Will Healthcare IT Mean Better Outcomes for Patients and Providers?Published: March 24, 2009 in Knowledge@Emory
Originally Published - 2005
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.”