Monday, April 20, 2009

Health Information Technology Stimulus, a note from the field.


I am not a member of your distribution list but recently received a request from Anthony Williams of ChemSpider to respond to your concerns regarding the cost-benefit of electronic health records.

To begin with I want to clarify that I write this through multiple perspectives: I am a patient with multiple co-morbid conditions e.g. diabetes and arthritis; a clinical information systems consultant and former director of a cardiopulmonary rehabilitation program (Respiratory Therapist). I have been employed as clinician, vendor of ‘high tech’ products and community organizer.

So, you probably expect that this will be a cheering disagreement with ANYONE who dare be skeptical about the return on investment projected from electronic health record adoption initiatives. When speaking to that person who suffers from chronic disease in a failing healthcare system you would be correct. For that view, see my blog at American Citizen. For a more objective review, please read on.

Since this is an informal communication, I will not perform an exhaustive review of the literature or ‘deep dive’ as suggested; but then again I have been swimming with sharks for quite some time now. That said, I point the reader to a few websites which might serve as a starting place these are: The California Healthcare Foundation and Health Affairs. I have found both the Foundation and the Journal Health Affairs to be objective with regard to the adoption of public health initiatives and peer review.

After 30 years in healthcare with the last ten focusing on clinical informatics –a fancy market-term for computer science applied to a specific business domain; I agree with anyone who questions the validity of broad conclusions that a single technology will address the current catastrophic situation we face in our healthcare economy. THIS IS NOT THE APOLLO PROGRAM in which my father was employed as an aerospace scientist. Many draw this parallel incorrectly. In a social sense we are gathering momentum toward a national goal as we did in the 60s, but the similarities stop there. The aerospace industry was new in 1960 and was created from the programs ‘launched’ (sorry couldn’t help it) during that decade. The implementation of electronic health records and similar technologies in the decade of 2011 will require a significant change-management effort. Our existing business model in healthcare is well established and resistant to reform. So don’t hold your breath for the savings.

Primary Care Physicians and their staffs are far too encumbered by routine workflows that prohibit the expenditure of time required to adopt these technologies, learn new processes for population management and deploy a tactical plan for sustainability in the practice. Folks like myself who spend time working directly with physician practices, hospital systems and outpatient services are aware of the ‘adoption barriers’ and feel overwhelmed by the scope of the task at hand. We spend our time assisting ‘systems of care’ with technology adoption; focusing our efforts on wise selection based on both direct and indirect investment. The education effort alone requires many HOURS of hand holding, before which many DAYS are spent addressing the cultural issues e.g. “we see fifty patients a day now, how is this going to help us see more”.

A fundamental problem is just that; “how is this going to help us see more patients?”

Our economic rewards model in healthcare is askew. Physicians and hospital systems have readily used new technologies and procedures to expand revenues in the past (which only makes sense) and the ‘not for profits’ have used these revenues to offset losses from care for our indigent (becoming more and more of us huh?).

The interested reader will note that payers (insurance company’s etc.) have recently adopted the use of pay-for-performance initiatives which are the starting point for reimbursement reform. These programs require data collection both from claims systems and the point-of-care thereby requiring expensive human capital. I am not sure if any of the programs have addressed these costs when calculating investment returns. An additional third tier for payment is now being considered wherein physicians will receive monthly case-rates for managing complex patients like myself. This blend of incentives: pay for procedure + pay for outcomes+ pay for services such as care coordination makes blatant sense.


Unfortunately- with the additional workloads associated with the new model it will become necessary to implement information systems which allow physicians to manage a population of patients as well as -one case at a time-. Since doctors are overwhelmed with tasks; decision support systems at the point of care will facilitate safer, more cost effective transactions between patient and provider. This is all common sense, right?

“BUT WAIT” you say! “Why do we need to do all of this?” ………………………Well, I won’t insult you with data, but you will note we do more procedures, use more new drugs and spend thousands more per capita yet have no significant difference in our health outcomes when compared with European nations. I call this the CABG (Coronary Artery Bypass Graft) factor: Revascularization procedure volume has no relationship to coronary disease mortality rate. However the Primary Care Factor does and it is well established that a tight bond with a primary care practitioner facilitates improved health outcomes. You will also note that pharmacy costs in our country are $752 per person vs. $424 in Switzerland, so perhaps if we do less surgery, use fewer drugs and establish a culture of mutual partnership between patient and primary care physician we will begin to see a reversal. Of course the problem with this is the fact that it ‘stinks of HMO methods’ similar to those of the early 1980’s –remember Gatekeepers! Good-luck getting the providers to take full risk on their patient-panels again!

So which policies should we consider to back off a $ Trillion or so in our annual healthcare budget. I imagine our administration has focused on the primary-care coordination model and electronic prescribing initiatives for this reason: Primary-care and patient relationship and decision support during treatment is the low hanging fruit.

If you ask your doctor today: “how many diabetics do you have that are in poor control” he or she will take a wild guess. If an electronic health record is in place however you will get an answer such as: “less than 20% of my patients are in poor control and we update our list to invite them to education sessions monthly; those who miss appointments are called the day before with a reminder.”

If electronic prescribing is in place the physician is presented with the patients formulary as the prescription is written thereby increasing the likelihood of a generic prescription (see France above). Furthermore, the patient’s entire drug history is presented and a ‘status filled’ flag is sent to the system when the prescription is picked up at the pharmacy. You can imagine the bearing on direct cost and indirect costs e.g. complications from non-compliance that can be achieved in this case.

The problem is: How the heck do we incent our practices to run a report to determine the phone numbers of all patients who did not fill their prescriptions last week then make a phone call to determine the reason? This is where we will need a sincere change management plan for our existing doctors and a method to introduce the strategies into our medical schools (already in place in many).

Ultimately, if we succeed we might see a multi-billion dollar savings. The pressure of course will be exerted downstream on our pharmaceutical manufactures but that is the topic of another note.

If we save even $50.00 per person (a far cry from the $328.00 between France and us) it would calculate to many billions of dollars (approximately $12B I think). This will probably cover the expense of adopting e-Prescribing on common web-native architecture.

So, the technology alone will not account for the savings. The technology AND cultural change AND economic reform will. What I fear is that in three years the American Citizen will hear about the billions of dollars wasted on healthcare information technology without carefully considering the variables and time course for measuring the impact.

Shalom to all,

Jeffrey Halbstein-HarrisAntevasin Consulting GroupAssisting communities to monitor and improve healthcare919-805-1901 Cell919-779-7368"Go to the people, live with them, learn from them....Start with what they know, build with what they have...."Lao Tzu