HIT issues and debates

Essential barriers to widespread HIT adoption include financial concerns, legal and regulatory issues, technology issues, and organizational and cultural blocks. More specific barriers can usually be classified under one of these headings. However, HIT is a complex issue, and most HIT adoption factors intersect with multiple debates.

Summarized here are five barriers to widespread HIT adoption.

Privacy and security
Privacy and security concerns rank second to cost among reasons providers resist HIT. HIPAA established a "federal floor" of patient privacy protections for "covered entities" with access to patient data (health care providers, insurance companies, public health organizations). However, many third parties that do not qualify as "covered entities" have access to patient data (data warehouses, employers, personal health record vendors and other research organizations unrelated to direct health care).

HIPAA's guidelines are not specific enough to address the complexities of regional or inter-practice information exchange. State and local regulations about privacy also vary widely, as do the specific parameters of technology, so it may be difficult to accomplish streamlined inter-state or inter-practice security protections. It is difficult to harmonize privacy protections nationally and regionally.

Obtaining and maintaining legal patient authorizations for records release is difficult when many systems and many authorized users have access to a patient's record at once. Most HIT products audit their users, but restricting access to sensitive information is tantamount, and HIT appears to complicate that restriction.

Interoperability and obsolescence
Without infrastructure for information exchange, each EMR is a stand-alone product, a "data silo." The ability to exchange information between specialists and general practitioners, hospitals, physician practices and diagnostic centers is essential to maximizing HIT products, but has not yet been universally established. An effective digital record should follow a patient throughout his/her lifetime, over many regions and settings; interoperability is crucial in achieving this function. Unfortunately, clumsy data exchange is still a roadblock to HIT adoption.

Currently, medical information is fragmented. There are no technical standards enabling systems to talk to one another. Furthermore, there is a lack of standardized medical terminology. In turn, the most common components of EMRs such as lab results are talked about and referenced differently, making it difficult for systems to exchange data. 

CCHIT certification is meant, in part, to reduce the chance of obsolescence for high-quality HIT products. CCHIT checks HIT vendors for baseline functionality, security and interoperability standards. There has, however, been a flood of HIT applications in the last five years, and it is frequently difficult for physicians to select the technology that is best suited for their practice.

The resolution of ownership, privacy and security issues is vital when working toward interoperable technologies. The easy exchange of information, while important, must also be ethical, appropriately limited and secure. Many stakeholders feel there are not adequately stringent privacy regulations at federal, state and organizational levels to justify interoperable patient records. Most recently, the 2008 HHS appropriations bill asked for a "privacy and security framework that will ... govern all efforts to advance electronic health information exchange." And, in the past year, 15 state health information technology bills have become law.

Quality improvement (QI), pay-for-performance (P4P) and performance measures
A 2007 report by the AHRQ cites the difficulty of improving national health care when quality and performance data measurements are not standardized or exchangeable. AHRQ suggests common methods for collecting, aggregating, and reporting health care performance data and proposes a core set of national rules and standards for these processes. These common methods and standards have yet to be widely adopted.

Standardized data measures in HIT systems could reduce disparities between different providers' treatment of specific chronic diseases, therefore increasing national quality of care. Physicians treating the same diseases have comparable approaches to long-term monitoring of disease: these approaches can be distilled into technology protocols that enhance decision support, reduce prescription error, make clinical documentation more accessible and reviewable, and remind patients and their providers to keep track of certain chronic problems.

Some payers are already using quality standards/performance measures to evaluate their payment of claims. This is called pay-for-performance, or P4P. P4P is linked to HIT because of the way technology broadens providers' ability to document, analyze and submit information about their practices to other entities. Payers argue that when data collection is easy and the exchange of this data is electronic, P4P payers can analyze physician data to determine who is "performing" at a high level. P4P offers rewards for "high quality" ratings, but most physicians are uncomfortable with the way "quality" is defined by third parties.

The AMA believes that it is important that performance measures be designed by physicians for physicians, and that they acknowledge the realities of all HIT stakeholders — not just that of payers. Many public and private sector organizations are working toward sets of performance measures and standard methods for communicating them, including the AMA's Physician Consortium (see our section on AMA policy and activity to learn more about the AMA's involvement in this issue).

Cost of HIT and uncertain ROI
Although national survey methods have varied widely in trustworthiness and methodology, it is currently estimated that the adoption of an EMR costs around $30,000 per physician. This is too much for many physician practices.  

In an attempt to alleviate the cost barrier, on Aug. 8, 2006, the Centers for Medicaid and Medicare Services (CMS) and the Office of the Inspector General (OIG) simultaneously established rules creating an exception to the Physician’s Self-Referral Law (Stark) and a new safe harbor to the Anti-Kickback Statute. The rules became effective on Oct. 10, 2006. The rules were implemented in response to a provision in the Medicare Modernization Act (MMA) that directed the Secretary of Health and Human Services (HHS) to adopt standards for ePrescribing and to create an exception to help promote widespread adoption of ePrescribing. They are intended to support and promote physician adoption of ePrescribing and EHR technology. In general, the rules provide that donations of technology will not violate the Stark law and the Anti-Kickback Statute if certain conditions are met.

Prior to August 2006, the Stark law and Anti-Kickback Statute prohibited hospitals, or other stakeholders to assist physicians with the acquisition of EHRs or ePrescribing technology.  Thus, CMS created two new exceptions to the Stark law, and the OIG added two new safe harbors to the Anti-Kickback Statute that would  make donations of EHR and ePrescribing technology possible under certain circumstances.  The rules reflect an attempt by CMS and the OIG to create consistent, complimentary rules that balance the goal of widespread HIT adoption and the fraud and abuse concerns that arise when free or discounted goods are offered to referral sources.

Still, some argue that the most significant financial benefits of HIT are actually reaped by insurance companies, not physicians. It is estimated that 80 percent of potential savings generated by HIT actually come in the form of lowered insurance premiums and increased physician productivity. Faster reimbursement cycles and the ability to "code-up" with better documentation may draw increased revenue to physician practices, but for many physicians, this is not enough incentive to spend the required start-up money.

National spending on health care is expected to increase to $3 billion by 2009. Medicare, the single biggest health care payer, is expected to be insolvent by 2019. Medicare's payment of claims is dropping every year. HIT and pay-for-performance are touted as reforms to this systemic financial crisis by reducing inefficiencies and disparities in health care. However, there is disagreement as to whether Medicare and other payers are paying for quality or efficiency or simply for more volume due to the enhanced billing capability afforded by HIT.  

Practice culture issues
Practice workflow changes significantly when an EMR, or HIT of any kind, is implemented. Physicians and their employees are resistant to these changes for many reasons. Some employees' services may be rendered obsolete by technology. Providers may have to significantly reduce their patient load as they adjust to the new system. Responsibilities may have to be redistributed. In general, practices are resistant to new technologies, particularly those which are difficult or complicated to use.

Most EHR literature declares that committed self-assessment is required for successful transition to EHRs or any other HIT product. Physician practices must be frank about current flaws and current strengths in order to find the product that suits them. This research is time consuming, and many physicians do not have the will or the technological savvy to do appropriate preparation or staff education for transition.

Physicians are worried about whether participating in HIT adoption efforts will make them vulnerable to audit, payer control, malpractice litigation, privacy-based lawsuits or federal sanction. With broader access comes broader oversight and vulnerability. Physicians are concerned by the potential control of their autonomy and decision-making by third parties with access to clinical data.

For information on private and public organizations engaging with these issues and working toward solutions, see key players and initiatives.