Technology Review: A Pound of Cure

http://www.technologyreview.com/computing/22852

The federal government is about to spend big on health-care IT. Too bad the medical industry has a vested interest in inefficiency.

Technology is once again being touted as a cure-all, this time for what ails the American health-care industry. The Obama administration's $787 billion stimulus plan includes $19 billion for health-care IT spending that provides incentives for doctors and hospitals to adopt electronic health records. Starting in 2011, stimulus funds will provide additional Medicare and Medicaid reimbursements for health-care providers using such systems.

These federal funding programs assume that the critical hurdle to widespread adoption of electronic medical records is cost. Indeed, hospitals surveyed in a study published last year in the Journal of the American Medical Association reported cost as the major barrier. Yet compared with other businesses, the health-care industry has been unmoved by the logic of lowering costs to increase profits. The truth is that these folks could have digitized the whole industry ages ago. The technology has been around for a long time: Wall Street began phasing out physical stock certificates over 35 years ago. Even the cash-strapped airline industry has gone ticketless, removing huge labor and overhead costs. These industries started using electronic records because they believed it would save money. The health-care industry simply has not followed suit.

The reason lies neither with cost nor with inadequate technology. Rather, the health-care industry's reluctance to digitize its records is rooted in a desire to keep medicine's lucrative business model hidden. Dangling $19 billion in front of a $2.4 trillion industry is not nearly enough to get it to reveal the financial secrets that electronic health records are likely to uncover--and upon which its huge profits depend. In those medical records lie the ugly truth about the business of medicine: sickness is profitable. The greater the number of treatments, procedures, and hospital stays, the larger the profit. There is little incentive for doctors and hospitals to identify or reduce wasteful spending in medicine.

The amount of unnecessary spending is huge. In a project that analyzed 4,000 hospitals, the Dartmouth College Institute for Health Policy and Clinical Practice estimated that eliminating 30 percent of Medicare spending would not change either access to health care or the quality of the care itself. The Congressional Budget Office then suggested that $700 billion of the approximately $2.3 trillion spent on health care in 2008 was wasted on treatments that did not improve health outcomes. This excessive spending has kept the entire health-care industry growing faster than the population, and faster than inflation, for decades.

While electronic medical records do have sizable up-front costs, they also have the potential to save big, in part by streamlining administrative costs. According to a 2003 article by Dr. Steffie Woolhandler in the New England Journal of Medicine, administration accounts for 31 percent of expenses in the U.S. health-care industry, or more than $500 billion per year. (To put that in perspective, Google has spent well under 10 percent of that on all its R&D.) Richard Hillestad of the Rand Corporation wrote in Health Affairs, in 2005, that health-care information technology could save physicians' offices and hospitals more than $500 billion over 15 years thanks to improvements in safety and efficiency.

Electronic medical records would make it much easier to conduct the studies needed to track down this wasteful spending. According to one estimate, only about 4 percent of U.S. hospitals use comprehensive electronic record systems; most rely on paper records. As a result, analyzing the effectiveness of specific treatments--for example, spinal-fusion surgery versus physical therapy for back pain caused by a herniated disc--is unnecessarily expensive and time consuming. Physicians must compile data for a significant number of patients undergoing each treatment and correlate that information with each patient's outcome.

Using electronic health records, in combination with data mining and search technology, would make this kind of analysis much easier. Patients who fit specific criteria could be identified and tracked automatically, for example. Researchers would be able to analyze larger numbers of patients and a wider variety of treatments. With easy access to this kind of information, wasteful spending could be identified more readily, allowing payers, whether Medicare or private insurers, to stop reimbursing for expensive but unnecessary tests and procedures.

An even bigger threat to the sickness industry's business model is that by allowing automated tracking of patients over time, electronic health records would set the stage for early detection and preventive medicine. Currently, the entire industry is organized around treating sickness, rather than keeping people healthy in the first place. Three-quarters of health-care spending is devoted to chronic care, but the National Cancer Institute and the Centers for Disease Control and Prevention allot just 12 percent of their budgets to research on early detection. Moreover, the payment system is structured around reimbursement for treatment rather than prevention.

With widespread use of electronic health records, it would be easier to expand preventive medicine, not only by educating patients about lifestyle changes but also by conducting mass screenings. A recent American Cancer Society study concludes that prevention, early detection, and better treatment decreased cancer death rates between 1990 and 2005 by 19 percent for men and 11 percent for women. I would like to see funding for technologies that could ultimately improve early detection. Studies are now being launched on CT scans that can evaluate a patient's heart in less than one heartbeat. They produce finer resolution than existing technologies and return fewer false positives. These tests cost $1,000 now, but within five years, thanks to expected advances in computing power, we should see a $200 CT scan to detect heart disease before a heart attack.

The ability to detect cancer early enough and cheaply enough for effective treatment would prove much more cost effective than the current approach, which involves spending hundreds of thousands of dollars to extend the life of a cancer patient for a few months--generally, with low quality of life.

As valuable as electronic health records are for streamlining costs, their biggest contribution will lie in moving medicine toward early detection. Let's hope that the adoption of this screening technology is not postponed as long as electronic medical records have been, in a misplaced desire to protect the lucrative status quo. Like all good technology, it's probably going to get off the ground on the grassroots level. Expect your local Walgreens to promote these tests sooner than your doctor does.

Comments

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[Scott L. Burson]

I am sure there is a lot of waste in the health care system, and your point, Andy, that providers have no incentive to reduce costs is well taken.

But I think you underestimate the difficulty of doing a good job of computerizing this information. It's very different from computerizing stock trading, which was all numbers and symbols already. Medical information is much more varied in nature and some of it is necessarily free-form. For a very interesting story of how things can go wrong, have a look at this: http://www.syleum.com/2009/03/17/healthcare-data-model/

While some of the commenters on that page are probably right that the problems went beyond the data model, I think it's still an important cautionary tale. A national medical records system needs to be designed very carefully, and unfortunately, government-funded IT projects are not noted for careful design (the FBI can tell you about this).

My own feelings are mixed. I agree that computerized records could be a good thing, but I fear the road to get there is going to be much longer and bumpier than people think. As Fred Brooks famously said about designing large software systems, "Plan to throw one [implementation] away. You will anyway."

[Roy G Bryan]

Andy, the records are not the problem. First, you need to define healthcare. The most rapidly growing portion of the medicare program are power wheelchairs. Is this healthcare? I think not. Is a free new knee for someone who gets sore on the golf course healthcare? We need the market to decide what is value and that means the patient must have "skin in the game" and pay for stuff. They must suffer an economic consequence if they choose to have care. Until that happens this all gets worse.

[Brent Jarvis]

Roy,there is no "the problem". There are many, many issues with the healthcare systems. Andy's article points out the major amounts of resources spent solely on administration (31%), and eHR is one approach to dealing with the major inefficiencies in that chunk. Once implemented, eHR can also lead to efficiencies in most other areas of healthcare.

I'm not sure why you consider going after "luxury" items as being the place to focus. Luxury is a symptom of the inefficiencies, and eHR is one extremely viable tool to attacking those inefficiencies.

[Ayesha]

Great article!

[family practice emr]

Technology in health care I think will definitely lead to better care and EMR could improve the quality and accuracy of medical-record documentation and improve quality of care.It truly has a big impact in our life especially in the field of medicine.

[EMR Medical]

Thanks for the reviews and article.