The following thoughtful review article on the reasons for the slow adoption of health IT appeared in the New Atlantis Magazine a few days ago (The issue for Winter 2008 -Number 19).
The article was written by James C. Capretta, who is a fellow at the Ethics and Public Policy Center. He is also a policy and research consultant for health industry clients.
The Clipboard of the Future
Why Health Care Records are So Low-Tech
The electronics and computing revolutions of the past several decades have reshaped much of medicine, giving us advanced imaging techniques, microchips for monitoring and regulating heart function, and countless new diagnostic tools—not to mention the ubiquity of computers in the labs where basic research is conducted and new treatments are developed. But while the practice of medicine has been transformed, the information infrastructure of health care lags behind. The clinical information system, consisting of patient records and the data needed for determining what constitutes effective medical practice, remains decidedly low-tech. Just about every other American industry—financial services, travel, entertainment, communication, you name it—has been radically remade by new information technology (IT) applications in the last two decades. But not health care.
Most Americans have instantaneous access to their banking records over the Internet. They can see cancelled checks, pay bills, switch investment portfolios, and schedule alerts to help them stay on top of their finances. But they never see their medical records, do not have ready access to their children’s immunization history, forget the last time they had their cholesterol checked, do not know if their blood pressure is normal or elevated, and generally have no idea what all the tests they have had over the years mean for the likelihood they may face a serious illness, like cancer or heart disease.
In a field as important and data-dependent as health care, this lack of useful and reliable information is difficult to understand and accept—especially since the needed data is generally collected and stored, just not in a format that is usable.
The problem starts in doctors’ offices. Most physicians—at least four out of five, according to researchers at RAND—continue to keep their patients’ records on paper or in isolated computer files which cannot be shared or accessed by others. When doctors see patients, it remains the norm to fill out a paper form to record their observations. When a diagnostic test is performed, even if a report is generated by a computer, a paper copy is what gets kept in the patient’s file. No electronic copy is transmitted to the doctor or the patient. When the patient is sick and needs a prescription drug, that too is written down, with a scribbled note given to the patient to take to the pharmacy, and a copy or similar record placed in their file.
All of this data could be permanently recorded electronically, but it generally isn’t. Moreover, those doctors and medical institutions that do store their clinical records in an electronic format do so mainly for their own internal, operational reasons. By and large, this data is not accessible by patients, and, more often than not, it cannot even be shared with other health care professionals using computerized recordkeeping because there is no uniform standard for medical data systems.
The paper-based nature of most medical records can make coordination among a team of physicians attending to a patient much more difficult than it needs to be. Frequently, when a patient goes to see a specialist for the first time, none of the records kept by his primary care physician are accessible to the new doctor. The specialist will typically order a whole new series of diagnostic tests to ensure the file he starts contains records he can trust, even if the same tests were just performed at the request of the other physician. Not only is this duplication costly, it also undermines quality care, as the patient is in danger of getting conflicting treatment plans based on competing and incomplete patient records.
Paper-based clinical records also hinder the evaluation of what should constitute standard medical practice. Today, much of what physicians do for patients has surprisingly little support in clinical evidence. New technologies, surgical procedures, and drug treatments are all too often brought into mainstream medical practice based on narrowly-constructed trials and intuition, not hard evidence. With patient records stored on paper instead of on computers, it is much more difficult to aggregate and analyze the actual data in order to determine what works and what doesn’t work in the real world. Consequently, as cost increases put pressure on family and government budgets, the country remains poorly equipped to make distinctions between wasteful and necessary services.
Continue reading this excellent contribution here:
http://www.thenewatlantis.com/archive/19/soa/medicalrecords.htm
Having read this through all I can do is say well done. The key issues have been canvassed and considered at an appropriate policy level and I think the suggestions about the barriers to adoption and how to overcome them are sound.
A good read.
David.
James C Capretta has hit more than one nail on the head. His view of the world is that of an American. “The problem starts in doctors’ offices.” At least four out of five, physicians “keep their patients’ records on paper or in isolated computer files which cannot be shared or accessed by others.”
ReplyDeleteAustralia is a little better in that virtually all practices generate prescriptions electronically onto paper and a large proportion receive and store some patient clinical information (such as pathology results) in the practice computer even if only in a simplified format. This suggests Australian doctors are possibly somewhat more advanced than those in the US in the deployment of clinical based systems in medical practices. Although many Americans would prefer not to believe that could be so.
But is this advanced state of 'enlightenment' of much benefit to the patient?
As James points out WebMD and Revolution Health are high profile organisations. They are Internet-based businesses and they want to be on the cutting edge of consumer-empowerment in health care. But so what?
The consumer can subscribe to any number of Internet-based personal health record facilities. Some have been around for years in one guise or another. But so what? The consumer can approach their doctors and ask or tell them to send all their medical stuff to their online health record - but are these patients’ doctors going to use it? Why should they? What’s in it for them? And how easy peazy is it for them to do so?
If 80% of physicians in the US are so far behind ‘other industries like banking’ then empowering the consumer without empowering doctors will be an exercise in perpetual futility.
So the issue becomes one of ‘How do you empower the doctors?’ and ‘How do you empower the consumers to empower the doctors? And ‘How do you empower the doctors to empower the consumers?’ and ‘Are the doctors the only health professionals who need to be empowered?’ Sleep on it.
Why is it taking so long is very much the central question if the imperative for dramatic improvement and the desired goal are both clear. As he suggests money certainly is part of the problem, but what about power and control? Does the doctor really want the patient to be ‘in control’?
ReplyDeleteAs a patient I think I should be a lot more in control than I am. If my doctor doesn't want me to be in control then I will find one who does. But that's easier said than done with the current doctor shortage so I guess I'm stuck. Quite often when I have contact with the health system I feel disempowered, helpless and sometimes quite intimidated, although I don't really think I can do very much about it. Friends tell me that's just the way the system is.
ReplyDeleteThe main beneficiaries may well be the patient so why should the doctor pay anything? And if it’s the patients will they pay the price and if so how much?
ReplyDeleteYes and he also said doctors stand to lose their monopoly control over clinical information and get paid nothing more for their efforts. Which posits the question - Does anyone know of a business model that counters the latter and a culturally sensitive service delivery model that addresses the former?
ReplyDeleteThank you David, what an excellent article, certainly well worth the read. Three decades ago in 1977 the visionaries were clearly ahead of their time. What we didn’t appreciate back then was the complexity of the task which lay ahead. We were also were working with prohibitive constraints imposed by the technology available at that time. Those constraints no longer exist. On the other hand however the health system in itself has become even more complex, thus building new barriers to progress.
ReplyDeleteThe world of IT usually moves like a hare but at other times it can move like a turtle. The turtle is more evident in health, than in most other industries; often for very good reasons. The impediments to progress, in the health sector, are not rooted all that much in technology. Rather, the barriers are a complex combination of strategic, cultural, political, and commercial issues. Unless these are appropriately addressed it could quite easily be another decade or more before the EHR and PHR become the norm; through the ubiquitous spread of electronic clinical record keeping systems which are integrated and inter-operating seamlessly, one with another.