Information technology (IT) is an integral part of all segments of life today. Since its first sprouts in the 1940s with the development of the electronic computer, the field has expanded to become a dominant player in every industry imaginable. From finance to agriculture, IT systems have interspersed into the design and functionality of the services provided. In the past twenty or so years, a vital component of societal functioning – the healthcare industry – has joined the ranks of businesses integrating IT into its previously analog systems.
Medical service providers worldwide have made several attempts to implement Electronic Health Records (EHR) and Health Information Technology (HIT), learning in practice which theoretical elements work best and which require further development. This paper is going to examine the implications of using IT to support healthcare reform in Asia and central Ethiopia to determine the success factors and challenges of this complicated process.
Before analyzing any case studies, it is important to introduce the theoretical assumptions of IT integration into the medical services industry. Glaser and Salzberg (2011) use terms like EHR, health information exchange (HIE), accountable care organizations (ACO), and patient-centered medical home model (PCMH) to frame their ideas about HIT. The latter two refer to alternative systems to treat patients in the US. Mainly, they serve as possible substitutes to the current set up of the medical services industry in the country, relying on a different performative and financial structure in delivering its services.
For example, ACOs function like independent organizations formed by coordinated healthcare practitioners whose main objective it is to provide and charge for quality services. In ACOs, “compensation for care is based on provider improvement of clinical performance and efficiency,” which ultimately implies a fee-for-service payment which rewards volume rather than the quality of the service (Glaser & Salzberg, 2011, p.195). The financial structure of ACOs imitates the one currently in use in the US and therefore needs improvement.
Another framework is the patient-centered medical home model, the primary goal of which is to provide tailored services to its patients. As such, it advocates for the establishment of a long-term relationship between a client and a physician who “provides first contact, continuous, and comprehensive care” (Glaser & Salzburg, 2011, p.196). Contrary to ACOs, PCMH relies on the “bundled payment – episode of care” payment system which charges patients based on defined periods during which a certain condition was treated rather than for specific procedures (Glaser & Salzburg, 2011, p.198).
The advocates of this system believe that such a set up “incentivizes providers to coordinate patient care and reduces costs incurred through redundancy in services” (Glaser & Salzberg, 2011, p. 198). Therefore, bundled payment financing appears to be a more progressive way of approaching healthcare reform that shapes more efficient services for all.
Ultimately, both of the models described above rely on EHR and HIE to execute their delivery. EHR, which represents an electronic record of patient data, both clinical and geographic, including results of laboratory tests and treatment decisions, is the most important tool in universalizing medical care. Standardized, countrywide EHRs can significantly improve the treatment processes for patients who frequently change their provider preferences or move from one hospital to another for other reasons.
Shared through the health information exchange systems, these records can give a holistic overview of the previous conditions and treatment received by the patient, allowing doctors to make better-informed treatment choices for their patients (Halamka, 2010). Theoretically, such technological measures can aid greater efficiency of medical care and reduce client costs, improving healthcare experiences for many.
Whether the integration of HIT performs as designed in practice is another question. It is known that by 2014, 75% of office-based medical practitioners in the US have adopted EHR (Mathematica Policy Research [MPR] & Harvard School of Public Health [HSPH], 2015). The implementation of the Affordable Care Act (ACA) three years prior, designed to create a competitive environment within the healthcare industry brought a “new level of complexity” into sharing data between providers (Dornan et al., 2019, p. 2).
In this case, one has to answer a question of what is more important: improved information access for all providers across the industry or a free-market formation of costs and qualities of services in medical care. Perhaps, there needs to exist protection and centralization of all EHRs so that market pressures would not affect data quality and availability. The conflicting incentives of the two policies make EHR implementation a hindrance to the execution of the ACA, and vice-versa. However, the benefit of HITs seems to be so clear that one must wonder why its integration cannot be classified as standalone healthcare reform.
Conversely, HIT implementation encountered some hurdles in other countries as well. Dornan et al. (2019) find that the electronic medical records (EMR) worldwide are highly uncoordinated between not only individual healthcare providers but also departments within those hospitals. They also indicate that the main challenge “facing public health practitioners is that as…EHR systems progress, the gap between high- and low-…income countries widens, increasing the risk that the most vulnerable populations are left behind” (Dornan et al., 2019, p. 2). As the researchers analyze 32 studies across 15 countries in Asia and Africa, including Singapore, China, Iran, and others, they find many challenges to EHR implementation.
Firstly, infrastructure, such as stable electricity and mobile technologies, varies widely amongst all participants. Their sophistication determines the efficiency of implementing EHR, creating potential risk in transitioning to HIT-based medical services. Thus, although a theoretically effective measure, EHR can become a problem to healthcare reform in case the registered data becomes lost or unavailable for practitioners to access. This can potentially disrupt the normal flow of providing medical care and lead to serious complications in individual and public health.
Secondly, familiarity with the HIT systems of existing practitioners plays a big role in the success of technology implementation. For instance, in Iran, a “lack of efficient planning, a lack of skilled manpower, and limitations in information technology training for healthcare professionals” was found to hinder the adoption of EHRs (Dornan et al., 2019, p. 3). Therefore, a potential reform that relies on well-functioning electronic databases can fail to be executed and therefore needs to address the development of the technology first.
Lastly, the researchers highlight ethical concerns regarding EHRs, which can make further healthcare reforms difficult to execute. Data security becomes a significant concern for many people as the frequency of cyber-attacks rises. Healthcare systems that already rely on EHRs can face challenges in adopting changes in case of a major data breach. Patients may develop an adverse reaction to the system, deeming it unreliable or become concerned about potential conspiracy theories. Thus, the mere setup of HITs can undermine the trust of patients towards healthcare providers that use it, motivating them to pursue alternative treatment methods (Dornan et al., 2019).
Other sources indicate that information technology is crucial to revolutionizing healthcare. Manyazewal and Matlakala (2018) analyzed the result of the business process reengineering (BPR) reform in Ethiopia to find that HIT was a statistically significant predictor of employee satisfaction. The researchers surveyed healthcare providers in Addis Ababa to quantify the overall reaction to BPR and discovered that despite the “substantial gain in infrastructure and workspace, stewardship of healthcare resources was less benefited” (Manyazewal & Matlakala, 2018, p. 1).
HIT, as an outcome predictor, was found to have a positive influence on the rate of employee satisfaction, implying that its successful implementation is viewed as beneficial for improving the medical services industry in Ethiopia. Conversely, the lack of an existing support system for HIT hindered the progress of BPR.
Amongst other factors that influenced the reform outcomes were financial resources, top management and support, and collaborative working environment, all of which were found to be underdeveloped even post-implementation. This suggests that the interaction of these components is necessary for aiding healthcare reform and that IT alone cannot create a hindrance to the process. As HIT implementation involves tackling provider structure, payment systems, and caregiver responsibilities, it is important to remember that its success depends on the functionality of these parts. It is also, of course, influential of the quality of the outcome.
The researchers note that “financial systems raised another key concern in reengineering public hospitals,” and that their mobilization “did not centre on evidence-based plans” (Manyazewal & Matlakala, 2018, pp. 11-12). Thus, one can infer that, in tandem with the poorly developed HIT, compensation structures negatively impacted the implementation of BPR. Consequently, the synergy between all components supporting health information technology systems is required for their functionality and a noticeable positive effect.
The former argument is supported by the researchers of MPR and HSPH. They emphasize that the underdeveloped state of the US healthcare payment structures ultimately induces the introduction of new technology to have an adverse effect on the price of the product (MPR & HSPH, 2015). Noting that “in every product-competitive industry the dynamic is exactly the opposite,” they point towards the central problem with HIT system implementation in the United States (MPR & HSPH, 2015, p. 83).
Given these considerations, the original thesis question that asks to illustrate the impact of the HIT implementation on healthcare becomes simplistic. Other macroeconomic factors need to be considered to evaluate said impact.
Apart from payment systems, the researchers cite hospital hiring practices and employee retention, disagreement about the purpose of health information exchange, and “stakeholder concerns about privacy and confidentiality” to be crucial for smooth implementation of HIT and HIE (MPR & HSPH, 2015, p. 27). Therefore, answering the question about the impact that HIT makes on healthcare reform requires one to consider the development of the said macroeconomic factors first. Otherwise, the results are likely to be contaminated with the evidence that reflects the state of those systems.
Several varying efforts to implement HIT have been made in the United States. Named the Health Information Technology for Economic and Clinical Health Act (HITECH Act) collectively, they targeted different communities via distinct methods to improve the efficiency of their overall functionality and service quality (MPR & HSPH, 2015). Notably, one of the programs called the Regional Extension Center (REC) was put in place to assist 100,000 small practices and medical professionals in serving communities in danger. The primary support mechanism consisted of “clinical and health experts to support a range of services, including vendor selection, EHR implementation, attestation assistance, and quality improvement activities (MPR & HSPH, 2015, p. 35).
The results showed an overall significant improvement in adopting and using the EHR systems, although regional results were variable. For instance, health professionals working with Medicaid patients experienced stagnation in process implementation when the Medicaid system was delayed. Small practices in non-metropolitan areas found it difficult to recruit competent, HIT-trained staff to support their current progress. However, the overall feedback on the program from the participants has been positive and has drawn a vector of improvement in adopting HITECH (MPR & HSPH, 2015).
Another program focused on training college graduates and healthcare professionals to be proficient in using the HIT. Besides the acquired skills, its primary incentive was to HIT-certify the participants as free or small-fee examinations were offered at the end. The stimulus did not receive a massive response in the initial phase, but by the time the program was over, more than “9500 individuals had taken advantage of the free vouchers made available…electing to sit for the certification exam” (MPR & HSPH, 2015, p. 41).
Overall, the program exceeded their goal by 200 percent, and the post-factum survey indicated that the participants believed they learned valuable skills and knowledge. Thus, both of the programs designed to integrate HIT into existing practices meaningfully were able to achieve their goals and learned that improvements could be made in the meantime.
In summarizing the role of HIT in healthcare reform, it is vital to be aware of both the advantages and disadvantages that it brings. On a macroeconomic level, its implementation seems to offer a solution to structure and centralize healthcare records, making healthcare more universally accessible and less costly. HIT and its payment systems introduce the competitive market to the healthcare industry, revolutionizing the existing model of services and offering a more client-oriented economy.
Inversely, the process creates ethical concerns regarding the use and the safety of the data as the frequency of cyberattacks increases. Conversely, the adoption of HIT cannot be performed smoothly if the underlying financial structure of an economy is weak or contradicts the goals of such programs. The latter implies that more work needs to be done in evaluating the interaction of the components that govern HIT and HIE and the existing financial and legal systems.
Microeconomically, HIT seems to offer an advantage to providing more comprehensive treatment for a smaller cost. Moreover, it allows healthcare professionals to build a diverse set of skills and ease the transition to new medical technology. EHRs and HIE seem to be useful not only for the doctors but for the patients as they can have access to the most up-to-date information regarding their well-being and greater flexibility in making treatment choices. Therefore, although HIT and related components require detailed, country-specific analysis in feasibility, implementation, and efficiency, they can bring many advantages to medical professionals and patients in building a better system of healthcare.
Glaser, J. and Salzberg, C. (2011). The strategic application of information technology (3rd ed.). San Francisco, CA: Jossey-Bass.
Halamka, J. (2010). Healthcare IT implications of healthcare reform [Blog post]. Web.
Dornan, L., Pinyopornpanish, K., Jiraporncharoen, W., Hashmi, A., Dejkriengkraikul, N., & Angkurawaranon, C. (2019). Utilisation of electronic health records for public health in Asia: A review of success factors and potential challenges. BioMed Research International, 2019, 1-9.
Mathematica Policy Research, &Harvard School of Public Health. (2015). Health information technology in the United States, 2015: Transition to a post HITECH world. The Robert Wood Johnson Foundation. Web.
Manyazewal, T., & Matlakala, M. C. (2018). Implementing health care reform: Implications for performance of public hospitals in central Ethiopia. Journal of Global Health, 8(1), 1-15.