Strategic Action In Health Information Technology : Why The Obvious Has Taken So

Recent enthusiasm for the automation of medicai records and the creation of a heaith information infrastructure must be viewed in the context of a four-decade history of anticipation and investment. To understand the current opportunities and chaiienges, we must understand both the evoiution of attitudes and accompiishments in heaith care information technoiogy (iT) and the cuiturai, economic, and structurai phenomena that constrain our abiiity to embrace the technoiogy. Because prudent IT investment couid make a profound difference in U.S. heaith and disease management, our strategic response must begin with an understanding ofthe pertinent history plus the chaiienges that iie ahead. MORE THAN FORTY YEARS HAVE PASSED since the first use of computer systems to support patient care through the management of clinical information. Among the early experiments, the Lockheed/Technicon system at El Camino Hospital in Mt. View, California, is perhaps the best known and most influential of the "hospital information systems."' But the idea rapidly gathered momentum, and by the late 1960s there were experiments vdth fullfledged electronic medical record (EMR) systems that collected data directly from clinicians and were designed for use in both inpatient and outpatient settings.^ Archaic by modern standards, these systems predated personal computers, local area networking, and the World Wide Web. Yet many embraced a vision of health and health care supported by EMRs, even though some observers expressed concern about the influence the technology would have on clinical practice and the training of practitioners.^ During the subsequent three and half decades, society has been inalterably changed by the growth of computing and electronic communications, with modern cell phones having more computing power than machines that supported Ted Shortliffe ([email protected]) is professor and chair ofthe Department of Biomedical Informatics, College of Physicians and Surgeons, at Columbia University in New York City. 1222 S e p t e m b e r / O c t o b e r 2005 DOI 10.1377/'hltha£f.24.5.1222 O2005 Project HOPE-The People-to-People Health Foundation, Inc. S T R A T E G I C A C T I O N "The existing clinical culture demonstrates a variety of attitudes regarding the role that IT can and should play inpatient care." multiple time-shared users in 1970. Those who have worked in health care computing during this period of remarkable change often express frustration regarding the slow rate of adoption of information technology (IT) in health care when compared with other societal components (including finance, electronic commerce, travel planning, general news and information dissemination, and educational support, to name just a few examples). It would be misleading to suggest that the world of medicine has been unaffected by the IT revolution that has been touching other aspects of society. We know, for example, that health information is among the most frequently sought search categories on the World Wide Web, and consumers have been increasingly empowered to participate actively in both treatment and prevention. Similarly, it is a rare physician who does not use computer systems to obtain laboratory or radiology results for his or her inpatients, and increasingly to submit prescriptions or to access drug information. The typical modern hospital is filled wdth computers—evident on every nursing unit (albeit too often in inadequate numbers for the growing demand), in outpatient clinics, and throughout the specialty units. For the first time in those thirty-five years of evolution in health care IT, we see a U.S. president calling for FMRs for all Americans within a decade and a newly created Office of the National Coordinator for Health Information Technology (ONCHIT) in the Office of the Secretary of Health and Human Services (HHS)." One might guess that the potential for a "revolutionary" change in how medicine is practiced is at hand, but similar observations have been made for years.̂ Thus, we need to place such optimism in context by assessing what has succeeded and what still remains to be realized, while asking what barriers exist that have prevented optimal progress to date. The existing clinical culture demonstrates a variety of attitudes regarding the role that IT can and should play in patient care. Many practitioners are encouraged by the progress in clinical computing and believe that the technology can and will increase both the efficiency with which they practice and the quality of the care they deliver. Others are concerned that the technology might interfere with an almost sacred relationship between physicians and their patients, potentially dehumanizing the care process and encouraging impersonal "cookie cutter" approaches to the deep human problems that emerge in the context of disease and its management.^ Others, while grudgingly accepting the inevitability of the technology and its clinical use, worry about whether they can personally develop the skills and attitudes necessary to use IT effectively. They may even worry about how they wHl be judged by their patients, or potential patients, based on either their use of or their failure to use IT in their practices. HEALTH AFFAIRS Volume 24, Number 5 1223