What’s Wrong with Our Health-care System? Part III
In Part II of this series, we examined the role of cost-effectiveness in medicine. In this part, we take a look at infrastructure, primarily electronic Health records (EHR), and incentives—pay for performance (P4P). In the USA, thus far, EHRs have made little difference, with a few exceptions, notably the Veterans Administration and a small number of institutions (Frieden & Mostashari, 2008; Kupersmith et al 2007; Asch et al 2004; Linder et al 2007; Chaudhry et al, 2006; Shekelle et al, 2006). Since EHRs have been touted as the best thing since the discovery of penicillin, why are we not making much progress? The first thing we need to discuss is what an EHR is, since not all EHRs are created equal.
The Institute of Medicine defines an EHR as a system that includes:
(1) longitudinal collection of electronic health information for and about persons, where health information is defined as information pertaining to the health of an individual or health care provided to an individual; (2) immediate electronic access to person- and population-level information by authorized, and only authorized, users; (3) provision of knowledge and decision-support that enhance the quality, safety, and efficiency of patient care; and (4) support of efficient processes for health care delivery. Critical building blocks of an EHR system are the electronic health records (EHR) maintained by providers…and by individuals (also called personal health records) (NIH Committee on Data Standards for Patient Safety. Key Capabilities of an Electronic Health Record System: Washington, DC: National Academies Press 2003).
Originally the idea of an EHR was to replace paper records that were becoming too voluminous for systems to handle, and horribly inefficient to search. But, as the concept evolved and was put into practice, it became evident that EHRs could be much more. Some of these degrees of sophistication are reflected in the levels of EHRs, which imply also the degree of integration with other systems, and capability.
It is estimated that of all the physicians in small practices, only 5-10% have EHR systems. Yet, these physicians are probably the group that could benefit most. So, why has implementation taken such a long time? For one thing, EHR systems are not cheap. For example, it could cost $20 billion over the next 5 years just to equip health care services in this country with EHRs. While this is not chump change, it is only a fraction of the $50 billion originally envisaged by the Bush administration for the Iraq war, which will cost the U.S. at least $2 trillion when all said and done. The second obstacle is training–training all these physicians to use the new systems and change their operations to take advantage of what can be achieved. That is a lot of investment in time and resources, and does not take into account the resistance of changing long-held ways of doing business. In addition, the use of EHRs has to be better integrated into P4P programs.
A basic P4P program would reward physicians for following clinical practice guidelines based on the information they gather from patient EHRs. So far, though, particularly for pilot P4P programs that are CMS-based (Centers for Medicare and Medicaid) the results are lamentable. Lets imagine, however, what is possible.
An obese female patient aged 34 comes into a physician office complaining of a multitude of symptoms that the physician recognized as incipient type II diabetes. Because her health service facility has a well-designed P4P program it recognizes that an ounce of prevention is worth a pound of cure. Not only does our physician properly diagnose our patient’s disease, but taking into account all the clinically available information on the EHR system, prescribes several prevention programs for our patient to lose weight and change her lifestyle, based upon EBM, and which is paid for by the healthcare facility. Tracking programs within the EHR system also encourage the physician to make follow-up appointments to see if the patient is really following the medical advice that has been dispensed. The physician gets paid a bonus for the patient when she avoids all the horrible comorbidities that come with type II diabetes, and the patient gets better. A win-win situation. The physician does not spend 10 minutes prescribing a bunch of expensive pills, either, since the EBM data available in the HER system tells her this isn’t worth it. Fiction? Perhaps for now. But if we’re ever going to get a handle on health care costs and improve outcomes, this has to happen.