In 2005, the phrase “the soft bigotry of low expectations” was coined in an attempt to explain the frustrating phenomenon of continued educational underperformance despite growing federal investment in education. The idea is straightforward: well-intentioned policy decisions that lower both formal and informal educational achievement benchmarks and standards for disadvantaged communities lock those communities into multigenerational patterns of underachievement and poverty.
Whether one agrees with the concept as applied to education policy, there can be little doubt that a particularly pernicious variant is at work in health IT — undermining public and private sector efforts to modernize care delivery and evolve beyond fee-for-service reimbursement that are crucial to the success of any variant of health reform, and locking care providers and their patients into a frustrating technological stasis.
The symptoms of that stasis are familiar to anyone who has been to a doctor’s office. In an age when millions of us carry around super-computers in our pockets, we are still greeted at the doctor’s office by a clipboard and a pen. A credit card company throws an electronic flag if an account has been accessed suspiciously on the other side of the planet, but most doctors have no way other than the telephone to know that we filled a prescription or followed up on a referral. Pre-teens communicate via text message, social media and video chat. Doctors, by and large, still communicate with each other via fax.
The question naturally arises: why? Why is healthcare — arguably the most important sector of our economy — so stubbornly resistant to the information technologies that we take for granted in nearly every other aspect of our personal and professional lives? More to the point, why don’t medical information systems talk to each other?
There is a simple explanation: healthcare suffers from the hard bigotry of no expectations, exacerbated by well-intentioned policy decisions that repeatedly lower both formal and informal technological implementation and usage standards, locking care providers and their patients into a status quo that subjects all of us to the aggravations of technologies that simply do not meet the most basic expectations of the 21st century information economy.
The most recent example is the latest in a series of backward steps for the federal meaningful use program. The details of the program are complex, but the basic proposition is straightforward: care providers who adopt and “meaningfully use” government-certified health IT qualify for a significant taxpayer subsidy. “Meaningful use,” of course, is measured according to government-determined standards. So far, so good — but as is often the case, the execution of this costly federal policy has failed woefully to live up to the animating concept.
The trouble came when many subsidized technology vendors immediately fell short of already low government-determined standards. Care providers who spent significant dollars on “meaningful-use certified” health IT products were understandably vexed at their inability to qualify for the promised subsidies. They complained loudly and in great numbers, unintentionally serving the interests of their underperforming vendors. Government officials quickly responded by lowering those meaningful use standards and extending implementation deadlines — repeatedly. As a result, in 2014 most health IT in prevalent use, much of it federally-subsidized to the collective tune of $24 billion and counting, is incapable of so basic a task as sending an electronic patient referral from one doctor to another.
True fact: the federal government now defines as a “hardship” the use of many technologies that the very same government continues to subsidize under those repeatedly-lowered meaningful use standards. More to the point, the use of those technologies frustrate care providers, impede workflows and drive up systemic costs — precisely the opposite of the impacts the meaningful use program was created and funded to achieve.
The real mystery, of course, is why anyone puts up with this sorry state of affairs. Patients and care providers alike, most of us carrying around those ubiquitous pocket super-computers; why do we accept in healthcare the kind of retrograde IT that we’d never put up with in any other context? Why do we — taxpayers all — stand complacently by while our government pours tens of billions of our dollars into subsidies for lousy technology? Why do policymakers repeatedly lower standards and continue to pour those dollars into the pockets of technology companies whose products create problems instead of solving them?
The solution is clear: we all need to raise our expectations. The related problems of non-interoperability and obsolete technology in healthcare will not be solved by government mandates, rules or dollars. It will only be solved when doctors and their patients start demanding the same basic IT functionality in healthcare that exists in every other sector of the modern information economy.
Healthcare technology vendors, like sellers in any market, are highly susceptible to ordinary market forces. Demand 21st century performance of them and many will deliver—finally achieving the long-expected promise of IT to help revolutionize care delivery while reducing costs and improving care.
If, on the other hand, we continue to set (and subsidize) low expectations, we can bet those same vendors will be only too happy to keep failing to meet them.
Dan Haley is athenahealth’s vice president of government and regulatory affairs, responsible for all aspects of the company’s interactions with government and government officials at the federal, state, and local levels. Prior to joining athenahealth, Mr. Haley was a partner at a global law firm, where his practice focused on government and regulatory affairs and complex commercial litigation. He has held senior positions in a number of statewide political campaigns, served as general counsel to Sen. Scott Brown’s (R-Mass.) reelection committee, assistant Chief of Staff to Gov. Mitt Romney (R-Mass.), and worked at a number of national political committees. Dan is a graduate of Middlebury College and Harvard Law School.
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