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Better Care Through HCIT 101: Part One, Who Owns the EMR and Why Do They Care?

February 12, 2009
by Joe Bormel
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Better Care Through HCIT 101: Part One, Who Owns the EMR and Why Do They Care?





When Gwen Darling started her Social Media, multipart blog, I appreciated that she was leading something important at Healthcare Informatics. She was taking an important emerging topic, dividing it into bite- (blog-) size pieces, and serving it over time. Brilliant, well done and welcome.




Now, it’s my turn.




Somewhere along the way, I decided that part of my life should be committed to improving healthcare through better information and information technology enablement. I’m sure there are a lot of kindred spirits reading this. I’m neither alone nor unique.




As I shared in the bio that introduces my blogs here, I’ve found some important challenges that really bear group discussion. At times, these challenges can be obstacles. When that occurs, they need to be identified as such so that the three options – go around them, go over them, or go through them – can be framed and evaluated. Notice all my options start with “go” and don’t include apathetic inaction. Again, I’m neither alone nor unique from my readers!




My strategy is to post an installment about every two weeks, looking at specific challenges. In contrast to other blog styles, such as closing with a rhetorical question, or deliberately choosing a controversial aspect of a complex issue like privacy, I intend to close with what I take home as a small lesson from the topic. I’ve identified about a dozen of these topics; the next two installments I’ll be posting are entitled “My Garage” and “The Bell Curve.” Suggestions, reaction and dialogue continue to be welcome and important.




Today, I’d like to briefly explore ownership of electronic medical records. This question takes on new life in light of the Economic Stimulus Package. In an opinion piece, “

A Health-Tech Monopoly,” the author addresses the motivation for stimulus funding, and it’s not just job creation and/or otherwise fueling the economy --- it’s positioning for government-run healthcare.




The stimulus spending on EMRs is dubbed “a down payment on national health care.” Undeniably, this is one proven (by other countries) route to cost control. The opinion continues that, along with political the goal of cost control come price control, and denial of some treatments and drugs. See

Nadeem Esmail's " 'Too Old' for Hip Surgery " for several examples of potential implications.




My goal is not to address whether government control is good or bad; we’ve obviously struggled with this question and how to structure assuring basic care for the last century. Rather, it’s important to consider this perspective when looking at the economic stimulus for EMRs directly.




Both House and yesterday’s Senate bills are explicit about two things: “meaningful use,” and specific financial incentives. These are outlined with specifics for hospitals and physicians. There are also explicit penalties for non-adoption, starting in 2015 or 2016 (Senate vs. House timelines). And of course, the requirement of certified EHR technology and ability to report clinical quality measures (as specified by government). As part of reasonable disclosure, I need to acknowledge that I participate in several organizations that have provided recommendations which were considered in the language of these bills.




My conclusion for this post? Although the ownership and related adoption of the EMR is political center stage now with its economic stimulus funding, the tremendous economic impact of healthcare on government is the primary sub-text. When

Neal Ganguly and I discussed this last week, Neal framed the question as creating societal value (and avoiding wasteful, non-value spending). The lesson here is that we can never take the goals of EMR adoption for granted, or leave them implicit. It’s possible to achieve significant cost control with zero clinical decision support. Similarly, it’s possible to dramatically improve healthcare with clinical decision support and evidence-based care management, while simultaneously causing healthcare costs to spiral upward.




Let’s all keep up our professional leadership to ensure that our vision for better healthcare remains central, while simultaneously moving aggressively toward a sustainable economic model to pay for it, both supported by the EMR.






Topics

Comments

Jim,
Cost control in healthcare decisions is, unquestionably, the elephant in the room. So is the opposite way to frame that, demand induction. Somewhere in the middle is 'hope,' both rational and irrational.  And, of course, often irreducible uncertainty. 

The best case study I know of is the course and fate of APACHE, 2 and 3, as a means to classify end-stage clinical situations without emotions, in an attempt to bring balance to ICU decisions. I'm a big believer acuity tools to enhance fair and rational decision making.

As you know, some political leadership, both career and appointees have been and are trying to gain the influence you describe by framing their arguments in terms of clinical quality. In the grander economic scheme, politically it quickly becomes an issue of individual choice versus public health 'quality.'  Then, the lobbying and direct-to-consumer campaigns start.

Both of my octogenarian parents, have been offered very expensive procedures with 'interesting' rationales. To extend on the point you made above, Dartmouth's John Wennberg would not approve of those offers.

To be concrete, my dad's been offered surgeries to address three asymptomatic issues that each fail his preferences and EBM. He was recently told, in my presence, that he has a 15% chance of dying of all causes in the next five years, which reduces to only 5% chance of dying of a stroke, if he has an end-arterectomy. And, there's a randomized surgical trial to substantiate that claim. Obviously, you can't compare the 15% to the 5%; it's not a 10% reduction, it's apples to oranges.  I suspect his 'all-causes' mortality is still basically 15%, with or without surgery.

My mom's situation was a little more complicated. I advocate for both parents and others. I ended up agreeing with my mom's procedure. I've spoken to a handful of non-involved, practicing physicians. They've called out some important additional perspectives; getting opinions can be very valuable. My point is simple: there is a strong bias toward delivery of services in the zipcodes where my family lives.

I asked a department chair in a large, prominent health system.  He said this: There is evolving confidence that surgeons and anesthesiologists are developing with taking very old people, say 100, year old patients, in favor of taking them to the operating room for elective procedures. Their argument: "By the time someone has lived into their 90s, they obviously don't have bad genes, obesity, diabetic or coronary risks.  These patients are ideal candidates to benefit from joint replacements, carotid endarterectomies, and other quality-of-life or risk reducing surgeries." Humans are amazing.

Let me conclude by re-stating your point: If the goal is cost control, there are more influential places in our healthcare policy debate to start than incentivizing EMRs. Our friends at AHRQ couldn't agree with you more.

Perhaps the lesson is this:  At this point in time, EMRs appear to be one of the most politically expedient way to address our nation's crises.

In our role of blogging informaticists we seem to be drawn into these "political" debates which, as you point out, may have their heart and soul in a grander economic scheme. The great unspoken, however, is how we spend our healthcare dollars. We throw obscene amounts of money at the incurable conditions of our "end of life" patients. It is a politically taboo topic to discuss and bears too much sentiment for meaningful inclusion in any economic debates, yet it dwarfs the costs of implementing an EMR. Maybe as a physician I feel safer bringing it up, "Caring for people with chronic disease now accounts for more than 75 percent of all health-care spending. And over-use and overspending is not just a Medicare problem—the health-care system as a whole lacks efficient, effective ways of caring for people with severe chronic illnesses." according to a new report from the Dartmouth Institute for Health Policy and Clinical Practice. "The researchers, for instance, discovered staggering variations in the number of services that patients with severe chronic disease receive at the end of life, depending on the hospital, region or state and not on how sick they are." Maybe our politicians need to gather up the courage to tackle the entirety of healthcare economics if their real goal is to save the budget.
I fear that this is a bit overshare for our informatics blog, but it is getting harder to untangle the roles of politics, economics and care.

Thanks for elaborating I hadn't heard that part of your dad's story.

I mentioned 'hope' and the importance of hope very briefly. Hope, caring and subsequent outcomes, both good and not-so-good are extremely important parts of the practice of medicine. Clinical decision support, like APACHE, are factors, just like lab values and vital signs. None are so strongly prognostic alone that they should drive decision making.

I've had patients in critical care units for many days with end-of-life, seemingly hopeless, with multi-organ failure, Adult-Respiratory Distress Syndrome and heart failure at the same time. Miraculously, when they've come back for routine annual care, walking, it's deeply humbling. Then they tell you that that just got back from camping with their grandchildren. It makes you want to cry.

I've had the reverse situation, where the patient in the ICU wasn't seemingly hopeless, got appropriate care, and just kept getting worse and died. The best doctors I've worked with react with "They weren't aggressive enough. Even when they might have been extremely aggressive."

As you know, there's a rich body of work that looks at the economic question you hypothetically raised. One ends up needing to consider the Quality-adjusted-Life-Years and the patient's desires. Is being on hemodialysis and very weak a life worth living? Can we sort of the component of depression? It's not a question most of us want our insurance company to be helping with.

My point is that there is a lot of individual variation in perceived value. Clinical decision support aids like APACHE, Acuity Systems and clinical-adjusted quality reporting systems are important. Doing 'cost control' without such systems is a little more instrumental than any of us want. Tougher questions often become a lot less tough with appropriate information to inform those involved.

Joe/Jim

You've raised an extremely interesting topic, even though it may be a tad outside the traditional realm of what we discuss in this forum. I can offer a personal experience.

As readers of this magazine may know, my father had a near-death experience in the fall of 2007. For all intents and purposes, he was a "goner." I was told that his ruptured aortic aneurysm had a near 100 percent fatality rate. After the surgery to repair the rupture, surgeons could not close the wound for three days due to swelling. He subsequently caught an HAI from his ventilator that was as nasty as they come. At one point, he had an infection in his urine, his kidneys were near failure and he was on the verge of being trached because they could no longer leave the breathing tube in his throat. I specifically remember the doctor taking me to the side and talking about the APACHE score his point being that I shouldn't expect a recovery.

Now to your point: what if, based on that score or some other measure, the insurance companies and/or physicians determined that his chances of survival were too minimal to warrant the expense of care (which was huge)? Today, my father is up and running like nothing ever happened. It's a truly amazing story, and exception to the rule, but how do we handle the fact that a 1 percent chance of survival necessarily means that people (albeit it few) will die who need not have? What survival possibilities warrant what expense of care? One can imagine a spreadsheet which would determine life and death.

Ex. 8 percent chance of survival justified $10,000 of care. The operation necessary would cost $30,000.

Would the insurance company pay the first portion, then the family would have to come up with the rest? Tough questions, but certainly some that will have to be addressed in the future.

Joe Bormel

Healthcare IT Consutant

Joe Bormel

@jbormel

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