At the 2011 American College of Medical Informatics (ACMI) Winter Symposium we studied the overlap between health IT and economics and what leading healthcare delivery organizations are achieving today using IT that might offer paths for the nation to follow for using health IT in healthcare reform. We recognized that health IT by itself can improve health value, but its main contribution to health value may be that it can make possible new care delivery models to achieve much larger value. Health IT is a critically important enabler to fundamental healthcare system changes that may be a way out of our current, severe problem of rising costs and national deficit. We review the current state of healthcare costs, federal health IT stimulus programs, and experiences of several leading organizations, and offer a model for how health IT fits into our health economic future.

OBJECTIVE: To examine the financial impact health information exchange (HIE) in emergency departments (EDs). MATERIALS AND METHODS: We studied all ED encounters over a 13-month period in which HIE data were accessed in all major emergency departments Memphis, Tennessee. HIE access encounter records were matched with similar encounter records without HIE access. Outcomes studied were ED-originated hospital admissions, admissions for observation, laboratory testing, head CT, body CT, ankle radiographs, chest radiographs, and echocardiograms. Our estimates employed generalized estimating equations for logistic regression models adjusted for admission type, length of stay, and Charlson co-morbidity index. Marginal probabilities were used to calculate changes in outcome variables and their financial consequences. RESULTS: HIE data were accessed in approximately 6.8% of ED visits across 12 EDs studied. In 11 EDs directly accessing HIE data only through a secure Web browser, access was associated with a decrease in hospital admissions (adjusted odds ratio (OR)=0.27; p<0001). In a 12th ED relying more on print summaries, HIE access was associated with a decrease in hospital admissions (OR=0.48; p<0001) and statistically significant decreases in head CT use, body CT use, and laboratory test ordering. DISCUSSION: Applied only to the study population, HIE access was associated with an annual cost savings of $1.9 million. Net of annual operating costs, HIE access reduced overall costs by $1.07 million. Hospital admission reductions accounted for 97.6% of total cost reductions. CONCLUSION: Access to additional clinical data through HIE in emergency department settings is associated with net societal saving.

OBJECTIVE: We assessed the usability of a health information exchange (HIE) in a densely populated metropolitan region. This grant-funded HIE had been deployed rapidly to address the imminent needs of the patient population and the need to draw wider participation from regional entities. DESIGN: We conducted a cross-sectional survey of individuals given access to the HIE at participating organizations and examined some of the usability and usage factors related to the technology acceptance model. MEASUREMENTS: We probed user perceptions using the Questionnaire for User Interaction Satisfaction, an author-generated Trust scale, and user characteristic questions (eg, age, weekly system usage time). RESULTS: Overall, users viewed the system favorably (ratings for all usability items were greater than neutral (one-sample Wilcoxon test, p<0.0014, Bonferroni-corrected for 35 tests). System usage was regressed on usability, trust, and demographic and user characteristic factors. Three usability factors were positively predictive of system usage: overall reactions (p<0 0.01), learning (p<0.05), and system functionality (p<0.01). Although trust is an important component in collaborative relationships, we did not find that user trust of other participating healthcare entities was significantly predictive of usage. An analysis of respondents' comments revealed ways to improve the HIE. CONCLUSION: We used a rapid deployment model to develop an HIE and found that perceptions of system usability were positive. We also found that system usage was predicted well by some aspects of usability. Results from this study suggest that a rapid development approach may serve as a viable model for developing usable HIEs serving communities with limited resources.

OBJECTIVE: Health information exchange (HIE) systems are being developed across the nation. Understanding approaches taken by existing successful exchanges can help new exchange efforts determine goals and plan implementations. The goal of this study was to explore characteristics of use and users of a successful regional HIE. DESIGN: We used a mixed-method analysis, consisting of cross-sectional audit log data, semi-structured interviews, and direct observation in a sample of emergency departments and ambulatory safety net clinics actively using HIE. For each site, we measured overall usage trends, user logon statistics, and data types accessed by users. We also assessed reasons for use and outcomes of use. RESULTS: Overall, users accessed HIE for 6.8% of all encounters, with higher rates of access for repeat visits, for patients with comorbidities, for patients known to have data in the exchange, and at sites providing HIE access to both nurses and physicians. Discharge summaries and test reports were the most frequently accessed data in the exchange. Providers consistently noted retrieving additional history, preventing repeat tests, comparing new results to retrieved results, and avoiding hospitalizations as a consequence of HIE access. CONCLUSION: HIE use in emergency departments and ambulatory clinics was focused on patients where missing information was believed to be present in the exchange and was related to factors including the roles of people with access, the setting, and other site-specific issues that impacted the overall breadth of routine system use. These data should form an important foundation as other sites embark upon HIE implementation.

In the current issue of this journal, Kaushal and colleagues1 present an exemplary, thorough analysis of the financial impact of installing computerized physician order entry (CPOE) in a major academic hospital. This excellent work quantifies quantifiable parameters clearly, estimates other parameters conservatively, and lists problems associated with measurement of the remaining small set of other factors. This work is arguably the best that can be done with respect to evaluating CPOE return on investment (ROI). Why does it not quite seem to be enough or to be sufficient to persuade? The answer to the foregoing question lies in the culture of informatics research and in the health care industry's collective culture of decision making. The research community feels compelled to refine estimates of CPOE's financial return to a greater and greater degree along the analytical lines in the work of Kaushal et al. Using adoption estimates and implementation plans, proponents of CPOE installation in many institutions may base their arguments solely on the Kaushal et al. financial framework. Other proponents may take a different approach, emphasizing instead the broader array of workflow and professional productivity factors that lead to greater financial return. Still other CPOE proponents pursue the challenge of extending financial models to estimate the benefits of CPOE in every hospital, in every ambulatory practice setting, and in every community. A growing body of hard data on the benefits of CPOE presents a compelling case for all who make CPOE decisions to go forward (see references cited in Kaushal et al.1). They should accept, once and for all, that substantial benefits will accrue to hospitals and patients following the successful implementation of effective CPOE systems. The challenge is not to fine-tune the financial benefit models, but instead to determine how to identify and successfully install an effective CPOE system. Many other factors not included in financial models contribute to the success or failure of CPOE implementations. The challenge to society and to industry is to determine how to extend successful CPOE implementations from the setting of a premier academic medical center to every care delivery setting in the nation. We must understand more fully limitations of ROI analysis in hospitals. We must question and document the extent to which such analyses serve as a valid justification for extending CPOE into diverse, nonhospital-based settings where most medical care is delivered. Such an investigation should start with available findings from the large, sophisticated academic medical centers with adequately abundant technology, talent, and time to develop and install CPOE systems. Even in these settings, we are reminded that “many savings from CPOE are not realized in the operations budget” and hence preclude accurate confirmation of financial benefit. Examples of difficult-to-quantify benefits mentioned in the Kaushal et al. article include advanced systems for specialized treatment issues, scheduling efficiencies, and documentation capabilities. To advance the argument for successful adoption within hospitals, as well as to promote broader adoption of health care systems in community-based ambulatory settings, the foregoing list must be extended. From a purely financial perspective, hospitals and large clinics can only accrue substantial financial benefits if their clinical systems are linked to administrative and operational systems used to capture costs and charges, to systems that measure efficiency and quality, and to systems that measure clinical and financial performance. Linking CPOE systems to pharmacy and medication administration processes can provide value to patients and fiduciaries. From a financial and operational perspective, however, this benefit is even greater if these same clinical systems are tightly coupled with those systems used to manage the complex distribution of expertise, medications, and supplies within a hospital. Although CPOE is not needed to realize many gains in these areas, the very near-term survival of health delivery organizations may depend on their ability to link, in real time, activities at the point of service with thoughtful management of inventory and other business processes—just as this is critical to retailers and manufacturers. To a sad and significant degree, however, health care delivery organizations conduct their businesses within an incentive structure that epitomizes the concept “market failure.” Operations within a hospital or clinic can be rationalized. However, such rationalizations do not reflect the totality of care delivery processes that American patients experience as they navigate through the current complex and turbulent U.S. health care delivery system. The necessity of incorporating into ROI calculations the impact of reimbursement and payer mix provides a glimpse of the misaligned and perverse incentive structures at play in health care. There is a difference in calculated CPOE ROI if one receives reimbursement through fee-for-service rather than fixed fees for care delivery. The cynical dependence of ROI on variations in payment mechanisms speaks more about external forces influencing the introduction of clinical systems than do the detailed financial analyses. Focusing on this confusion distracts one from the central point—that to deliver better care, effective implementation of CPOE becomes a responsibility. Whether the ROI can be accurately measured is immaterial to this goal. Perhaps those health care institutions that have not mounted the organizational will to deploy advanced clinical systems suffer because their best administrative and financial talents focus the majority of their time striving for optimization of reimbursement and regulatory rationality, instead of devoting their time to critical internal strategies for successful health care delivery per se. Financial ROI analysis for clinical system installations is incomplete in that it does not reflect the values of patients and health care professionals affected by the systems. From the perspective of the patient, the ROI is measured in safer and more effective medical care. Such care leads to better outcomes, better health, and higher levels of personal and professional productivity. Patients who endure complex illnesses or suffer unneeded complications know that effects of health care delivery extend beyond hospitalizations into the activities of the family members, ambulatory care providers, and other caregivers over a lifetime. Similarly, the ROI measured by those who must make a capital investment is not the same as the ROI measured by health professionals who must take the time both to use CPOE systems and to adapt their work patterns to achieve the goal of improved quality of care. To the health care professional, the true ROI may be measured in terms of ease of use, total expended effort, and satisfaction with the results achieved. From the perspective of one who delivers care, the best hallmark of a truly effective computer technology may be the extent to which one no longer is even aware that one is using a computer to accomplish a better outcome. As in other industries, measurement of the effects of information technology on the clinical setting suffers from a “productivity paradox” described by the economist Robert Solow in 1987.2 Solow stated that computer technology can be found everywhere but in the productivity data. Solow pointed out the difficulty of teasing out the impact of a subtle but pervasive technology from broader transformations taking place within an economic system. The Internet, for example, allowed businesses to take new approaches to managing all aspects of supplier-marketer relationships. Solow's point was that one cannot easily measure how much improved economic performance was due to the enabling technologies and how much was due to significant transformations in how businesses managed their internal operations and their relationships with customers, competitors, and suppliers. In most industries having far less impact on the gross domestic product than health care, the use of advanced technologies is now a matter of necessity rather than debate. One must infer that no matter how laborious and tortuous is the evolution of our health care delivery systems, within the next decade, advanced clinical systems will become deeply embedded in our clinical work whether or not we ever can measure ROI beyond our current capabilities. Health care leaders are beginning to realize that investing in effective clinical systems is as much a matter of organizational will as a matter of financial rationale. Indeed, one might argue that undertaking ROI analyses deals not with determining a theoretical outcome, as much as it does with addressing the fear that the institution lacks the culture, incentives, and workforce to ensure that successful system implementation, which is admittedly not a trivial task.3,4 Both the size of the investment and the risk of achieving successful implementation are at play when hospitals are asked to “make large up-front capital investment without clear data on return on investment or confidence in physician use of implemented systems.” Given the strong arguments in favor of adopting clinical information systems, perhaps it is time to put aside the ROI arguments and focus instead on ensuring that all implementations are successful. Such routine success will require the absolute commitment of every individual within an organization who has any direct role in the transmission and actionable use of health care information in a clinical setting and an equally substantial change on the part of the vendor community. Such commitment only comes when global financial incentives are aligned with the personal motivations of the diversity of individuals who must use health information technology. In major centers, the knowledge engineering and workflow expertise may be hidden costs occurring “piecemeal over many years and probably represented a relatively small part of the entire [system] costs.” For many other institutions, the quandary is not so much one of cost and time of expertise as it is of the very availability of such expertise at critical junctures. In many instances, the cost and availability of intellectual capital may be a far greater constraint to implementation than insufficient financial capital. The introduction of health information technologies into communities presents even greater challenges. This task demonstrates how much more work must be done to extend cost-benefit analysis into additional settings. To realize successful longitudinal, patient-focused care, health care professionals and patients require an infrastructure that provides timely, secure access to a wide array of health care information. That information is at present distributed across many sites and difficult to integrate. A clinical system capable of delivering optimal care in physician offices, pharmacies, home care, and other community settings will require access to medication histories, personal health information, improved clinical communication, and standardization of many other currently disparate aspects. Building such an infrastructure while mindful of costs and patient preferences requires a daunting effort. Lessons gleaned from hospital-based ROI analysis may provide partial guidance. Yet, in these settings even more than in the hospital, one must place emphasis on the cost of an appropriate infrastructure, the availability of intellectual and financial capital, and addressing the misaligned incentives among patients, employers, government, intermediaries, health plans, practitioners, pharmacists, and other involved parties. One of the greatest obstacles to healthier communities may be the enormous gap between what we know how to do in the large and sophisticated health care systems and what we know must be done in our communities, our pharmacies, our long-term care facilities, and our ambulatory practices. Professional informaticians must continue to address these broader problems while learning from existing thorough analyses. The profession must extend, not just refine, these analyses to develop a better understanding of the broader financial impact of health information technology and the less tangible but even more powerful benefits accrued to patients and other stakeholders. Society must then address the daunting challenges required to achieve the widespread and effective use of technology in every medical setting, no matter how small in size, no matter how impoverished in capital and technical talent, and no matter how remote. If medical need and health care professionals' desires to improve caregiving become the motivating factors for better use of health information technology, our success in introducing these solutions will produce an ROI that every patient and health care professional will understand.

In this issue, Ohsfeldt and colleagues1 estimate the financial cost that would be incurred by all hospitals in Iowa if they implemented computerized physician order entry (CPOE). Small hospitals (defined as fewer than 200 beds) account for 70% of nonfederal, general, short-term hospitals.2 The estimates of Ohsfeldt et al. add to a growing literature describing the financial and administrative burdens incurred when modernizing the information technology infrastructure of the small hospital.3,4 For many of these institutions, lower revenues, higher costs, and poor access to capital combine to make the necessary investment in information systems unrealistic. The work of Ohsfeldt et al. focuses on the financial burden of implementing CPOE but not the value proposition that motivates the leadership of a hospital to proceed with an implementation. Early adopters of this technology, including community hospitals5 and many other hospitals now poised to make the investment,6 seem convinced that delivering safe and effective care requires information technology to assist clinicians to “do the right thing all of the time.” Nonetheless, even when investments are viewed as important, affordability is a significant barrier, given the many competing demands for capital. Of necessity, Ohsfeldt and colleagues made several assumptions that influence the extent to which the estimates derived are applicable to every institution. First, the estimation of the presence of clinical systems already in use was of necessity a simplification of the framework that a hospital must employ when considering costs. Second, the estimates of costs were derived from one established information systems vendor and may not be fully representative of the options available to small hospitals in the vendor marketplace. Third, the estimates for small hospitals assume that they can gain economies by forming purchasing cooperatives, but it is not clear whether this option will be available to all these institutions. The need for capital by small hospitals must be remedied through some combination of loans, regional funding, and pay-for-use and pay-for-performance funding approaches.2,7,8 Group purchasing, mentioned by the authors, particularly when coupled with sharing of expertise is one of several mechanisms to lower overall implementation costs. Small hospitals that are part of integrated delivery systems often benefit from system-wide efforts to deploy comprehensive CPOE implementations. The simulation model used by Ohsfeldt et al. addresses primarily the technology-related costs and less so the major investment needed in organizational and process change.3,4 Herein lies a further challenge for the small hospital already strapped with resource constraints necessary to maintain financial viability. Individuals with the required implementation process management expertise are either not present in sufficient numbers or are too immersed in other activities to devote the required time. How can the small hospital assemble and organize the relatively large number of professionals required to ensure a successful implementation while at the same time ensuring that these participants' other responsibilities are met? Day-to-day participation by practicing physicians is especially problematic because small hospitals generally lack the complement of available clinical champions, physician administrators, hospital-based practitioners, intensivists, clinic directors, and training directors who often play critical roles in implementing clinical systems at larger institutions. Organizing this effort is akin to changing the wings of an airplane while it is in flight. Small hospitals in particular require models for implementation that fit their environment and resource availability. A statewide CPOE effort taking shape in Massachusetts, which combines financial assistance with other forms of support, may establish such a model for other areas of the country.9 Selecting vendors with a more “off-the-shelf” approach to software may also be a sound interim strategy for reducing some of the complexity of implementation, but at the cost of limiting functionality in the short-term. Interoperable, standardized systems offer hope in the more distant future. Without significant commitment by regional or statewide authorities working together with the payors and other stakeholders, many small hospitals will continue to delay or sidestep investments in information technology that could help their nurses and physicians to do their jobs better and to improve the likelihood that their patients receive a consistently higher standard of care. Predominantly rural states will be particularly underserved because they rely on local, usually small, community hospitals for much of their care. The Critical Access Hospital Program provides more favorable Medicare reimbursement for rural hospitals that meet particular qualifying criteria and expresses a national commitment to sustain local hospital care. Now similar recognition—backed up by aggressive, multifaceted programs in the region, state, or through other affiliations—is needed if these local health care providers are expected to deliver care at the high level of quality and safety that their communities expect. The financial challenges documented by the work of Ohsfeldt et al. remind the reader of the even greater challenge faced by physicians practicing in small, independent practices. Most physicians are self-employed, and 60% of them work in practices with two or fewer other physicians.10 The issues raised when addressing the small hospital may very well pale in comparison with the transformation required for CPOE (and other clinical system implementation) within small physician practices. Affordability—both money and time—is a major barrier to implementing systems in the small practice setting. Without similar strategies for financing, consolidation of expertise, and support for workflow transformation, the increased level of care provided by hospitals adopting CPOE will not be paralleled in the physician practices where patients obtain most of their care. Small physician practices and small hospitals are a critical foundation of our health care system. The costs that these organizations face when contemplating necessary information technology seem formidable to the point of not being affordable, especially if each organization must work alone to address its critical needs. If society expects to address the nation's health care quality challenges,11,12 it can ill afford to leave this vital sector unequipped to achieve this goal.13

The continuing development of the field of medical informatics has raised new questions and placed before us new dilemmas. Spurred by the proliferation of information systems to support the broad missions of our institutions, and the evolution of these systems from luxuries to necessities, organizational issues have assumed increasing prominence. Among a dazzling array of organizational issues now before us is the tension between the long-standing academic role of informatics groups within medical centers and the ever-expanding service role. In the academic role, we seek the knowledge to create improved technology and to train the next generation of informatics researchers. In the service role, we seek to put existing technology, developed internally or purchased from vendors, to best use across the full scope of medical center activities. The dilemma before us is not whether both roles are important—the answer to that is clear—but rather how to organize ourselves within our institutions to address both of them. How much organizational distance should exist between the people who carry out these different roles, and who should direct their efforts? Most academic medical centers are actively searching for answers to these organizational questions, and many AMIA members are engaged in this pursuit. The answers obtained will be of profound consequence for our field. The salience of this issue directed its selection as the focus of the ACMI Debate at the closing session of the 1997 AMIA Fall Symposium. The purpose of the debate was not to generate a universal answer, for no such answer exists, but rather to illuminate the many factors that must be considered as our institutions search for an appropriate organizational model. To frame the debate, we intentionally polarized the issue around a specific proposition: Resolved: Academic medical centers should have a single unit responsible for information systems supporting the clinical and academic missions and also should be charged to carry out high-quality education and research in medical informatics. The polarity is such that the affirmative team would argue in favor of one group under one leader who would carry out all roles. The negative team would argue for a significant level of separation. We adapted the standard high school and college debate format to fit the available time and to use competition as a device to promote deeper understanding of key issues. There were no judges and no declared winners. Each team had two members: Warner Slack and William Stead for the affirmative, Mark Frisse and Mark Musen for the negative. The format included eight-minute constructive statements, two-minute cross-examinations, and three-minute closing (rebuttal) statements in this order: First affirmative constructive statement, by Slack Cross-examination of Slack, by Musen First negative constructive statement, by Frisse Cross-examination of Frisse, by Slack Second affirmative constructive statement, by Stead Cross-examination of Stead, by Frisse Second negative constructive statement, by Musen Cross-examination of Musen, by Stead Closing (rebuttal) statements by Frisse, Slack, Musen, and Stead, in that order In preparing this summary, we sought to convey the substance and spirit of the debate in a manner suited to printed text. This narrative follows the order of the debate as it occurred on October 29, 1997, at the AMIA Fall Symposium in Nashville, Tennessee. The constructive statements included here were edited from the notes the debaters used to prepare their statements. The cross-examinations and closing statements were edited from the debate transcripts and retain much of the colloquial language used in the event. We include bibliographic references only to direct quotations and citations used by the debaters themselves. The format of this and any debate, and most notably the polarization of a multifaceted issue, often requires participants to take extreme positions. The debaters' views, in reality, overlap more than this report would suggest. Some of the debaters believed that they could, if asked, argue with equal effectiveness in support of their opponents' position. 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Features characteristic of hypertext are no longer the providence of specialized hypertext systems. Interfaces exhibiting the “power of linking” can be found in software ranging from document preparation programs to operating systems, providing users with many new approaches to individual and group information management. To take advantage of the new opportunities afforded by this migration, it is important to understand hypertext at representation levels beneath the more superficial aspects of the human-computer interface. Three abstract models for hypertext—representative members of a spectrum of popular formalisms—are presented to provide insight into the meaning and potential of hypertext. Each model represents a different level in the design-decision process necessary for effective hypertext development, and each model plays an important role in development and use of information management software exhibiting hypertext features. © 1992 John Wiley & Sons, Inc.

This panel will employ two different interpretations of the phrase “growing up” to address areas of common interest between hypertext and information retrieval researchers. First, the panelists will question whether or not hypertext is “growing up” as a scientific discipline; They will discuss characteristics that separate hypertext research from other related disciplines. Second, the panelists will discuss the problems encountered when a hypertext system “grows up” in size and complexity; They will discuss the very real problems expected when representing and integrating large knowledge bases, accommodating multiple users, and distributing single logical hypertexts across multiple physical sites.