Earlier last year, David Blumenthal, President of The Commonwealth Fund and former National Coordinator for Health Information Technology (2009-2011), was interviewed by Vivek Garg of One Medical Group and Khin-Kyemon Aung of Harvard Medical School. We have chosen to reproduce this interview as it holds important messages for all physicians and health services researchers who are interested in improving health care delivery. A link to the interview published in our journal can be found here.
It has been almost 2 years since you stepped down as National Coordinator for Health Information Technology. Reflecting on what has happened since then, what has gone right? What might have gone better?
Dr. Blumenthal: The country has been very successful with adoption of EMRs but not as successful in creating the requisites for exchange of health information. There are still a lot of rough edges—EMRs are not being used anywhere near their full capacity, and in some instances, are interfering with physician throughput. However, the effort has been well launched and a more capable, informed health care system will evolve on the foundation of electronic health systems.
The federal effort, via the Office of the National Coordinator, to foster the evolution of electronic health systems seems unique in its level of coordination and support for innovation. How did it come about?
Dr. Blumenthal: As a public sector start-up, we had to create policies, programs, and grant mechanisms, and we had to build credibility and reach out to stakeholders, all under great time pressure. We needed vision and leadership to do something so dramatic and new. The people around the President understood that the health care system would not improve without better information and better information management. It was only with support from the Congress, the President, and his immediate staff that the policies to develop electronic health systems were made possible. The confluence of the health care spending crisis, the broader economic crisis, and a change in leadership allowed us to choose projects that would be long-term, beneficial investments. There were many unique circumstances, which repeat themselves from time to time. Think about the creation of community health centers, the NIH, Medicare and Medicaid; these were all similar, once-in-a-generation programs that resulted from a combination of opportunity, leadership, vision and availability.
Some of the dialog around electronic medical records has been sour lately with prominent stories about their pitfalls in the New York Times and the Wall Street Journal. Why do you think this is?
Dr. Blumenthal: Every time the federal government expends large amounts of money on a new project, it receives enormous scrutiny. Public expectations can be hard to meet, and there is a natural inclination for journalists and other observers to look for flaws.
Programs are not perfect and EMRs are not perfect. If your standard of judgment is based on whether EMRs are performing exactly as people expected them to, then it is easy to be critical. However, if your view is based on what it takes to get to a high performance health system, then you would have a different, more nuanced standard. I do not think the criticism will fundamentally affect the program unless it is repealed or de-funded. We will have universal adoption of EMRs in 5–10 years, which will create a cycle of continuous innovation in digital health.
You are one of the pre-eminent historians of the presidency and its relation to health care policy. How do you see the health care policy landscape evolving in President Obama’s second term?
Dr. Blumenthal: I think the President has learned a lot—it is apparent that he has. Despite his success in passing the Affordable Care Act, he made significant mistakes in its passing and early implementation, which mainly had to do with how he communicated, or failed to communicate, this policy to the American people. He deserves enormous credit for his conviction and courage in passing it. I think he has learned a lot about communication, and it is apparent with how he is handling Medicare and the budget crisis. I suspect, and hope, that will be how he manages the inevitable ups and downs that will accompany the Affordable Care Act’s implementation.
You recently assumed leadership of The Commonwealth Fund, one of the most renowned health care philanthropic organizations. What are your goals for the Fund?
Dr. Blumenthal: We are committed to creating a high performance health system, one that provides efficient, cost-effective health care, particularly for vulnerable populations. We are looking very closely at what strategies we use to pursue those goals—there will be some areas of continuity and some areas of change. We are undergoing a strategic refresh over the next 4–6 months, looking at current programs. On the whole, we will continue to focus on health system performance and vulnerable populations.
Federal and state governments, as well as individual health systems, are taking significant steps to link “value” to payment through a multitude of reform models. What models do you see as being most successful over time, and what is necessary for them to succeed?
Dr. Blumenthal: We have created models of health care delivery that are universally admired across the world, that excel in performance. These include pre-paid group practices and other institutions such as the Group Health Cooperative in Seattle, Kaiser Permanente, HealthPartners, Geisinger, Virginia Mason and ThedaCare in Minneapolis. Most high performance systems are different in some special way that enabled them to create a unique environment for practice and care. We have to figure out what this is and how to replicate it in areas where Americans get their care day-to-day. 75–80% of health care is still delivered through the fragmented, fee-for-service system. This problem is multidimensional and will require persistent effort to change the many facets of our health care system. The best way to go about this for us at The Commonwealth Fund is to figure out where we want to invest our relatively modest resources, and The Commonwealth Fund is looking at exactly this.
You have had a remarkable career that has spanned clinical medicine, policy research and implementation, and management. What advice would you give other physicians and health services researchers who are interested in improving health care delivery?
Dr. Blumenthal: A couple of pieces of advice: (1) Stick to it—for young physicians in particular there is a lot of pressure during training to follow a traditional path toward specialization and life-long clinical practice. This is a time honored route, and we certainly need excellent clinicians. But if you have an interest in improving health care delivery, you will have to depart from this well-beaten career track to some degree. (2) Take risks—whenever you depart from the beaten path, it can be lonely. Taking those risks pays off in the long term. (3) Seek experiences outside of routine clinical care—management in the private sector, service in government, fellowships abroad. Find ways to get non-traditional perspectives on the health care system. I am all for degrees that are non-health care focused such as an MBA or MPP; there is something uniquely enlightening about seeing health care through the eyes of someone who is not a part of the health care system.