First Things First

Coffee Brown, MD, University of New Mexico, Talk Radio News

There are many blocks in the arch of medical reform, but Health Information Technology is the keystone, according to a panel of policy makers who spoke and answered questions at the Brookings Institution. Everything from electronic medical records, to electronic ordering, to integrated billing, to error reduction and decision support, won’t fix medicine by itself, the experts concluded.

Presenters at the event included: U.S. Sen. Sheldon Whitehouse (D-RI); former Rep. Nancy Johnson (R-Conn.) and Chairman of Health IT Now! Coalition; and Charles P. Friedman, Ph.D., Deputy National Coordinator for HIT Department of Health and Human Services. to discuss the current administration’s plans to upgrade the use of information technology in medicine.

“We are at a preposterous level of health information primitiveness,” White said.

According to moderator Darrell M. West, Vice President and Director, Governance Studies, Brookings Institution,, only one major business in the U.S. is less computerized than medicine; mining.


West co-wrote Digital Medicine: Healthcare in the Internet Era, published by Briikings. He said only one major business in the U.S. is less computerized than medicine; mining.

"Amazon can tell me what I’ve bought before, what I looked at today, and what I might like to buy tomorrow,” he said, adding that the majority of U.S. hospitals still keep manually-written, and, potentially life-saving, patient records in paper form.

According to the Institute of Medicine, only one in five clinicians in the U.S. are using electronic medical records.

West said the most optimistic projections are for savings of about $120 billion per year, but he believes the figure will be less.

Whitehouse quoted estimated healthcare savings as high as $320 billion per year , and he thinks that number could be a trillion.

The panelists agreed that interoperability is the first hurdle for the technology. Many, or most, of the computerized systems that exist now in hospitals can not share data with other computers.

This is intentional, Johnson said, because the competitive private business model favors a proprietary approach to information.

West said his doctor was using EMR now, but would never integrate the last 26 years of notes, “because that would cost too much.”

"Having HIT on a doctor’s desk is like having a car in the garage. you can enjoy the radio, air-conditioning and cigarette lighter but without a good road, you’re not going anywhere,” Whitehouse said.

The infrastructure, lines, connectivity and hardware all have to support the data flow, he said.

He pointed out that just moving data is not enough, “We need information aggregation, cross-checking, error reduction, decision support” and portability. The patient must be able to take data from system to system when traveling.

“Medicaid alone is approaching a $37 trillion obligation, not counting Medicare, VA benefits, S-CHIP, and similar entitlements. HIT is a necessary first step toward avoiding a healthcare cost tsunami,” he said.

Johnson discussed the tension between making the new healthcare more individuated and patient centered and avoiding the sort of consumerism that lets patients cow doctors into ordering expensive but unneeded tests and procedures.

She also pointed out the enormous proportion of healthcare costs that go to hopeless or marginal care, such as end-of-life care, or the prolongation of the lives of non-viable newborns. “No other country counts one breath as ‘live birth,’” she said. Many require hours, days, up to one year of life before being considered “live births”, she finished.

Friedman said the outlines of healthcare reform are clear and unlikely to change, but many details are still being worked out, not least a carrot and stick program to encourage and/or coerce stakeholders to adopt and “meaningfully use” HIT. “Meaningfully” is still being defined, but refers to applying this technology to actually improve clinical outcomes.

Whitehouse said that Republican opposition to Clinical Effectiveness Research surprised him. “No company would attempt a transformation one one-hundredth this complex” without Quality Assurance and accountability. “Someone has to be in charge."

Low-hanging fruit.

Coffee Brown, University of New Mexico, Talk Radio News

The Alliance for Health Reform presented findings of recent pilot studies showing that major improvements in healthcare are possible now, even in advance of new technologies and structures.

Ed Howard, Alliance for Health Reform, said that less than two percent of hospitals have “fully integrated” Health Information Technology (HIT). Even as hospitals invest in hardware, software, and training, the systems won’t work unless everyone uses them, he said. Where HIT is used effectively, he finished, quality and cost control are measurably improved. In other words, HIT does deliver better, faster, less expensive care.

But only when its use is coordinated among providers (often called “Care Teams”), according to Carolyn M. Clancy, MD, Director of the Agency for Healthcare Research and Quality (AHRQ). When the Electronic Medical Record (EMR) merely recreates the chart as an electronic document, “it can actually allow us to make the same mistakes faster.”

She cited the Provnost Study showing that when computers helped to coordinate care among all of the caregivers, using checklists, prompts, and feedback, infected lines in the ICU were reduced nearly to zero.

Jon Rasmussen, Pharm. D., Chief of Clinical Pharmacy Cardiovascular Services, and Susan Kuca, RN, Cardiac Care Coordinator, described Kaiser Permanente’s intricately coordinated care. They said the program had reduced the risk of subsequent fatal heart attack by 88 percent if begun immediately after hospitalization, and by 73 percent even if started much later, such as when a patient with existing heart disease came into the system from elsewhere.

Greg Halvorson, Chairman and CEO of Kaiser Permanente Health Plan, said we are the only industrialized country without universal health care. He said healthcare can and should be both better and more affordable. Halvorson described a RAND study covering 5 million patients over 2 years that found 25 percent of care was wrong or harmful, implying that U.S. savings in healthcare from efficiency alone could be one-half to one trillion dollars.

Diabetics account for 30 percent of Medicaid dollars, yet their carewas rated as “right only eight percent of the time.”

Big deductibles had the opposite of their intended effect by causing beneficiaries to delay care too long, he said.

In the case of chronic care, one percent of patients use 35 percent ofthe dollars, and ten percent use 80 percent of total dollars. “Chronic
care is a team sport,” Halvorson said.

The consensus of the panel was that, even without a single new treatment or device, coordination of ongoing care could save billions
or trillions of dollars, while improving outcomes.

21st Century House Calls

Coffee Brown, University of New Mexico, Talk Radio News


In a statement echoed by several subsequent speakers at the “The Wireless Future of Health IT” panel discussion, Craig Barrett, Ph.D, Chairman, Intel Corp., said, “Most of the focus on Health Information Technology (HIT) has been on the Electronic Medical Record (EMR), but it can be much more than that.”

The President’s budget includes $36 Billion over ten years, “but how will it be spent?” Barrett asked.

He said that HIT can expand access to medical care, allow for more home monitoring, and allow greater computing power.

Access can be expanded by “e-visits,” which allow the physician and patient to visit over the web. It can allow a local physician to consult with a regional expert, or an expert on some exotic disease, or permit consultation with a specialist who cannot immediately come in person.

Home monitoring can allow medicine to be more pro-active, and thus prevent much more expensive hospitalizations. Devices like blood pressure cuffs, glucose meters, and blood oxygen monitors, among many others, can communicate with medical computers, generating automated patient advice, a provider call-back, or other responses. The equipment needed to make this available would typically cost less than a single hospital admission.

Computing power is increased in a number of ways. As HIT becomes more integrated databases can be shared. Off-site computing could, for example, allow a more powerful remote computer to process cat scan images, or a more specialized program to help analyze an EKG.

Hit can coordinate ambulances with road closures, emergency department diverts, and other resource changes.

These were among many examples Barrett and other experts used to show that the point of HIT is not a bigger, better, faster form of a paper medical record, but a whole new approach to medicine.

“However,” Barrett said, “These things all require policy changes.” Right now, Medicare and Medicaid tend not to cover any of the computer adjuncts, or wellness care in general. Patients would like to remain at home as much as possible. “Over 90 percent of diabetic care is already self-care,” he said.

Truly integrated electronic healthcare, from the ubiquitous cell-phone to international expertise, to automated prompts and triggered responses, to coaching for best self-care and adherence to complex regimens, could keep more patients better cared for in the comfort of their own homes, he finished.