Magical Thinking Obscures the Goal: Improved Outcomes

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High hopes have been pinned on the potential of IT to improve health care delivery here and around the world, but the current focus on standards may be misplaced, according to a new paper¹ published online on August 19, 2008, by Health Affairs. The authors draw on the observations and surveys of Connecting for Health (a public–private collaborative operated by the Markle Foundation, New York City) in concluding that applying standards in the absence of policy is like trying to push string.

Standards develop over time, gaining acceptance only after they have been widely adopted—and this step is not easily mandated. History, in fact, is littered with failed, vendor-approved standards, the authors argue. Serious structural obstacles to the adoption of IT include current legal and financial incentives, which provide scant motivation to share information across institutions. In addition, despite three years of effort by the newly created Office of the National Coordinator for Health Information Technology, the Healthcare Information Technology Standards Panel, and the Certification Commission for Healthcare Information Technology, the authors note, we remain far from the use and implementation of these standards to enable health information sharing.

The authors maintain that protocols are created, but standards are adopted. “The process of standardization is incremental, never solving every problem at once and often leaving prospective data-sharing protocols to be worked out in the field, and only then submitted for ratification after the fact,” they write. One need only look at the work-arounds being created by savvy radiology-practice CIOs for the purpose of centralized reading for distributed sites for evidence of the preceding.

“The risk here isn’t just overemphasis on standards—that would be an oversimplification of effort,” the authors write. “The risk is that by not accompanying standards with work on information policies and incentives, the current efforts may, paradoxically, slow the very transformation that health IT can deliver.”

That brings us to the peculiar but wonderful demonstration underway in Minneapolis, whereby radiology and outpatient imaging groups have assumed the financial and administrative burdens of radiology benefit management by purchasing decision-support software and managing outpatient imaging utilization. With some practices experiencing as much as a 10% reduction in volume—not to mention the cost of the enabling technology and software—one could argue that this project has yielded financial benefits to the payors, but slim benefits for the radiology groups that financed the cost of the software and experienced reduced volumes. A true incentive would be there if those groups became the exclusive providers of outpatient imaging in Minnesota.

The three main points that the authors make are that protocols are created, but standards are adopted; information won’t be shared until there is a compelling reason to share it and trust is established; and, most critical, in networked systems, it is impossible to separate the creation of standards from the development of information policy. The alternative to magical thinking with respect to standards is to focus on the crucial destination. That, the authors remind us, is patient outcomes.

In radiology, a common criticism of standards voiced by vendors and those imaging informaticists who push the envelope is that standards inevitably lag behind the market. Nonetheless, the adoption of the DICOM standard in radiology has played a pivotal role in the remarkable advances in radiology communications made possible by imaging informatics. In addition, the work of Integrating the Healthcare Enterprise has provided invaluable guidance to the vendor community on radiology workflow, resulting in clear patient benefits.

Clearly, imaging informatics could be pushed further toward improved patient outcomes with an assist from enlightened information policies and incentives.