Tag Archives: cost control

Step 1 – Opposing Views of EMR’s Ability to Improve Care and a Possible Synthesis

The Argument In Favor of: Computerized electronic medical records (EMR) will improve quality of care. EMR facilitates streamlining administrative processes, reducing overhead. Accurate and quickly accessible patient health information is a prerequisite to timely, informed, patient-centered medical care. Numerous studies have shown that CPOE can reduce medication errors and adverse events as much as 99%, increasing safety and reducing costs.(1) The ability for practitioners to access the same record in real-time from multiple sites or to send a record electronically to another provider puts potentially life-saving information where it is needed most. Decision support systems built on top of EMRs can support care by managing clinical complexity, controlling cost by suggesting less expensive alternatives, catching drug-drug or drug-allergy interactions, and promoting best practices.(2) EMR can help empower patients by connecting them to tailored health education materials. Other information intensive industries spend approximately 10% of their budgets on IT whereas health spends only 3%. If the health sector spent similarly, it would be able to realize significant gains.

The Argument Against: Electronic medical records rarely improve medical care and can even make it worse. Jeffrey Linder et al found that there was no association with presence of EMR and quality for 17 different measures, and this has been confirmed by other studies.(3) Providers who have experienced gains are generally academic medical centers whose results are not reproducible outside of that setting. In one example, Children’s Hospital of Pittsburgh rolled back a multi-million dollar CPOE implementation in the pediatric ICU after it was discovered that mortality had increased. Physician productivity can drop as much as 20% for the first 6 months after EMR implementation. A good ROI has generally only been obtained by large, integrated networks through savings on administrative overhead. Until technology systems mature and implementation processes improved, resources would be better invested elsewhere.

A Potential Synthesis: Electronic medical records are an enabling technology that supports cost-savings and quality improvement processes only if meaningfully and effectively used. David Cutler maintains that other industries required ten years to realize industry-wide gains from the use of information technology. The health sector started using IT later than other industries, but will be able to realize significant gains after clinical workflows and local cultures adapt. EMR data enables providers to do monitoring and evaluation and quality improvement that would not be possible otherwise, but business processes must be modified to take advantage of them. Providers should first implement technologies and features that have proven to be effective, such as CPOE, automated prescribing and dispensation. National “meaningful use” regulations, while imperfect and politicized, help guide physicians, health system planners and vendors on methods to increasingly leverage technology to improve health.

—-

1. Koppel, JAMA 2005; Bates, 1998; Pestotnik 1996.
2. Perreault L, Metzger J. A pragmatic framework for understanding clinical decision support. Journal of Healthcare Information Management. 1999;13(2):5-21.
3. Jeffrey A. Linder, MD, MPH; Jun Ma, MD, RD, PhD; David W. Bates, MD, MSc; Blackford Middleton, MD, MPH, MSc; Randall S. Stafford, MD, PhD. Electronic Health Record Use and the Quality of Ambulatory Care in the United States. Arch Intern Med. 2007;167(13):1400-1405.

Public Health Experts Need to Reclaim the Phrase “Preventive Medicine”

“Preventive medicine” is a hot phrase in discussions of health reform. If we just get more people (why not everyone!) screened we can find disease early and save money by attacking these diseases before they become serious and expensive.

But this use of  ‘prevention’ is expensive. Or said another way: There’s a lot of money to be made in this kind of ‘prevention’.

True preventive medicine prevents disease: Reducing airborne particulate matter and pollution prevents incidence of asthma. Funding schools to provide healthy meals prevents childhood obesity. Eliminating the use of lead in paint prevents abnormal development in exposed children.

We must recognize that health screening technologies are not tools to prevent disease; rather, they are tools of early detection of disease. In a sense they define disease. Indeed as screening tools increase in specificity, the thresholds in defining disease status follow in their specificity. Certainly, early detection may give the upper hand to the patient and provider who can implement treatments that reduce the likelihood of that condition becoming life-threatening. But do all abnormalities warrant medical intervention?

Screening technologies such as MRIs are become increasingly sensitive to discovery. In his book How Doctors Think, Jerome Groopman, M.D., cites a physician: “The hateful part of MRIs – I mean they can be a wonderful technology – but they find abnormalities in everybody.” No doubt, part of the rise in the number of chronic conditions can be attributed to our increased ability to find abnormalities, even though not all abnormalities may warrant a medicinal response.

Screening tools do not and cannot prevent abnormalities. They can only find abnormalities.

The primary driver of health care costs is medical technology. Earlier detection coupled with expensive (yet often unproven) interventions have reduced mortality while increasing morbidity. Indeed, many diseases which even 15 years ago would have been a death sentence have now become manageable chronic conditions (HIV/AIDS is an obvious example). This is a testament to our ability to innovate and develop life saving technologies.

Simultaneously, technology has improved our ability to detect ‘disease’ while ensuring chronic care management through pharmaceuticals and/or invasive intervention through biopsies and more. Today, more than half of all Medicare beneficiaries have more than 5 chronic conditions. Soon it will not be uncommon for the bulk of Medicare beneficiaries to have eight or even ten chronic conditions.

One article published in the New England Journal of Medicine notes:

The demands of the public for definitive wellness are colliding with the public’s belief in a diagnostic system that can find only disease. A public in dogged pursuit of the unobtainable, combined with clinicians whose tools are powerful enough to find very small lesions, is a setup for diagnostic excess… Clinical medicine can only say, “With the methods we used, we found none of the diseases we looked for.” No one can measure the absence of all disease. (emphasis mine)

The unfortunate reality is that it is possible to over ‘prevent’ (to use the expensive version of the word). What is needed is not a halt on innovation nor a moratorium on technology. Rather what is needed is a conscious assessment as to when to screen and when treatment is necessary.

The decision as to when to do what should be made between physician and patient, but information is needed to build suggestive guidelines. Health IT, allowing for the aggregation of (anonymous) data, can help.