Skip to comments.Let's Move Medicine Into the Information Age
Posted on 06/29/2006 7:59:52 PM PDT by neverdem
At a Department of Veterans Affairs Medical Center just a few miles from my office in the U.S. Capitol, you can glimpse a piece of American medicine's future. Sitting at an ordinary desktop computer, Dr. Ned Evans hits a few keys on the keyboard and clicks his mouse a few times. Sample patient data spill out: X-ray images, lab notes, and blood pressure numbers. "Everything I might want, everything I need, I can see right here," he says. "It's a seamless part of life. It lets me do just about everything better."
And when the New England Journal of Medicine used 11 measures to compare VA patients with Medicare patients treated on a fee-for-service basis, the VA's patients were in better health and received more of the treatments professionals believe they should. According to the VA's own medical professionals, a computer system called Vista is the key to their success. "I'm proud of what we do here, but it isn't that we have more resources," explains Sanford Garfunkel, the director of the Washington VA Medical Center. "The difference is information."
While it's a glimpse into the future, the VA's computer system isn't a breakthrough. Everything the VA's system does has been possible for some time. I used electronic medical records myself 15 years ago to track the complex regimens of pills and procedures I used to treat my heart transplant patients. I published papers based on the data I collected, and feel I did at least a little to advance the science of transplantation as a result. Given how much data it requires, it seems likely that transplant medicine would have developed much more slowly without computers. But the use of information technology in medicine simply hasn't lived up to its early promise. Even today in transplant medicine, there's no common standard for sharing or keeping data.
Many of our doctors and hospitals remain stuck in a medical stone age. While people speak of a medical "system," American medicine is in fact very unsystematic: It lacks the standards, measures, and ability to exchange information that constitute a true system. Even where the VA and other organizations like Kaiser-Permanente and Utah's Intermountain Health Care have built systems, the systems canÍt communicate with each other or exchange records. While the VA has invested a lot in its computer system, most hospitals haven't invested enough. Among America's important economic sectors, health care spends the smallest percentage of its revenue on information technology--only about 3 percent. Industries such as banking spend 10 percent or more.
Doctors have embraced every kind of clinical technology from digital thermometers to MRIs and CT scanning machines. But the information side of medical practice remains a generation behind the rest of our economy. I still write prescriptions and keep records much the same way my father did 70 years ago. Most of my fellow physicians had very little computer training in medical school, and many still see the computer as a distracting intermediary between them and their patients.
The medical profession's failure to embrace information technology have had catastrophic consequences. Primitive recordkeeping drives up costs, makes it nearly impossible to measure quality, and undermines the control that patients want over their own health care. For the overwhelming majority of Americans, these are the three biggest problems with health care. Moving medicine into the information age can begin to solve all of them.
A revolution in information management has lately remade numerous sectors of the American economy, while passing by health care. Take one example: by making better use of information technology, the nation improved shipping so much that the percentage of America's GDP spent on logistics fell from over 14 percent to less than 10 percent, while new procedures like overnight shipping and just-in-time delivery became an integral part of daily life. Telephone companies, airlines, retailers, and banks also charge less for services that are better than they were in the past, to a considerable degree because of advanced computerization.
Health care, however, has moved in just the opposite direction. Fifteen years ago, Americans spent less than one dollar in ten for health care. By the end of this decade, nearly 20 percent of our national income could go for health care. Some of the increase was probably inevitable because our population is getting both older and more affluent, and because new medical advances require more resources. But much of the medical cost explosion is linked to waste--in particular, misdirection of resources due to a persistent underinvestment in health information technology.
Researchers at Dartmouth College have found that America wastes as much as a third of the $1.8 trillion we spend on medical care. Without up-to-date clinical data, doctors often need to reorder tests that others have already done. Without good aggregate information about which procedures produce good results, doctors sometimes perform unneeded surgeries or prescribe drugs that do little to prolong or improve patients' lives. Much of this ineffective, squandered, and duplicative effort could be eliminated if we just had better records and sharing of information.
Even worse, American health care leaves us with almost no way to tell the difference between doctors and hospitals that provide superior care and those that need improvement. Some doctors who provide substandard care may get paid well for it; some who provide superior care may be underpaid. Right now, financial incentives are, at best, loosely linked to the quality of medical care a doctor or hospital dispenses. This lack of quality control explains many of the weaknesses in our health care system.
Sometimes our failure to use technology has deadly consequences. Doctors write about 2 billion prescriptions each year, but because of unclear handwriting, some get filled incorrectly: about 7,000 people die annually as a result. Under the Medicare bill the President signed in 2003, however, we've begun the process of rolling out a national electronic prescription system that should eventually eliminate many of these problems. But even properly filled prescriptions can sometimes be dangerous: Without a way of accessing a patient's drug records, doctors have no way of knowing what medications he is already taking when he shows up at an emergency room.
I have personal experience with the difficulty this lack of information can cause. As a cardiothoracic surgeon working on the cutting edge of medicine, I would send transplant patients home with as many as 15 different prescriptions. Their doctors, mostly family physicians working in rural Tennessee, had little hands-on experience with the just-evolving field of transplant medicine. Sometimes, they would prescribe drugs that would interact poorly with one of the prescriptions I had written. Often, these treatments would make patients worse and result in emergency room visits. Simply because good, transferable records weren't available, patients ended up needing thousands of dollars worth of additional care.
Right now, American health care often takes doctors and patients out of the loop and replaces them with bureaucrats from insurance companies or the government. While managed care, for instance, may save money, it also stops many people from choosing their own doctors. Pressed for time and the need to do endless paperwork, doctors and nurses can't devote as much attention as they would like to their patients.
Other forces also interfere with the doctor-patient relationship that should lie at the heart of medicine. Some predatory trial lawyers have created a litigation lottery that drives up costs for every doctor in the country, while often failing to compensate people who experience real problems. Arbitrary litigation leads to the practice of "defensive medicine" on an enormous scale: Rather than risk getting sued, many doctors order unnecessary tests or avoid doing risky but potentially lifesaving procedures. As a result, everyone suffers and the quality of medical care declines.
Better medical records could be invaluable in separating inferior physicians from better ones. They would provide a clear paper trail to track doctors' decisions and medical actions. And they would give patients more control over their own information and course of treatment. Today's lack of information leaves many people feeling less secure: If a traveler gets into a car accident a thousand miles from home, the emergency room he arrives at should have a system that can bring up his full medical history, allergies, and information about the medications he takes. Right now, it's very unlikely the doctors treating this patient will know anything about him.
The case for action
The problems with America's health care system did not develop overnight, and we cannot deal with them instantly. Moving the entire medical system into the information age will take time. Fixing things will require commitment from the government and private insurers, from the medical community, and from Americans who use health care.
Medicine has remained behind the times in large part because we have no uniform standards for keeping medical records. The government needs to take the lead in creating such standards. Right now, every hospital, doctor, and residency program uses slightly different terminology to describe and code an individual's problems. One group might refer to pain in the "thoracic cavity" while another might refer to "the chest."
Private efforts to standardize medical records and share them electronically have failed repeatedly because they never provided any real benefits to the medical profession: For the vast majority of doctors, it remains easier and probably better to keep records by hand than to use most existing computer software. After finishing a heart transplant at 5:00 a.m., I didn't want to spend another two hours entering every bit of data about the procedure into a computer, particularly since I knew that I wouldn't be able to share it. I did it anyway. But I could understand why many of my colleagues didn't. Today's lack of a uniform set of recordkeeping standards puts sharp limits even on good systems like the one at the Department of Veterans Affairs hospitals: Doctors can electronically search patients' records all they want, but without a standard vocabulary, they may not always find what they look for.
The Senate has passed legislation I developed along with Senators Hillary Clinton, Edward Kennedy, and Mike Enzi, which will begin the process of moving America toward a national system of electronic medical records. The House plans to consider the bill in June and I hope that the President will sign legislation before the end of 2006. Making such a system work everywhere will take additional computers and software and fiber optic cable. But much more, for the system to work, government will have to set standards for everyone to follow. The private sector has tried to do this for over 20 years, and still hasn't managed.
Our measure allows doctors, nurses, medical technicians, patients, and medical administrators--the people who know health care best--to design the format for electronic medical records. Once the standards exist, the government will need to lead by example. As our single largest health insurer--the government pays slightly more than half of all medical bills in this country--federal officials need to make sure Medicare, Medicaid, the State Children's Health Insurance Program, and the Indian Health Service take the lead in using the records for all of their beneficiaries.
The government can't create the system entirely on its own. The medical profession needs to play an active role. First, doctors will need to overcome their reluctance to use electronic medical records and work to create a standard they can accept and use. Second, state medical boards and medical associations need to make sure that every doctor gets training in how to use electronic medical records. Use of information technology needs to become a part of continuing medical education for every physician in the country. Doctors will also have to accept increased scrutiny; publicly available measures of treatment, patient outcomes, and quality will bring much more transparency to the work of doctors. The bill I helped write will begin some preliminary experiments at rewarding doctors who provide better-than-average care.
Equipped with better information, consumers will also need to take more responsibility for their own health. Individuals will own their electronic medical records, and a combination of legal and technological safeguards will make sure that, except in life or death emergencies, nobody else can access them without permission. This, in turn, will require patients to play a more active role in medical care: All of the information in the world about medical quality will do little good if people don't pay attention to it and act upon it. Giving doctors better information won't fix all our problems unless patients have a better idea of how to work with their physicians.
For far too long, America made the mistake of investing little in health-related information technology. It's long past time to move the entire nation towards health care that's truly systematic and working in sync with our information-age economy. If we create a privacy-protected electronic medical record for every citizen who wants one, we'll not only save money, we'll save lives.
Bill Frist is a heart and lung surgeon, and U.S. Senate majority leader.
How about we get GOVERNMENT OUTTA HEALTH CARE!!!!!!!!!!!!
Killing the passive smoking debate Fumento also discusses the 39-year study of 35,561 folks exposed to second hand smoke which found nada. I linked the BMJ article in comment# 64 on the thread.
From time to time, Ill ping on noteworthy articles about politics, foreign and military affairs. FReepmail me if you want on or off my list.
Many of those same V A patients had their SSNs compromised with the theft of a single laptop computer.
Your well-intentioned plan represents an attractive target to some quite talented computer security pirates (foriegn and domestic.)
How long would it be from the time that your electronic system was first instituted to the time in which Hillary Rodham (who has an apparent interest in other people's files) would be able to peruse your prescription records?
No thank-you, Dr. Frist.
Good to have *minimal* govt involvement in health care, so while Frist's ideas have enormous merit, the govt should serve only as a broker/facilitator/test-bed funder of the best ideas toward making this vision happen.
Beyond proof of concept, the dollars ought to be spent by the private sector only. I think there is a place for govt to fund high risk/high reward ideas that industry might not otherwise; this seems like a prime example. (But let me stress that, unlike the space program, I'd like to see the dollars spent limited by ORDERS of magnitude! Proof-of-concept needs to be carefully circumscribed...)
The govt can also be helpful by assisting with various indemnifications and tort reform--isn't this the point? The structural defect in healthcare torts should be obvious to one and all: countless people suffer because of stone-age healthcare IT record-keeping and information coordination, yet tort lawyers have no deep pockets to punish, so they can do nothing to fix the problem. (Yes, I know, GAG, shows just how despicable the tort leeches are).
What I'd most hate to see is that this vision becomes the sugar that speeds universal health care (cough, rationing, cough) down the throats of the american people. Wasn't the revolutionary cry 'give me LIBERTY or give me death'? Yammering for govt control of healthcare is kind of like saying, Give me SLAVERY (to crappy healthcare), or in other words, death!
Hmmm, not a bad tagline...
I hate our medical "system." I'll hate it more when they can electronically TRACK me....because then they will be better able to know that I'm Doctor "shopping"....i.e. shopping for a doctor with an independent brain who thinks outside of the box and doesn't solve every problem with a prescription drug. I see little good coming from ELECTRONICALLY tracking my records. I only see further control of what we can and cannot do to solve our own medical problems. I'm sure the past 2 years of my records had they been "electronic" would be a red flag to SOMEONE in government or my insurance company. Because, you see, THEY are the experts, NOT me.
Thanks for the ping!
I don't want Hillary with that power...Just imagine some political hack having access to every medical complaint (physical or emotional)...
Sounds good but wouldn't the DNC consider an election a life or death emergency?
Me neither because of privacy concerns, but HIPAA is law already.
Ah, but 70 to 80 percent of what we Family docs see are viruses or social problems.
The CT of your coronary arteries will tell if you have plaque build up, but we Family docs are the ones who know you smoke 2 packs a day because you work three jobs and have a menopausal wife who is driving you to drink and a girlfriend who makes you hit the viagra and give her expensive gifts...
A lot of the diagnoses depend on history and it takes time to get a history...alas, these "EFFICIENT" types are great if you have a major problem, but for monitoring and caring for people, you need a relationship.
I suspect the way the social planners want to go is nurses and PA's to do the routine stuff, and technology oriented superdocs to diagnose the fancy stuff.
Let's move treatment techniques, doctor/hospital performance, prescription success/failure, nursing home performance, success/failure, psychaitry performance success/failure, and prevention techniques into the information age.
Privacy-protected electronic medical records for every citizen (who wants one?...raise your hand)? Totally unnecessary.
As a general rule, I share your concern for the potential to abuse or compromise confidential, personal information in electronic medical records.
One of the cliches that I heard in training is that "history is ninety percent of the diagnosis." For routine problems with patients who can give a history, most of the time you can get by, for the time being at least, without a complete medical history. Once things start to get complicated, the patient can't give any history or both, then a complete, organized medical record is priceless. Without a good medical history, it must be more like veterinary medicine.
A little over ten years ago while I was a resident, I was called during the night to admit a patient who was minimally responsive in the ER. She had already been intubated, i.e. a breathing tube was placed, three times, but she removed the tube twice also vomiting in the process. After the second removal, she had been restrained. That happened before I got to the ER. The patient's family had already gone home. IIRC, she was a 35 year old female, and the admitting diagnoses were change in mental status, pneumonia and secondary aspiration pneumonia. The patient had a CT of the head to rule out stroke, lumbar puncture to rule out meningitis, blood and urine cultures to rule out sepsis, and all of the usual chemical analyses of blood and then some to rule out metabolic and toxicological disorders. The patient was admitted to the ICU and given broad spectrum antibiotics. She had all sorts of consults from subspecialists, i.e. pulmonologist, neurologist, renal, etc. Tests for antibodies to various and sundry pathogens were ordered.
I followed the patient informally, as was my wont for patients that I admitted while I was on call overnight, as I was doing a cardiology rotation at the time. Everything was coming up nada, and she was in the ICU for 2 weeks already, still intubated and going nowhere fast. Rounds were over, and I had time to kill. So I went through her chart, which weighed enough to be a doorstop. After at least an hour or more, I found a hard copy of the thyroid function tests that I ordered on the night of her admission 2 weeks prior. Then it usually took a few days to get the results. All the results were abnormal, IIRC, especially the below normal thyroid stimulating hormone. The unit's clerk didn't catch it, nor did the intern or the attending physicians. It was placed in a mess of other lab results, unnoticed until my obsessive - compulsive traits got the better of me. An endocrinologist was called to see the patient.
The patient was extubated and out of the ICU in about a week after being started on thyroid replacement therapy, IIRC. A medical student learned from a family member of the patient that during her last pregnancy the patient had a spontaneous delivery at home where she had been found alone in pool of blood. Checking her outpatient chart from the clinic showed that after that near disaster she had been complaining of no periods and blood tests showed a stable, mild anemia on two different visits. Each time the patient was lost to follow up. The patient had Sheehan's syndrome, aka postpartum pituitary necrosis. A neurologist also diagnosed anoxic encephalopathy, aka hypoxic encephalopathy, and she was transferred to the traumatic brain injury unit for almost three more months of rehab. Two CT scans of the brain were reported as normal. When the MRI was ordered, rule out Sheehan's Syndrome had to be suggested. It did not rule out. I wished I caught a look at the total bill.
How about a medical history that a potential patient could fill out on their own if they chose, could be scanned or downloaded from their own PC onto a disc or similar device that would be carried on them like a credit card or dog-tag and read (only) by a hospital or medical office computer when necessary (as opposed to a national database)?
On the same note, this information age allows one to have consults from doctors all over the U.S. For example, just two weeks ago I electronically sent my MRI's to a specialst to be read all the way across the country. I have to have labs done multiple times a week and they are sent to another specialist quite a distance away immediately, plus I get a copy electronically. I would not have access to these results nor would I have the advantage of picking known specialists who can help me much quicker than my local doctors (who encouraged me to do this). I can participate actively in my own diagnosis and treatment, and I have an active choice in specialists that are few and far between. This lady would have benefitted from that. The neatest thing about this is my insurance company had totally supported this, and according to one lady with whom I spoke, it is actually saving them money because of less time between diagnosis and treatment. The same HIPAA standards apply. The technology has been a life-saver for me.
You would be surprised at the number of folks who can't tell you the names of the drugs, their dosages and the number of times a day that they take them for chronic illnesses. Sometimes you get comments like, "I take a little red pill for arthuritis and big blue for pressure." If they had a computer, they wouldn't know what to do with it. Extracting relevant information is like pulling teeth. Having all prior medical history, prior surgical history, current medications, doses and frequencies, not to mention herbal, over the counter drugs and health supplements, social history, i.e. bad habits, and allergic and/or adverse drug reactions would be a godsend when the patient came in the door in extremis.
Maybe if they could get all of that in a standardized portable data file, is this the right terminology, pdf format, they could exploit information technology more profitably? Somehow they need physicians, nurses, lawyers that specialize in privacy and computer geeks that know how to protect access codes and passwords for competent patients to figure out how to generate a summary sheet or status report with a way to correct any prior misdiagnosis.
Believe me, I wouldn't be surprised. For those folks, a national database probably doesn't matter anyway. For the rest of us, it is totally unnecessary.
Great example of information technology at its finest. Thanks.