March 21, 2023
It isn’t the first thing that comes to mind when assessing the lessons of a pandemic, but it is still a well-supported outcome: Widescale health emergencies hasten technological use and development.
Before the so-called Spanish Flu pandemic of 1918, the communications technology was the telephone, and contagions were a concern well before that strain of influenza was unleashed.
“People who are in quarantine are not isolated if they have a Bell Telephone,” reads a 1910 ad from the St. Louis Post-Dispatch. A 1916 promotion in the Evening Express of Los Angeles encourages readers to, “Order By (sic) Telephone From Any of Our Six Stores.”
A hypothetical 2019 ad for Zoom, which enjoyed a greater than 300 percent growth rate in revenue during the first year of the pandemic, might suggest users, “Meet virtually and avoid whatever illnesses your work colleagues are carrying.”
Where increases in technology adoption like the EHR were driven by federal incentives in the Meaningful Use program, recent jumps in technology use—see telehealth—are the product of crisis. But all crises eventually end, so what happens to technology use then?
The answer to that question is determined less by the efficacy of the technology itself and more by the infrastructure and policies established around it. Wireless telegraphy, for example, was thought to be the foolproof information exchange methodology that would prevent another pandemic after the 1918 influenza outbreak.
“What had been seen as a transformational technology was something else entirely: a marginal improvement to communications systems that required good governance in order to have a public health impact,” writes Heidi Tworek in Tech Stream, noting that contact tracing apps took the place of wireless telegraphy in the early months of the recent pandemic and ended up achieving a similar result. “Such apps may have a part to play, particularly in preventing panic. But they were never going to matter as much as political will and smart governance.”
Returning to EHRs as an example: The federal government paid hospitals to install them and has since been gradually increasing the requirements for how they are used. While there is some wailing and gnashing of teeth over these sometimes burdensome and potentially costly performance measurements, it’s pretty clear that the carrot/stick of incentives/fines has fueled the broad adoption of health IT platforms across the country.
For a counterexample, look to health information exchanges (HIEs), which were supposed to facilitate the broad sharing of healthcare data to the benefit of hospitals, providers, patients and public health overall. While HIE use increased during the pandemic, many challenges remain to ensure continued and effective use afterward.
To be clear, it isn’t because HIE technology has failed somehow. It hasn’t, and we can know that by looking at the places where HIEs have succeeded. Delaware, for example, used its comparatively small size and few health systems to create a robust HIE. Probably the antithesis of Delaware is sprawling, complex California, where HIE dividing lines are drawn based on existing alliances and who uses which EHR.
Looking at California more closely, it’s clear that the state has the technological, financial, and intellectual resources needed to implement a statewide HIE. What’s absent is the essential structure and intent necessary to weave healthcare technology into the fabric of the disparate statewide health systems.
As an aside, it also helps if a culture does not embrace bucking the system as a defining characteristic. While contact tracing apps didn’t do much to stem COVID-19 transmission in the United States, they did have a positive impact in countries like South Korea and Japan that embrace a more collectivist mindset.
So what do EHRs, telehealth, and HIEs tell us about the effective use of technology before, during, and after a pandemic? The simple lesson might be that the technology is the comparatively easy part, or that creating the right environment for adoption and use is just as important as developing an elegant platform.
As with Meaningful Use, the federal government offered grants and incentives to states and municipalities to develop HIE projects. In this case, the carrot was not enough to overcome competing initiatives, skepticism, and mistrust. With HIEs, decision makers may not have selected an approach that made implementation and cooperation more likely, and if such an approach is not implemented post-pandemic, HIE use will return to previous levels or perhaps decline even further.
“Specifically, we believe that the [Office of the National Coordinator for Health IT] ought to develop a public HIE option available to all US providers,” suggested Health Affairs. “There are several candidate public HIE options, including the CommonWell Health Alliance platform used in Delaware. A similar ‘public option’ platform could be developed for patients requesting their records, enabling this to become the default tool for consumers.”
For telehealth, an obvious key to continued use is federal approval of payment for remote visits and the requirement that insurance companies cover telehealth like they do in-person visits, but it’s not that simple. Currently, CMS is considering ways to extend or make permanent pandemic-related telehealth rules, but DEA concerns about the use of telehealth for visits that include the prescribing of controlled substances will complicate any rule the agencies finally settle on.
Of course, the use of a few examples—EHRs, telehealth, HIEs—is intended to be illustrative, not exhaustive. The future of health IT will also include wearable devices, smartphone apps, artificial intelligence, and things we haven’t thought of yet, and each of these will complicate decisions about how to incentivize widespread adoption and ensure effective use. As with the examples above, the crucial challenge is to create a tailored approach that includes necessary incentives and structures.
Emerging from the pandemic, and wary of the next viral outbreak, Americans should take confidence in the knowledge that the technology exists now to perhaps prevent a full-scale future pandemic. Indeed, the pace of technological change in healthcare over the past two decades has been nothing short of remarkable, even if you’re not wild about that EHR you’re using.
Moving forward, the efficacy of health IT tools should be based as much on how broadly they are used and how integrated they are in local, statewide, and national information systems as what bells and whistles they include. What COVID-19 showed us is that we’re building out healthcare IT systems to prepare for calamity, not to increase the share price of the company with the newest gadget.