Making progress in health information technology: more realistic leadership, less hype.

THIS ISSUE OF Frontiers of Health Services Management presents two different but complementary perspectives on achieving what most would agree is a necessary step forward for the U.S. healthcare system-moving off paper and into the digital age. Michael Sachs presents a vision of what this transformed system might look like; Rosemarie Nelson lays out a practical step-by-step road map for getting there. While one might be tempted to conclude "problem solved" and uncritically climb on the healthcare information technology (IT) bandwagon, I would first offer a few words of caution. The vision for the optimal integration of health IT into clinical practice should certainly be bold, but it should not be uncritical or unrealistic. Similarly, the road map should lead to more than putting a computer on the physician's desktop, lest we simply end up with digitized dysfunction. IS THE VISION FOR HEALTHCARE IT POINTED IN THE RIGHT DIRECTION? Sachs's vision of the near-term future is certainly hopeful and bold ("transformation of ...an information-enabled system without fragmentation is ...without question"), but it is by no means certain. While one would like to think that within a decade our resuscitated healthcare system would have the latest bioscience wizardry virtually available to all, far more basic problems need to be solved first. Health IT will hopefully be part of that solution. The current system is fraught with dysfunction, fragmentation, and, in some areas, is itself on "life support." Almost 50 million Americans are uninsured or underinsured. Almost half of our nation's hospitals are operating at a loss. Many emergency departments are so overcrowded that the average wait time is longer than a cross-country flight. Moving our sights from the hospital to the physician office does not present a better picture. The "one-two punch" of declining reimbursement and increasing practice hassles has led to widespread physician dissatisfaction, particularly in the primary care fields of internal medicine and family medicine. These physicians are retiring in mid-career or leaving practice for other non-patient care opportunities. Nor can we count on the next generation of doctors to fill in the gap. Each year fewer and fewer U.S. medical students chose careers in these primary care fields, and if it weren't for the international medical students accepting these training positions, the United States would already be feeling the effects of the impending shortage. If these challenges weren't enough, the population is aging; in spite of the dire IOM pronouncements of iatrogenic deaths (44,000-88,000/year) (Kohn et al. 2000), more people are surviving for longer periods of time with multiple chronic (and expensive) conditions. The implications of this demographic time bomb for Medicare are staggering (Rettenmaier and Saving 2004). Surfing the Web from the ICU Sachs's vision of patients biding their time in the ICU looking at their results and medical information is far-fetched and, if actualized, would lead to further waste of scarce resources. One of the reasons emergency departments have 6 to 8 hour waits is lack of bed availability in the critical care units. In the real world, when critically ill patients recover enough to sit up and focus on a computer screen (for medical reference reading or to download games), that patient is well enough to leave the ICU. How about the same vision, but for patients in a regular hospital bed? This might be a reasonable vision, assuming that the hospital really wanted to divert limited bandwidth from projects that involve, for example, mobilizing data and images for clinicians, but again, in the real world, patients aren't hospitalized except when severely ill. When patients are hospitalized for elective surgery, they are typically discharged once conscious and stable. Although there is nothing inherently wrong with extending ubiquitous Internet access to hospitalized patients, at a time when there is legitimate concern about just having sufficient hospital beds for our population, this seems at best frivolous. …