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Yup, we're way, way, way behind tiny New Zealand

November 13, 2009
by Mark Hagland
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So here’s a really basic question: how is it that a diverse range of advanced, industrialized nations—including Australia, New Zealand, the Netherlands, Italy, Sweden, and the United Kingdom, have all achieved near-universalization of EMR use on the part of primary care and other physicians? And before you jump in to say, “U.S. healthcare is unique,” keep in mind how broad the range of countries just mentioned actually is. Their healthcare systems differ as much from one another as from the U.S. healthcare system. What’s more, they span a range of advancement when it comes to medical technology in areas such as medical devices. They also differ very broadly with regard to overall healthcare spending, with the U.K. and Italy falling considerably below the U.S. not only in raw figures, but in terms of percentage of GDP spent on healthcare overall.

These findings come out of an 11-nation study of physician practice issues published on Nov. 5 in Health Affairs online. And they underscore just how backward we remain in the U.S. in healthcare IT overall, at least when it comes to EMR adoption, a core measure of healthcare IT advancement. Sure, we’ve got some really nifty innovation going on here in the U.S. that in certain niche areas is more advanced than in other countries; but at the same time, some of that niche innovation is addressing issues that are unique to the incredible complexity of our healthcare delivery and payment system, a kind of complexity most other advanced nations don’t share.

So as we push forward on meeting the gradually advancing requirements of ARRA-HITECH funding, let’s not fool ourselves here. So when you read that 99 percent of doctors in the Netherlands, and 97 percent of doctors in New Zealand and Norway, countries that spend roughly half of the percentage of their GDP on healthcare annually that we do, have adopted EMRs, and we’re at 46 percent, it really does mean something. Even the U.K. and Italy, long known (somewhat unjustifiably, I would argue) for “under-spending” on healthcare, are at 96 and 94 percent of physician EMR adoption, respectfully. (For balance, there is one country in this survey that actually has a lower percentage of office EMR adoption than we do, and that’s Canada, at an abysmal 37 percent.) I just hope everyone hearing those figures gets some fire in the belly about where we’re at on our automation journey, because excuses about the differentness of our healthcare system just aren’t going to cut it any longer.



Thank you Mark for an excellent tidbit. And I agree with you and Joe that the U.S. has little remaining excuse for it's terrible performance on so many health and health IT measures, especially relative to the dollars we spend.

Two real differences that I would point out (and these are NOT excuses, but real issues that must be dealt with) are that the U.S. is both geographically and demographically bigger than each of the 30 countries in the OECD report. In many cases an order of magnitude or two bigger.

Canada is roughly the same geographic size, Australia is about 65% of the size of the U.S., next in line is Mexico at about 17% of the size of the U.S. and the rest are all an order of magnitude or two or more (in the case of Belgium with ~0.3% of the size of the U.S.

Japan is about 40% of the population of the U.S., Germany and Turkey are about 25% of the population each, France, the UK and Italy each about 20%, Spain is about 12.5% and then the rest are all 10% or less (with Iceland at the bottom with about 1% of the U.S. population).

Again, not excuses, just actual economies of scale which do not work in the U.S. favor. I suspect that if we either had fewer people (like Australia) or less land (like Japan) we would be farther along with healthcare IT.

Those are two big differences, ... you are right.

A third is the deep differences in our incentive systems. This hit me between the eyes a year ago when I was looking at ICD-10 strategy. The obvious question was, if every other industrialized national has already adopted ICD-10 (in some cases long ago), how many surprises should we expect? The answer is that no other country uses them for billing, payment, claims and other processes with our scale of economic considerations in a free market. From the public/private perspective, no other country has our mix, combined with an employer-based component funded the way we do.

I have relatives who live in England, Spain and some awareness of France. I also have a large client in Canada, as well as two, large county system clients in the US. I don't pretend to think there is a simple or clean way to frame the above data.

What's going on with pharmaceutical spending in Hungary?

Thanks for your post. I have and read much of that issues of Health Affairs. More telling for me was the recent international measures from the OECD. I concede your implied point that ambulatory EHR adoption needs to be a pre-requisite, if we're going to manage our healthcare delivery with reasonable efficiency and effectiveness.

I had a strong reaction to the "Annual Checkup." Although rank is important, I think focusing on year-over-year progress, or lack thereof (perhaps, for example, our healthcare GDP percent going up,) is more important than relative international standing, from a management standpoint.  (my original source for this graphic was the WSJ but all of the data is on OECD's web site, in much more detail, for example, elaborations of the definitions and methodologies.)

What do you think?