1903 issue of the American Journal of Psychology.
Both the learning curve and institutional maturity have been much on my mind since reading about a recent Health Affairs study on the impact of EHRs over a five-year period. According to the research, EHRs were associated with an 11 percent uptick in 30-day mortality rates in 2008, but five years later, they were credited with a .09 percent decrease against the same baseline.
The reason, according to UC San Francisco School of Medicine professor Julia Adler-Milstein? Complicated things take time to understand and sort out.
To be sure, with most hospitals and clinics now using comprehensive EHRs and interoperability looking more promising all the time, that transformation is happening. Roughly nine years into going digital, healthcare may not be truly transformed on Adler-Milstein’s imagined timeline, but essential change is happening as we move along the technology learning curve.
The problem is that healthcare also has other learning curves that computers alone cannot address. Even as healthcare IT matures and the learning curve starts to even out for those who regularly use technology, numerous challenges remain, and the jury remains out on whether or not we have the fortitude and vision to fix them.
While widespread computerization alone will not fully address many challenges, healthcare IT can still make essential contributions to the maturation of American medicine in key areas that require inputs the healthcare IT industry cannot provide on its own.
Economics. In almost all industries, computerization has led to automation and improved labor productivity. Healthcare is one of the few, if not the only, exception to that trend.
“Healthcare is the only industry that has not experienced an improvement in labor productivity from technology and, in fact, labor productivity in healthcare continues to worsen,” reads a 2016 World Economic Forum white paper on digital transformation in healthcare. “The focus on expert labor without any technology automation to improve labor efficiency is a key contributor to rising costs, and these escalating costs do not necessarily translate into better outcomes for patients.”
It’s true that EHRs have not yet contributed to improved productivity. Physicians are putting in more hours entering data. Hospitals and clinics are hiring medical scribes to enter data for physicians during patient visits. These issues are real and taxing for clinicians, but they are not permanent. Surveys are beginning to indicate that physicians are now more satisfied and more committed than ever to improving the EHR they have. The Health Affairs study is additional evidence the maturity and familiarity make a significant difference.
In the not-too-distant future, EHRs and other forms of digital technology will play an essential role in a disrupted health system defined by digital principles: Smart care, care anywhere, empowered care and intelligent health enterprises. As this progresses, look for the labor paradox and other previously intransigent aspects of healthcare to shake loose and sort themselves out.
Communication and Integration. While financial support for healthcare IT adoption in acute and ambulatory environments has been a success, the same cannot be said for many other aspects of the healthcare system. Interoperability won’t enable comprehensive patient records until the entire spectrum of health—behavioral, long-term care, skilled nursing facilities and so on—can effectively exchange records.
How will that happen? Until some entity disrupts the market and introduces full-function EHRs for much less, only via a Meaningful Use-type program. Without it, full interoperability could take a while, which is unfortunate. Modern healthcare IT tools are evolving rapidly, and many can manage different environments even now, but spotty implementation stands in the way.
And then there’s the issue of uneven broadband availability, which hits vulnerable rural facilities particularly hard. At this rate, healthcare IT tools may be ready to manage an integrated healthcare IT network before the actual network exists.
Availability of care. These are troubling times for rural healthcare, where there are fewer providers and hospitals all the time. Healthcare IT offers rural organizations and providers opportunities in terms of telemedicine services that can both enable care and generate revenue.
So far, most inroads are being made in behavioral health simply because a physical exam is not usually necessary, and psychiatric care in some rural counties is practically nonexistent. Some providers of telepsychiatry say they’re seeing significant reductions in depression, anxiety and stress when remote counseling services are made widely available.
Here again, network availability and quality are issues. Maybe tele-behavioral health is the ideal solution outside urban areas. We’ll need quality broadband widely dispersed to know.
In some areas, hospital closures will be unavoidable absent philanthropic support. As the system evolves, however, telehealth tools could enable many to scale back and stay alive, ensuring that residents still have a source of care, however minimal.
Financial. At this moment, CMS is trying to move the entire healthcare system from paying for procedures to paying for quality. Defining and measuring quality is a difficult task without sophisticated healthcare IT systems that can track patient wellness, readmissions and other reporting criteria.
It’s difficult to exaggerate the potential impact of changes to payment criteria. Many facilities could face significant financial risk if their billings are reduced even a bit, especially if combined with readmission fines. In this scenario, healthcare IT can be an asset or an albatross—EHRs can support cost-cutting measures or cut so deeply into facility budgets that solvency becomes an issue on an upcoming board meeting schedule. Unless you feel completely confident in long-term revenue projections, the wise approach might be to buy an EHR system that doesn’t wreck the budget.
Ultimately, the maturation of both the U.S. healthcare system and healthcare IT systems will happen concurrently—the two are integrated. It would probably be easier were this not true. A healthcare system with mature workflows, concretized payment models and integrated care plans would have a lot to say about how healthcare IT systems developed.
That’s not where we stand. We’ve made much progress, but still stare upward at a dramatic learning curve. While the only viable option is for healthcare and IT to hold hands and continue the climb, many of the challenges that enable maturity and bend the learning curve will probably require significant outside assistance.
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