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Carol C. Diamond and Clay Shirky, Health Information Technology: A Few Years Of Magical Thinking?, Health Affairs Web Exclusive, August 19, 2008 [Abstract] [PDF] [Reprints & Permissions]

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Still Waiting For The Promise Of Managed Care

Steve Watson   ( 26 August 2008 )

Health IT And Magical Thinking: A Key Message For Policymakers

Peter Basch   ( 3 September 2008 )

Health Information Technology Success: A Third Ingredient

Julia Adler-Milstein   ( 19 September 2008 )

Still Waiting For The Promise Of Managed Care 26 August 2008
Steve Watson, Retired Family Practice MD WorldVistA.org Send comment to journal: Re: Still Waiting For The Promise Of Managed Care ssw0213{at}gmail.com Steve Watson	Thank you; I agree with your analysis. I'm a family doc, old enough to remember the origins of the term "managed care," with its promise to move us from the evils of "fee-for-service" and jokes about x-raying the patient's wallet, toward MBA-style efficiency that would save us money while paying the 30% cut the managers would take. I'm still waiting. As I learned more about how to manage my own office, I found that "you manage what you measure" -- and we were measuring and managing cost, not outcomes. So I love your conclusion that the goal is, "And then one million patients had better outcomes." In fact, why not 300 million citizens with better outcomes, including not becoming patients (i.e. ill or diseased) in the first place? Anyway, at the end of "Motivation and Trust" you discuss the proposition that "upgrades generally drive standards" and then you say, "The corollary is not true." A corollary is a proposition that would be easily deduced from a more general proposition; I think what you meant was, "The converse is false," which translates to, "Standards generally do not drive upgrades."
Health IT And Magical Thinking: A Key Message For Policymakers 3 September 2008
Peter Basch, Medical Director, Ambulatory Clinical Systems MedStar Health Send comment to journal: Re: Health IT And Magical Thinking: A Key Message For Policymakers peter.basch{at}medstar.net Peter Basch	Diamond and Shirky correctly state that enhancements in health care outcomes (quality, safety, effectiveness, efficiency, etc.) will not occur solely through the adoption of health information technology. With the exception of modeling data, the evidence is clear that health IT is outcomes agnostic. That said, there is compelling evidence that an enabling infrastructure of health IT, coupled with a trusted commitment to a workable privacy framework and a sustainable business case for quality, will lead to better outcomes. Diamond and Shirky go on to indict the current standards development process as slowing the adoption of health IT ("the perfect being the enemy of the good"). While this may be true, I do not believe that those leading these efforts are guilty of "magical thinking." And adopting the authors' alternative "good enough" approach may accelerate health IT adoption, but may inadvertently worsen magical thinking. The magical thinking I am referring to is the vision that health IT = quality, and that health IT adoption is therefore a goal (rather than an enabler). It is this overly simplistic vision has that has led to incentive programs that miss the mark, and the specter of mandates (that are even less likely to improve outcomes). A better approach to counter this magical thinking of policymakers and politicians is to advocate for linked accelerated development of reasonable standards, a comprehensive privacy framework, and appropriate payment reform.
Health Information Technology Success: A Third Ingredient 19 September 2008
Julia Adler-Milstein, Doctoral Candidate Harvard University, PhD Program in Health Policy Send comment to journal: Re: Health Information Technology Success: A Third Ingredient jadlermilstein{at}hbs.edu Julia Adler-Milstein	Diamond and Shirky rightly point to policy as a complement to health IT. While this combination will improve our chances of transforming health care, there is a third "ingredient": an understanding of the organizational changes that complement health IT. There are three key findings from research on the relationship between IT and productivity in other industries: (1) there is wide variation across organizations in the impact of IT on productivity; (2) organizations that realize productivity gains from IT go through dramatic restructuring to take advantage of the new capabilities afforded by IT; and (3) organizations that do not make such changes are worse off than had they not invested in IT at all. While Miller and Sim (Health Affairs, 2004) make a strong case for such complementary changes accompanying EMR adoption, far more articles encourage the design of IT systems around current work practices and work flow. This is likely to cement suboptimal practices and diminish the full potential benefit of health IT. Efforts to promote health IT must be complemented by policy and an understanding of the organizational practices that enable it to transform health care delivery. This requires abandoning a “technological determinist” point of view in which technology’s effects are seen as independent of the organizational structure in which it is embedded, another flavor of magical thinking. Instead, health IT must be viewed, and studied, as a component of an entire system of work.