Tuesday, April 07, 2009

Digital Health Records Debate

Push for digital health records sparks debate

By Mimi Hall, USA TODAY
WASHINGTON — The blank wall behind the receptionists' desk stands as a symbol of efficiency in Peter Basch's bustling office. A dozen years ago, Basch and his fellow doctors went paperless and ditched the stacks of patients' charts that stood there.
An early entry into the world of electronic medical records, Basch is an enthusiastic supporter. "It allows our staff and physicians to be far more organized," he says. And that means "more focused on the patient."

President Obama wants doctors' offices and hospitals nationwide to follow suit, and the government has set a goal for every American to have an electronic health record by 2014.

Kathleen Sebelius, the White House nominee for Health and Human Services secretary, calls the move to computerization "one of the linchpins" of overhauling the nation's health care system. Obama casts it as a factor in the nation's economic recovery, saying going paperless would "save billions of dollars and thousands of jobs."

Naysayers suggest health information technology (IT), the overall move to computerization, is full of false promise. Digital records can lead to better care and fewer medical mistakes, they say, but the costly transformation could waste money if the doctors and hospitals buy systems that can't be connected to share information.

"We could head for a techno-Katrina," warns Sen. Barbara Mikulski, D-Md., referring to the government's failed efforts to respond to the 2005 hurricane. "I do not want to do that, where we do a dollar dump, and at the end of the day, we have a lot of microchips floating around."

Costs of an upgrade

Studies published in The New England Journal of Medicine show that less than 2% of hospitals use electronic records in all departments and that 17% of doctors have functioning digital systems.

The Obama administration says the government could save $12 billion over 10 years if doctors go digital because electronic systems help reduce duplication of tests, prevent medical errors and prompt doctors to prescribe less-expensive drugs. "We are confident that health IT will significantly bring down the cost of health care and benefit all Americans," says Nick Papas, a Health and Human Services spokesman.

In February, as part of the $800 billion economic stimulus package, Congress approved $19.5 billion to jump-start health care's digital revolution by providing incentives to doctors and hospitals that take Medicare and Medicaid patients — which 90% do. The federal government plans to set up regional centers, staffed by "geek squads," to help offices get their systems up and running, and those who don't take steps to go digital will face graduated penalties beginning in 2015.

Obama tapped Harvard Medical School professor David Blumenthal to oversee progress.

Questions about the effort are being raised by health care experts.

Avalere Health, a research company for government and industry, released a study last month showing that it will cost the average doctor or small medical practice about $124,000 to upgrade to computers over the period that the government incentives are offered, 2011-15. Those incentives, the study said, would add up to $44,000 per office at best.

Blumenthal co-wrote a study in March that raised similar concerns about the investments needed to buy and maintain the systems.

"There's not much reason to believe that this is going to save significant amounts of money," says Jonathan Oberlander, a University of North Carolina School of Medicine professor.

Push for protections

Basch's seven-doctor practice went digital when it was bought by MedStar Health, so the doctors didn't have to pay for the switch. The office then saved money by going from 3½ staffers per doctor to two. Each of the examining rooms has a large computer screen so doctors and patients can look at records together. If a new drug would interact badly with one the patient is already on, the system lets the doctor know.

As part of MedStar, the office is connected to 500-600 area doctors, several hospitals and labs.

Those kinds of connections raise concerns among privacy rights advocates. Strict new protections, including a ban on the sale of personal health information, were included in the stimulus bill. It's too early to tell how well they will be enforced.

Last week, Kaiser Permanente announced it had fired 15 hospital workers for snooping in the electronic health file of Nadya Suleman, the octuplets' mom.

Without proper protections, health IT could end up harming patients, says Ashley Katz of the group Patient Privacy Rights. If patients don't feel certain their records are protected from employers, creditors and marketers, they may not tell their doctors the truth about certain conditions or behaviors, she says. "The more data you have out there, the more good things you can do," Katz says. "But also, the more bad things."

Healthcare, in the U.S., Britain and Canada?

When it comes to healthcare, the U.S., Britain and Canada are hurting
Healthcare in all three countries has the same problem. They just feel it in different places.
By Ezra Klein

April 7, 2009

When asked by the New England Journal of Medicine to detail his healthcare vision during the campaign, John McCain concluded with a rousing denunciation of "new government bureaucracies that will translate into higher taxes, reduced provider payments and long waiting lines."

Long lines come up frequently in the American healthcare discussion, the symbol of all that is to be feared about a government-run system. And it's true that in Canada and Britain, the two countries most often cited in discussions of what nationalized healthcare might mean, some patients report having to wait months for some elective treatments. Sometimes.

But we've got waiting lines too -- along with 50 million uninsured and a system that costs more than twice as much per person as that of any other country. We've just managed to hide our lines through clever statistical gimmickry.

Britain and Canada control costs in a very specific fashion: The government sets a budget for how much will be spent on healthcare that year, and the system figures out how to spend that much and no more. One of the ways the British and Canadians save money is to punt elective surgeries to a lower priority level. A 2001 survey by the policy journal "Health Affairs" found that 38% of Britons and 27% of Canadians reported waiting four months or more for elective surgery. Among Americans, that number was only 5%. Score one of us!

Well, sort of. American healthcare controls costs in another way. Rather than deciding as a society how much will be spent in the coming year and then figuring out how best to spend it, we abdicate collective responsibility and let individuals fend for themselves. So although Britain and Canada have decided that no one will go without, even if some must occasionally wait, the U.S. has decided that most of those who can't afford care simply won't get it.

When that very same survey also looked at cost problems among residents of different countries, 24% of Americans reported that they did not get medical care because of cost. Twenty-six percent said they didn't fill a prescription. And 22% said they didn't get a test or treatment. Those latter numbers are probably artificially small: If you can't afford to see a doctor, you never know that you can't afford the treatment she would recommend. In Britain and Canada, only about 6% of respondents reported that costs had limited their access to care.

Moreover, surveys conducted by the Organization for Economic Cooperation and Development have found that most countries don't have waiting lines or the uninsured. Not Germany or France or Japan or Sweden, all of which have more of a mix of public and private options. But Canada is next door, and Britain speaks our language, so we tend to spend a lot of time comparing our system with these systems and not a lot of time thinking through the full range of options.

In light of the "Health Affairs" data, smugness about our speedy access to care seems a bit peculiar. If someone can't afford care, we record their waiting time as zero. You don't wait for what you can't have. But a more accurate accounting would record that wait as infinite, or it would record when the patient eventually ends up in the emergency room because the original ailment went untreated. Research like this raises a simple question: Would you rather wait four months for a surgery or be unable to get it altogether?

Just last week, House Republicans expressed their preference for the latter. Their long-awaited budget document was admirably specific about changes to Medicare. They call for "a new Medicare program" in which enrollees are given a check "equal to 100% of the Medicare benefit," which they can then take to the private market to purchase their own care.

This proposal has a purpose beyond dismantling a popular government entitlement program. Currently, Medicare does not abide by a budget. It is not run like the Canadian or British healthcare systems. Instead, it pays whatever is deemed "reasonable and necessary." Because of that, costs are shooting through the roof: The Congressional Budget Office estimates that Medicare spending will more than triple by 2050.

The Republican plan gives Medicare a budget. Costs grow only as fast as the check grows. And because the check grows more slowly than health spending does, the program saves money. But this is, in effect, almost precisely the strategy of Britain and Canada: It is the government imposing an arbitrary budget on its healthcare spending.

The difference is that the British and Canadian governments try to apportion that health spending so that the whole population gets care. That can mean, alongside other cost-saving measures, longer waits for services. The Republican budget simply would give individuals a fixed check. That will mean that patients who exceed that sum and don't have money of their own go without needed care.

So Americans will continue to brag that no one waits, and Canadians and Britons will continue to brag that no one goes without. And somewhere, the French and the Germans and the Japanese and the Swiss and many others will wonder why we insist on choosing between such awful extremes.

Ezra Klein is an associate editor at the American Prospect.