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Knowledge@Emory – Special Section – September, 21
2005 |
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U.S. Healthcare: Ready for a Revamp?
Will Healthcare IT Mean Better Outcomes
for Patients and Providers?
By Myra Thomas
Few would argue that technology fuels modern business. Yet,
most industry analysts and medical practitioners admit
healthcare remains behind the times when it comes to using
technology to improve the quality of care and to streamline
administration. One recent and well-publicized public policy
initiative is seeking to address this critical lapse in the
medical field. In an official press announcement on May 11,
Senator Hillary Rodham Clinton (D-NY), Representative
Patrick Kennedy (D-RI) and Representative Tim Murphy (R-PA)
introduced the 21st Century Health Information Act of 2005.
The act gives the Secretary of Health and Human Services the
power to fund regional health information organizations that
electronically compile patient health data. Surprisingly,
Clinton political foe and former House Speaker Newt Gingrich
spoke up in favor of the act. (Today, Gingrich heads up the
Center for Health Transformation, a healthcare advocacy
group that he founded.)
What could move the strangest of bedfellows to agree on such
a heated topic? Needless to say, the crisis in healthcare.
Ballooning bureaucracies, skyrocketing costs and growing
patient error are just a few of the problems moving
political rivals to converge on the issue. So, just why are
medical practitioners resistant to IT advances, and what can
be done to change the entrenched culture? How can technology
ensure patient safety and medical outcomes, while preserving
patient privacy? Is technology truly the solution to
healthcare’s woes? Knowledge@Emory takes a look at this
complex healthcare issue, with a select group of healthcare,
academic and business leaders offering up their prescription
to the roadblocks in technological implementation.
Obstacles to Tech Implementation
According to John Fox, president and CEO of Emory
Healthcare, Emory University’s affiliated health system,
clinicians have a difficult job. The pace in most hospitals
and clinics is frenetic, and doctors and nurses believe that
their time is best spent on dealing with patient diagnosis.
Therefore, it’s easy to understand that the culture can make
it difficult to accept change, especially when those
technological changes might initially take up a portion of
the already overburdened working day. Fortunately, says Fox,
“Doctor perception can be wrong. Healthcare is bureaucracy-
and paperwork laden. Technology can relieve that. But, it
takes individual mastery of a learning curve for that relief
to be realized.”
Even with improvements such as electronic versions of film
images (from CAT scans and MRIs, for example), doctors often
resist the technology. Some doctors feel uncomfortable with
the computer and remain attached to the old image of the
doctor who holds films up to a light box, or writes in a
physical chart rather than using an electronic one.
“Physicians are extremely busy, and they’re accustomed to
working with the films and showing those to patients.
Dealing with the computer is an entirely different way to
interact.” But, says Fox, the beauty of electronic film and
charts is that the information is readily available to
doctors throughout a health system and can be viewed from
multiple locations simultaneously, and the cumbersome paper
and film needn’t be stored, located and transported through
the hospital.
Fox adds that when doctors see the impact on the quality of
care, they often are more accepting of the technology
changes. “Once doctors understand the many benefits of using
tools such as an electronic PDR (Physician’s Desk Reference
of prescription medication), then they understand the
benefits. The PDR grows every year with new drugs, new
complications, and new interactions. No one can memorize and
master all this information. Without technology to aid
doctors and nurses, in a particular clinical moment, they
will be prone to ongoing safety issues.” Of course, Fox
admits that technology is no panacea. “Even with the
electronic PDR, the clinician is still responsible.
Technology is merely an aid.”
Getting physicians to buy into the new technological changes
requires realigning incentives, says Dr. Paul Davis, CEO of
UnilianceHEALTH, a healthcare technology company. He says,
“A fair question would be: what is the value proposition for
the individual user? Is a particular IT system going to save
one time? Is it convenient to use? Is it going to improve
both fiscal and health-related outcomes? Is it going to
reduce risk for errors, which affect morbidity and
mortality? What is the ROI? Saving paper is a great start,
but “speeding up the mess” is not a very powerful incentive
for change.”
Cost remains another major obstacle to the adoption of many
technological changes in healthcare. Fox admits that the
Emory Healthcare effort to go paperless and film-less will
cost the medical system more than $50 million. (He notes
that Emory Healthcare will be in the first 5% of medical
centers to go paperless across an integrated inpatient and
outpatient enterprise.) However, smaller medical facilities
and private practices are certainly less willing to fork
over big bucks to something that may not yet be standardized
across the industry. Dr. Davis adds, “There is no national
protocol or standard for all the available systems, as of
yet. One could envision more expense down the road in costly
updates and maintenance, as such standards evolve.”
An even bigger technological challenge comes in trying to
incorporate existing information (legacy systems) into more
modern computer systems. Dr. Davis notes, “Much of this
information is locked in proprietary databases and utilized
to the benefit of their owners, not for the overall good of
the industry. Connectivity, in the form of open platform
healthcare IT systems, is the key to the problems we face in
the medical informatics industry. There are currently as
many as 800 different vendors selling EMR (Electronic
Medical Record) solutions. The elusive goal is to have all
of these systems communicate with one another, so that a
central database of medical information is available to the
providers involved with patient care, regardless of their
location during the process.”
Unfortunately, says Dr. Benjamin Druss, the Rosalynn Carter
Chair in mental health at the Department of Health Policy
and Management at Emory University’s Rollins School of
Public Health, coordination and communication are not the
industry’s forte. “Fragmentation arises from systems that
don’t provide professional or financial incentives for
clinicians to share information or work together. Healthcare
is rich in evidence-based innovations, yet even when such
innovations are implemented successfully in one location,
they often disseminate slowly, if at all. Diffusion of
innovations is a major challenge in all industries,
including healthcare.”
Understanding the Tech Benefit
Certainly, medical practitioners are much more willing to
adopt technological advances that relate directly to patient
care vs. those that relate to the more administrative side
of things. Says Fox, “On the medical side, we have better
and stronger imaging technologies, but we also have genomics
and large molecular therapy. All of this is starting to hit
its stride.” (The computer interpretation of human chemistry
is fueling the genomics revolution.)
Many of the changes are happening at light speed, and many
of the benefits in diagnosis are clear. Dr. Donald W.
Rucker, vice president and chief medical officer for Siemens
Medical Solutions, a supplier of healthcare technology and
equipment, notes, “We’ve moved from wireless electronic
medical records to better and better platforms and systems
that facilitate care. The hardware and software on the
imaging side is improving greatly. Today, modern 64-slice CT
scanners are so fast that they can image a beating
heart—capturing images so precise that in many cases the
need for invasive cardiac catheterization is prevented. We
have new PET scanners that can ID tumors and cancerous
lesions. The anatomical information is increasing to the
point that it can help on the surgical and prevention side.”
All of this innovation comes at a price—to the hospital, to
the patient, and ultimately, to the insurance provider
(either Medicare/Medicaid or a private carrier). Some of the
innovations will serve to prevent more costly, long-term
ailments, notes Dr. Rucker. However, inefficient
implementation of technology or the overly liberal use of
technology or testing comes at a high economic price.
Standardization of care, facilitated through electronic
patient data registries, could help to give doctors a
benchmark or guide of when to use certain types of costly
procedures or tests. However, Dr. Rucker warns that the
physician should still have the final say when it comes to
treating an individual patient.
Suzanne Delbanco, CEO of The Leapfrog Group, argues that if
technology can improve the quality of care, then it will
eventually benefit the bottom line. It could prevent
re-treatment of a misdiagnosed patient, for instance. (The
Leapfrog Group is a consortium focused on healthcare safety,
quality and affordability, made up of public and private
companies that provide health benefits.) Delbanco notes,
“Other technological changes, such as CPOE (computer
physician order entry), aid in reducing clinician error.
With CPOE systems, doctors enter medication orders via
computer linked to prescribing error prevention software.
CPOE has been shown to reduce serious prescribing errors in
hospitals by more than 50%.” She adds that as federal and
state regulation mandates greater transparency of medical
care, it will become necessary for providers to gather
quality information electronically, rather than manually.
The Imperative: Defining the Quality of Care
According to Dr. William A. Bornstein, chief quality officer
at Emory Healthcare and medical director of its information
services department, a big debate comes when trying to
define exactly what is “good care,” and just how technology
should facilitate that undefined standard of quality.
“Quality is reflected in patient outcome and the clinician’s
experience in achieving that outcome. The best outcome is
prevention. Next best, for those who get a specific disease,
is to cure it or, failing that, to manage it in such a way
that neither the disease nor the treatments have detrimental
effects. If outcomes are the best indicators of quality,
then you need to measure the outcomes. For instance, if
someone comes to the hospital having suffered a heart
attack, the outcome might be recovery and restoration of
normal activities. We’d aspire to have the patient have no
more episodes, but it’s all complicated by patient
behavior—smoking, drinking, diet, and his or her mental
health.”
So, while federal and state sources, as well as industry
analysts, push for access to medical outcomes via
technological means, Dr. Bornstein notes that the data can’t
necessarily take into account all of these “uncontrollable”
factors. “The other argument that usually comes up is that
certain hospitals or doctors take care of patients who are
sicker or patients who may live in a more challenging
socio-economic environment. In addition, measuring outcomes
is difficult, post-discharge. This is an area that typically
hasn’t been measured well, and what data we do have comes
from billing data. Does that accurately measure anything?”
However, says Dr. Bornstein, with the federal government
increasingly linking funding to medical outcomes, this
presents an even greater dilemma for many medical
practitioners. In July 2005, the Centers for Medicare and
Medicaid Services released a report noting the goal of
revamping its payment policies to reward providers and
practitioners for “delivering the right care, for improving
quality, and avoiding unnecessary costs.”
Given these challenges, the pendulum keeps swinging back and
forth between these elusive outcome measures and “process
measures” (elements of care linked by strong evidence to the
desired outcomes). An example of such a “process measure” is
the administration of beta-blockers to all patients with an
acute heart attack. These measures are now available to the
public on the websites of the Joint Commission on
Accreditation of Healthcare Organizations (an independent
not-for-profit organization) and the Centers for Medicare
and Medicaid Services. “All in all, the performance of the
U.S. healthcare system as gauged by such process measures is
mediocre,” says Dr. Bornstein. “Some of the performance gap
is real and some is due to documentation deficiencies (i.e.,
the drug was given or there was a contraindication, but the
nature of the paper record obscures this information).
Moreover, abstracting all this information is labor
intensive and costly. Information technology helps at all
levels by providing reminders, improving documentation, and
facilitating data retrieval.” Additionally, says Dr.
Bornstein, process measures are difficult to apply to
unusual, rare or acute conditions, as patient response
differs greatly depending on the patient’s age, health
condition, and more.
Interestingly, the patient also factors into the push for
greater access to medical outcomes. According to Colm Foley,
senior manager at BCG (The Boston Consulting Group), a
global management consulting firm, the Internet is playing a
powerful role in this development. Ever-popular medical
sites, such as WebMD.com and MayoClinic.com, offer consumers
ready access to disease symptoms and treatment. A plethora
of other sites, blogs and bulletin boards provide
information on everything from breast cancer treatment to
gallstones. (Of course, what’s available online may or may
not be accurate.) Along with the push for ready access to
medical information, consumers are also looking for
assessments of the doctors who treat them. Foley terms this
wave the “consumerization of healthcare.” While a growing
number of websites profess to offer background on physicians
in a specific area of the country, Foley notes that the
current data is limited at best.
All of the changes couldn’t have come at a more difficult
time for doctors. Dr. Bornstein says that healthcare
providers are experiencing one of the greatest periods of
discontent with the profession. They are besieged with a
level of medical and administrative information that is
overwhelming. At the same time, he notes, “We’re in the
midst of an evidence-based medicine movement, a quality
movement, and it is appropriate to focus on this. Then there
are the challenges and constraints of managed care and
medical malpractice insurance. All of this is new terrain,
and most doctors are trained to operate in an autonomous
manner. They’ve never received training in standardization.”
(Dr. Bornstein adds that technology isn’t necessarily the
entire solution to the problem. There is growing concern
about “unintended consequences of this technology.” As an
example, he notes a controversial article in the March 9,
2005 issue of the Journal of the American Medical
Association, which describes a study where a selected
computerized physician order entry system potentially
facilitated medication errors.)
Challenges and Promising Changes for the Future
Fortunately, says Dr. Davis, there is a promising public
policy development—the April 2004 formation of an Office of
the National Coordinator for Health Information Technology (ONCHIT).
Established by executive order, this organization falls
under the oversight of the Department of Health & Human
Services Administration. Over the next ten years, the ONCHIT
will handle the establishment and widespread adoption of
interoperable electronic health records (EHRs). Says Davis,
“The key to success will depend on cooperation among the
many groups involved to embrace technology standards that
will allow such a mission to be realized. Ultimately, it may
well require government mandates.”
Dr. Davis adds that as we move towards a sharing
approach—sharing medical data to standardize and improve
care—privacy concerns are heightened. Benn R. Konsynski, the
George S. Craft professor of decision and information
analysis at Emory’s Goizueta Business School, notes that
HIPAA (the Health Insurance Portability and Accountability
Act of 1996) did set a standard on privacy and medical data.
However, he argues that it also “tried to do too much at
once and that patient rights and authority should have been
laid out before that.” Konsynski argues that if HIPAA is to
work well in responding to privacy issues, then it needs to
change and be added to as the medical informatics industry
evolves.
Privacy concerns also translate back to the way the hospital
or medical center prioritizes the issue. Says Emory
Healthcare’s John Fox, “ Privacy is not an information
technology question. It is a cultural question. The
organization has to be mindful and respectful of privacy
rights, regardless of the technology platform. The
organization must make it clear internally that violation of
privacy is not tolerated. For example, if an employee takes
a paper chart that they aren’t supposed to access, the
medical record of a neighbor perhaps, that should be
immediate grounds for termination. With new technology, you
must use electronic controls of information–but the culture
has to be the same. The same respect for privacy with
patient information must be a part of the culture, the
policies, and the expectation.”
Konsynski agrees with Fox, noting that the technological
implementation challenge is more of a cultural one. He
notes, “Our capabilities for diagnosis and treatment are
superb. Our administration and governance is still in need
of re-design. We have Smart cards with relevant patient
information, expert systems for assisting in the judgment of
treatments, remote monitoring of treatment and progress,
RFID (radio frequency identification technology) for keeping
track of durables in hospitals and on prescription packaging
to attest to the condition and viability of the drug. These
and other activities will be growing in importance. Our
challenge is not good medicine. It is in good processes and
procedures that have all parties interacting
responsibly—patient, provider and payor.”
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