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A Comparative Look at Health IT

October 12, 2012
by Pamela Dixon and Steve Nilsen
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An interview with Dr. Alastair MacGregor, CIO and CMIO for Methodist LeBonheur Healthcare

The following is an in-depth interview with Dr. Alastair MacGregor, CIO and CMIO for Methodist Health System, a seven-hospital system in Memphis, Tenn. The interview maps his career path from a practicing physician and recognized leader in Scotland, to a consultant for the Ministry for Health and Seniors in Canada, to medical director of Cerner Corp., and now to the combined CIO and CMIO role he holds today. What led him down the path to informatics and what he considers the critical milestones along his journey provide insight into the evolution that is taking place in healthcare IT in the U.S., the United Kingdom and Canada? Below are excerpts from the interview.

Dr. Alistair MacGregor

Since you’re Scottish, I have to begin by asking you about the celebration of the British Healthcare System at the recent 2012 London Olympics Opening ceremony.  We found that surprising.

In the U.K., the National Health System (NHS) is an iconic institution and the country is quite proud of the system. The NHS is the largest employer in the European Union. As you know, it is publicly funded and you don’t have to be insured to avail yourself of its services. Even though it offers universal coverage, the British government spends much less of its gross national product compared to the U.S. health delivery system.

Interesting. Where did you receive your medical training?

The University of Glasgow Medical School. It was founded in 1451 before Columbus discovered the Americas and I was not one of their original graduates!

So you have an excellent point of comparison between the British healthcare system and the U.S. healthcare system. How did you end up in the “informatics” part of the medical field?

I began my career in the academic anesthesiology, critical care medicine, where very precise documentation was standard; but I later moved into family medicine where I was appalled by the quality of record keeping. We did not even have medical record folders; we had envelopes with index cards stuck in them. We were seeing about 60 patients per day in the clinic and doing 15 to 20 house calls, so we were spending about five minutes with each patient. I thought there must be a better way to review and manage patients’ histories, and that led me on the journey for an electronic medical record [EMR].

That sounds like it was a little difficult to figure out the patient’s medical history. How did you approach that issue?

In Scotland, as early as 1981, we took on a DOS-based family practice documentation system that a friend of mine had written using basic coding; and focused primarily on immunization call and recall, chronic meds and a repeat prescriptions module. I convinced my partners to purchase a computer that cost $8,000 had 20 megabytes of memory, and which pre-dated the PC. The Scottish Department of Health took [the documentation system] over, grew it, and ran it until about three years ago [2009], giving it away free to every clinic in Scotland. By the early 1990s about 85 percent of all general practices in Scotland had this EMR, which had grown in functionality.

In the late 1980s, I was a regional user of a reporting system from the University of Aberdeen Family Practice Unit, which created a report that extracted data from individual practices and aggregated it back to every family practice with a break-down of national, regional and practice figures for each physician within a practice.  Basically it was physician profiling in the late 1980s; by the early 1990s it totally took off. I then came to North America, stopping first in Canada, thinking—“they must be more advanced,” and thus I began the journey I have been on ever since. 

You also have Canadian healthcare system as a point of perspective in healthcare informatics?

Yes, in my first Canadian experience, I worked for the Ministry of Health in British Columbia. At that time all of Canada was considering following the U.K.’s primary care health reform initiated by Margaret Thatcher. Critical to those reforms was the deployment and use of EMRs. This was fascinating experience for me, because I was suddenly going from being very tactical and operational to contributing to helping set IT primary care health strategies for British Columbia.

In Scotland we used very simple codes to aggregate and analyze sub-populations that we thought would provide us with fairly good teaching for family practices residents. We started by looking at diabetics; our calls and recalls coverage numbers were poor but we had the data and the capability to measure our performance and improve. Looking at the data, I suspected we had a prescription drug abuse problem. We were using a paper prescription card system, which a few patients had figured out how to game and obtain multi-doctor scripts for valium, opiates and painkillers. Within a few months of switching to a single unique record, we realized we had an issue, but it almost started a war with a small minority of our patients because we challenged them on the fact that they were multi-doctoring.  These case studies made me appreciate the value of aggregating and reporting on data to manage sub-populations of patients. 

How has this tempered your perspective of the British and Canadian health systems?

The Canadian and U.K. systems are similar in that they have a strong primary care model. In the U.K. it is reinforced by having the primary care physician as the gatekeeper to other health service referrals. Patients must register with a single physician but usually can attend partners within that physicians group. Patients cannot go directly to a specialist without a primary care referral. That is a capitated model of health care delivery. There is much less fragmentation of patient information across U.K. providers than in Canada or the U.S. 

The Thatcher Primary Care Health Reforms were early versions of pay-for-performance and required the use of EMRs as essential tools to proactively [manage] sub-groups of patients. It transformed U.K. primary care from one patient, one chart, one encounter reactive medicine to proactive population management.   

How did you make your way to the U.S.?

Several months after I returned from my sabbatical with the Ministry of Health I received an offer from a Canadian company in Montreal. I resigned from my practice in Scotland, accepted their offer and was their medical director for three years. In the meantime, an ex-Ministry of Health leader had been to Cerner Corporation in Kansas City and suggested that I send my resume to them. Fortunately Cerner Corporation extended me an offer of employment, and that’s how I ended up in the U.S.

In terms of the organization chart of a healthcare system, what impact do you think the Health Information Technology for Economic and Clinical Health [HITECH] Act has had on the healthcare system?  What about five years from now?

It’s definitely raised the profile of IT as tool to manage patients rather than just for data entry. Some might suggest that regulatory compliance now ranks above patient safety, although patient safety is embedded within regulatory reform. Health reforms with their penalties and audits have the potential to significantly and adversely impact revenue. Compliance is essential for both health reforms and ICD-10. Non-compliance has the potential to close health organizations. The government health reforms have really forced IT to become a more strategic asset in health care organizations. 

This is very similar to what Margaret Thatcher did in the early 1990s in the U.K. Five years from now I see the health industry having a wide and deep level of EMR adoption. That will create an exciting platform for interoperability and data driven comparison across health systems. Having government manage health care does not raise the same debate in European countries that it does in the U.S. It just seems like good common sense in those countries. 

Healthcare Spending in the U.S. and Canada

The U.S. spends 22 percent more than second-ranked Luxembourg, 49 percent more than third-ranked Switzerland on healthcare per capita, and 2.4 times the average of the other OECD countries, according to the Organization for Economic Co-operation and Development’s OECD Health Data 2006.

Yet, the World Health Organization ranks the U.S. 37th in overall health system performance, according to the World Health Organization’s World Health Report 2000.

In Ontario, Canada’s most populous province, healthcare is projected to account for 50 percent of governmental spending by 2011, two-thirds by 2017, and 100 percent by 2026, according to Brett J. Skinner in “Paying More, Getting Less 2005,” published by the Fraser Institute.

Pamela Dixon and Steve Nilsen are, respectively, managing partner and general manager of SSi-SEARCH, Atlanta.

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