Here’s a little quiz for you. U.S. hospitals' errors kill more people each year than:
A. Breast cancer
B. HIV / AIDS
C. Cardiovascular disease
If you guessed A or B, you’d be right; and you’d be in the minority who recognize just how dangerous a place hospitals can be.
Healthcare is a classic information-driven industry. Yet until recently, it suffered from a dearth of technology to support those we entrust with our lives. To reduce the avoidable harm we do and improve efficiency and effectiveness in healthcare delivery, the American Recovery and Reinvestment Act of 2009 (ARRA) stipulated that hospitals and other healthcare providers adopt technology to meet what are called Meaningful Use criteria. As part of this program, every eligible provider in the United States was offered between $44,000 and $63,000 if they adopted technology to support meaningful use.
In my opinion, this is where ARRA went a bit awry. Meaningful Use is, in fact, not the best goal for healthcare. Meaningful users are.
What is the difference? Meaningful Use is all about what the system can do, while meaningful users are all about how you actually use the system. And those are very distinctly different activities.
Of course, technology adoption incentives did a lot of good to get healthcare practitioners to adopt technology. Electronic prescribing, which is one of the requirements of Meaningful Use Stage I, has been a tremendously good thing. It has rid us of doctors’ bad handwriting on a prescription pad, which by itself was responsible for a disproportionate number of medical errors that caused harm. Five years after ARRA, the majority of prescriptions are written via e-prescribing, and it has saved thousands of lives.
The flip side of Meaningful Use is that the vendors of these systems recognized that ARRA represented a once-in-a-lifetime opportunity to gain market share. Interestingly, I think the net effect has been to slow down technology advancement dramatically. Resources moved disproportionately away from R&D and into the land grab for market share. Nearly five years after Meaningful Use began, I have seen little progress in how e-health systems look and behave because everyone’s focus has been to “get that customer who’s not using our system onto our system.” This is in part because every vendor understands that once you have your patient records in one vendor’s proprietary format and system, the effort to switch vendors is significantly raised.
Sadly, the result is that most e-health systems still build on technology that is circa 1980 or at best 1990, and nearly all of them began as billing systems. That’s where the priority was. The most common database in use today in hospitals today is MUMPS, which was developed in the late 1960s at Mass General Hospital. Yes, it has low overhead and doesn’t require a sophisticated data base administrator to keep it running. However, there are real limitations to what you can do with technology that is more than 30 years old.
At the heart of the issue is that almost all the Electronic Health Record companies began as billing companies. In fact, until the past two decades, most hospital CIOs reported to the CFO, a structure that today is an anathema to quality care enhanced by technology. Medical billing in the United States has been historically driven by transactions with two distinct nomenclatures; the International Classification of Diseases (ICD-9) and the Common Procedural Terminology (CPT-4) code sets.
Systems were built to optimize revenue around the volume-driven rewards upon which the U.S. fee-for-service sick-care delivery network was built. The higher the burden of illness (more, and more severe ICD-9 codes) and the higher your volume of procedures (more, and more complex), the more money you could make. I’m not just talking about small differences, I’m talking about 300 percent+ differences in cost for caring for the same diagnosis in different parts of the United States.
When you have systems optimized for reimbursement of transactions you lose the most important part of medicine: caring for the whole patient. That is the real opportunity for the near future; and the group that figures it out stands to make more than just money: They will make more of a difference in healthcare delivery than any Nobel Prize winner of the past.
Healthcare IT must organize meaningfully around the patient
Although the recent Ebola case in the United States could have been much worse, I found it interesting how the initial reaction from the healthcare institution was, “The electronic health record (EHR) system had a bug, and it did not alert the doctor to the foreign travel history obtained by the nurse.” The EHR manufacturer quickly responded with, “The system was installed and configured exactly as you chose it to be.” And what was that configuration? Doctors don’t see nurse’s notes. This is a great case in point about the shortfall of a meaningful use mindset and the different outcome we might have seen with a meaningful user one.
Most EHR installations are nothing more than an electronic version of a traditional paper-based medical record. For those familiar with paper charts, there is a tab labeled “doctor notes” and another labeled “nurse’s notes.” It is a rare physician that reads the nurse’s notes. In many cases, I suspect that in implementing an EHR, separating out nursing documentation from physician documentation is an example of trading electrons for paper.
The right way to look at documentation is to say, “We’re documenting something to a common source.” If you’ve ever been a patient in a hospital, you know how frustrating it is to have five people ask you the same set of five questions when all of them are documenting your answers in different places, be it paper or electronic. The kicker is that there is absolutely nothing to alert you when what you’re documenting is substantially different than what someone else wrote down.
My view of a properly designed system would be to organize the medical record around the patient. When someone reads the medical record, they should be able to see that two people who examined the same organ had two different findings, which today is not how records are organized. Frankly, the data structures behind them are really not designed to allow that kind of display. But that’s where I think we will be in the future. We will stop organizing clinical documentation and findings by the person documenting, but will center it on the patient and the organ system to really understand where differences are. The real opportunity for better care is in the integration of information in a meaningful way.
As we approach Meaningful Use Stage 3, which now stretches to 2017 (and may go to 2018), I hope the industry will start to focus on users rather than use and yield a truly patient-centric, organ-centric approach.
A related hope is that some time in the next ten years, someone will be bright enough to recognize that there is a market for building a truly open, truly interoperable, truly flexible system that allows patient-controlled access to information and also connects to the myriad of regulatory and financial factors that systems have to connect to. It’s a tall order, but those who figure it out will be richly rewarded.
Jeffrey J. Guterman, M.D., M.S. is the Chief Research and Innovation Officer in the Ambulatory Care Network of the Los Angeles County Department of Health Services. He is a Clinical Health Sciences Professor of Medicine and Emergency Medicine at the David Geffen School of Medicine at UCLA. In Dr. Guterman’s former role as Chief of Ambulatory and Community Medicine at Olive View - UCLA Medical Center, he was responsible for developing and operating the primary and managed care delivery network in the San Fernando and Santa Clarita Valleys. His research focus on the application of information technology to enhance the efficiency and effectiveness of medical care resulted in practical and implementable solutions that are changing the way care is delivered.