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Researchers’ Look at HIT Development: Are their Perceptions of Co-Development Up to Date?

September 13, 2016
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Was the critique of provider-based clinical solutions development by Dr. David Bates and fellow researchers on target?

I read with great interest a “Perspective” op-ed article in the September 1 issue of The New England Journal of Medicine entitled “Accelerating Innovation in Health IT.” Authored by Robert S. Rudin, Ph.D., David W. Bates, M.D., and Calum MacRae, Ph.D., the article focused on some of the major challenges facing healthcare IT innovation going forward, as the authors see them.

The op-ed article’s authors get to the heart of things right away. “Even as information technology (IT) transforms many industries, the pace of innovation in health IT continues to lag,” they state in their first sentence. “Electronic health records (EHRs) receive few accolades from providers and have been cited as a major source of professional dissatisfaction among physicians. Despite a proliferation of patient-facing health apps, few have been shown to produce health improvements and many are barely used. The most common IT tools connecting patients to providers are patient portals that so far do little more than provide basic secure messaging and present unexplained clinical data,” they write. “Though many startups and research programs exist and venture capital investment has been growing, health IT success stories remain rare.”

While the authors, Rudin (an information scientist in the Boston office of the RAND Corporation), Bates (a practicing general internist at Boston’s Brigham and Women’s Hospital, and director of its Program in Clinical Effectiveness), and MacRae (a faculty member in the Cardiovascular Research Center in the Department of Medicine at Brigham and Women’s Hospital), tip a collective hat to some of what they see as factors contributing to the problem—“perverse financial incentives in health care that reward volume rather than quality and efficiency, regulations that restrict the flow of information ostensibly to protect patient privacy, and technical integration challenges,” as well as “the multiple demands of ‘meaningful use,’ which have delayed innovation in many areas of health IT”—they focus most of their attention on what they see as “a more fundamental barrier that has not yet received due attention: the disconnect between health IT developers and users. Alternative provider-payment models should create incentives for innovation by rewarding health care providers who use novel IT tools to control cost and improve quality, but the effect of these models will be attenuated unless the developer–user disconnect is addressed.”

The authors zoom into one key issue. As they put it, “Health IT developers typically work in one of three settings — established IT companies, startups, or academic research departments — where they have little to no contact with patients and clinicians and therefore often lack a deep understanding of users’ needs. Established IT firms, most notably EHR companies, have adhered poorly to user-centered design principles, despite federal certification requirements that they apply such principles.2 In startups, developers are typically young and healthy, with little firsthand knowledge of clinicians or the chronically ill patients who consume most health care services. Much of venture capital is therefore clustered in wellness companies making products such as fitness trackers that cannot help the patients most in need and thus will have little effect on health care costs.”

Now, here’s where things get interesting. The authors do acknowledge the existence of incubator organizations—about which I’ll say more in a moment. But they write this: “Some health care incubators are producing startups that target clinicians and chronically ill patients, but we believe that these organizations generally underestimate the effort needed to understand such complex and diverse users. Some academics have focused on understanding users’ needs, but efforts tend to be small and fragmented and to involve multiple years of development. Rarely do findings make their way into the design of novel functionalities, for which relatively few funding sources are available.”

So this is where I think that these authors are perhaps minimizing unnecessarily the potential for test beds that are springing up at a number of major integrated health systems, among them Intermountain Healthcare in Salt Lake City, the Mayo Clinic in Rochester, Minnesota, Cleveland Clinic, Geisinger Health in Danville, Pennsylvania, and most ambitiously, the vast UPMC health system in Pittsburgh.