Electronic Medical Records in the news as good medicine

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New York Times
Health Plan That Cuts Costs Raises Doctors' Ire
By GINA KOLATA

Published: August 11, 2004


ELLINGHAM, Wash. - Elbert Littlefield, 76 and seriously ill with diabetes and congestive heart failure, had all but given up trying to take care of himself.

With three doctors and with 24 pills in the morning and 14 at night, he was never sure if he had taken his medications correctly and could not even list what they were. He was repeatedly rushed to the emergency room and asked for his diagnoses and a list of his medications, though, he said, "there was no way in the world I could remember."




Now all that has changed through an innovative program that has lowered costs by, among other things, assigning nurses and creating electronic records for some patients in Bellingham and surrounding Whatcom County, in northwest Washington.

With a nurse's help, Mr. Littlefield, of Lynden, Wash., has learned to follow instructions and take his medications properly. And his record is in a computer file, so when he sees a new doctor or goes to the emergency room, he no longer has to try to remember diagnoses or the names of drugs he cannot even pronounce.

"All I have to tell them is that I'm on the shared care plan," Mr. Littlefield said, referring to the name of the electronic record. "There's no more questions asked."

But there is a catch. When, as with the Whatcom County program, medical care is improved, and money saved, there are winners: in this case, insurers, including Medicare, which could save millions, and pharmaceutical companies. And there are losers: general practitioners and hospitals, with each doctor standing to lose at least $2,000 a year, according to projections, and some doctors reporting that their costs are already much higher.

The program, which is considered a model for how health care can be improved, so far involves patients with just two diseases: diabetes and congestive heart failure. And though the organizers hoped to get doctors excited enough to make financial sacrifices to join, they were not entirely successful. Many did enlist, but one group of 60 doctors, the Madrona Medical Group of Bellingham, took part in the planning but chose not to participate in the program.

"We were seduced by the concept," said Dr. Erick Laine, Madrona's chief executive. "But it doesn't work."

The doctors were expected to purchase electronic medical records systems and to provide services that substituted for individual doctor visits, like e-mailing with patients.

The problem, said Dr. David Reuben, chief of the geriatrics division at the University of California, Los Angeles, medical school, is that "we have a health care financing system where the incentives are totally misaligned."

"Let's say you do a really good job of keeping somebody out of the hospital," Dr. Reuben said. "Or let's say you spare someone a physician's visit. You save the system money, but nobody benefits from the savings."

Or as Dr. Laine said: "The concern we had was that in a system that requires substantial investment, the benefits that accrue to the system need to accrue back to those making the investment. Unless that happens, the system is not credible and it is not sustainable."

His reaction, said Dr. Donald M. Berwick, president and chief executive of the Institute for Healthcare Improvement, a nonprofit group in Newton, Mass., illustrates why overhauling health care is so difficult in the United States.

"We could get the same or better results with half the money, but the flows of money do not allow you to find the waste and reinvest it," said Dr. Berwick, who is also a co-director of Pursuing Perfection, a program of the Robert Wood Johnson Foundation. The foundation made a $1.9 million, three-year grant that helped pay for the Whatcom County project's expenses, like training.

Yet the project has attracted attention.

"I think it's very promising," said Dr. Mark B. McClellan, the administrator of the federal Centers for Medicare and Medicaid Services, which oversees Medicare.

Medicare is starting studies along similar lines, he said. But he is aware of the economic conundrums.

"Often financial incentives are set up to reward more office visits and more complications," Dr. McClellan said. "We will have a lot easier time if we can improve our financial incentives."

The program that helped Mr. Littlefield shows what is possible, Dr. McClellan said. "For people who doubt that these kinds of care improvement programs can have an impact on health care costs, this is pretty convincing evidence that they can."

The Whatcom County project began in 2001, focusing on chronic illnesses, which account for more than 75 percent of all medical expenses in the nation. The planners asked patients to join the conversation.

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"That changed everything," said Dr. Marc Pierson, the project executive and an administrator at PeaceHealth St. Joseph Hospital in Bellingham.

They heard from people like Rebecca Bryson, a 47-year-old Bellingham resident with congestive heart failure and diabetes. She saw 14 doctors and took 42 medications.

Ms. Bryson said that the burden was on her to keep everyone informed of her medications and complications, and that she always worried she had forgotten something.

Just getting a doctor's appointment could be an effort.

Her lungs would be filling with fluid, she would feel as if she were drowning, and she would have to call her doctor's office and tell the receptionist to leave a note for the nurse. It may take an hour, it may take a day or more for the nurse to call. Then she had to persuade the nurse that she needed to see a doctor.

The solutions, which transformed Ms. Bryson's life, are the shared care plan and help from a nurse, a clinical care specialist.

Under the shared care plan, doctors and patients and their families have access to the computerized medical records. Patients can note changes in their reactions to medications, for instance, and every doctor can see the updated information.

The highly knowledgeable clinical care specialists serve as personal assistants to severely ill patients, going with them to doctors' offices, being available by cellphone to answer questions and teaching them to manage their diseases.

Their efforts have reduced doctor visits and medical complications. Patients with diabetes have lower glucose levels; those with congestive heart failure have remained stable rather than getting worse. And money is saved.

For example, in just two months, in January and February, the two nurses, seeing 70 patients, reported seven incidents in which they prevented costly options like calls to 911, emergency room visits and emergency visits to a doctor's office.

Ms. Bryson said her clinical care specialist, Nancy Stothart, helped her avoid doctor visits through simple steps like taking her blood pressure. Ms. Stothart also recognized serious problems when Ms. Bryson did not. Once it was severe dehydration; another time it was a pacemaker wire that had been dislodged.

"Nancy saved my life - twice," Ms. Bryson said.

Mr. Littlefield was one of those needy patients who ended up with a clinical care specialist because doctors were at their wits' end. These patients, the doctors said, were simply not following instructions.

Connie Golas, the specialist who worked with Mr. Littlefield, said doctors sometimes do not realize the patients' problems. It is not that the patients refused to follow instructions; it is that they did not know how.

Ms. Golas sees this, for example, when she visits patients and asks to look at their medications.

"They bring out this box or basket or shoebox and they pull out all these medications," Ms. Golas said. "They pull out one - it was from two years ago. They say, 'I guess I shouldn't be taking this now.' "

But Ms. Golas also understands the doctor's perspective. When patients say they cannot make a doctor understand, it may be that they did not really explain what was wrong.

"A seasoned nurse or receptionist will screen the pile of messages," Ms. Golas said. "If the patient doesn't know how to communicate, if he says, 'Well, I'm coughing a little more than usual,' instead of 'I can't breathe and have to sit up at night,' then that message may be put in among the calls about the snotty noses. The patient may not get a call for three days."

Doctors often have no idea that happens, said Dr. Bertha Safford, a family care physician in Ferndale, Wash., whose practice is part of a 41-doctor group.

"We recently had a meeting with clinical care specialists and patients," Dr. Safford said. "I was just horrified to hear their tales, and I took it back to the doctors. I told them, 'We have a serious problem. Patients can't get through.' The doctors said, 'Not at my office.' Every single doctor said that."

Dr. Safford was quick to sign on to the Whatcom County program.

She said she knew what would help her patients with chronic diseases: she and her colleagues ought to keep in contact with patients, they ought to send reminder notices about checkups and return visits if test results indicate a problem.

"It takes a whole different mind-set that it is our responsibility to do callbacks and reminders and to organize their care," Dr. Safford said.

"Patients rarely come in with a pure problem in primary care," she added. "It is the rare patient who comes in and says, 'I'm here to follow up on diabetes.' Instead, there is a new skin rash or a worry about arthritis. And then, 'Oh, by the way, I've got diabetes.' The chart's this thick and by the time I deal with all of their immediate concerns, the chronic condition is last on the list and it's very easy to forget things."

But participating in the program is costing each doctor in the group $500 a month for four years for the electronic medical record system. Other innovations, like group office visits and e-mailing with patients, are poorly compensated, if at all. Nor are the follow-up calls by a nurse checking on patients when a doctor changes a medication or recommends a different regimen.

"I've been in practice for 25 years and I've made less money this year than I ever did before," Dr. Safford said.

But, she said, she will not return to her old ways when the county's grant ends this year and will accept less income if she has to. "We made the culture change and there's no going back," Dr. Safford said. "It changes everything. I look at this as a wonderful blessing."

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New York Times

Road Map to a Digital System of Health Records
By STEVE LOHR

Published: January 19, 2005


ew dispute the need to move America's costly, fragmented health system from paper records and prescriptions into the computer age.

Converting to digital records, health authorities agree, would reduce medical errors and improve efficiency, saving both lives and dollars.

But what has been missing is a national road map that would encourage doctors, hospitals and insurers to invest in modern information technology.

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Yesterday, a group of 13 health and information technology organizations gave the Bush administration its recommendations for just such a road map for a national health information network.

The group's report suggesting the principles that should guide the creation of such a network made an emphatic call for open, nonproprietary technical standards for communication across the network.

The information on a patient inside a doctor's office, the report contends, must be capable of being sent across the network freely to hospitals, laboratories, specialists, insurers and researchers, if the promise of improved care and reduced costs are to be achieved.

"The issue we tried to address is how do we mobilize America's incredibly fragmented health system to really get this done," said David Lansky, a director of the health program at the Markle Foundation, which coordinated the work of the organizations involved, including the American Health Information Management Association, the Healthcare Information and Management Systems Society and the Liberty Alliance Project.

The study was delivered to the Bush administration's national health information technology coordinator, Dr. David J. Brailer, who had asked for recommendations on how to build a national health information network.

The 54-page document, which the group calls a "common framework," borrows heavily from the technical and policy approach of the Internet. The federal government, the report says, should guide the development of a health network with a light hand by providing some initial financing and endorsing basic technical standards, but should set up a separate "standards and policy entity" to handle the task.

The report also noted that while the task might seem to warrant "a 'moon-shot'-type approach," the "political and practical realities suggest that an incremental approach would gain more support."

The report concluded that a national health network should not include a central database of patient records nor should it require individuals to have "health ID cards," as some have proposed. It said that patients should control their own records, deciding whether their information can be used in studies for effectiveness of certain treatments and drugs.

One goal is to have the health network operate somewhat like Internet-based e-mail, in which people using different types of computers and software can send and receive messages because the open, standard technology for handling messages is used by everyone.

Separately, an article expected to be published today in the online version of the journal Health Affairs estimates that $78 billion a year could be saved by moving to electronic patient records in a network with open communications standards, or interoperability, in computing terms.

That is the estimated yearly savings after 10 years, when a truly open, automated system is in place across the nation, according to the report by the team of researchers in the Center for Information Technology Leadership. The center is the research arm of Partners Healthcare, a nonprofit medical group that includes Massachusetts General Hospital and Brigham and Women's Hospital in Boston.

The cost to doctors and hospitals of installing computers, networking equipment and software to build an electronic health network will be daunting - an estimated $276 billion over the next 10 years, the researchers estimate. The annual savings from digital patient records would be considerably lower - about $24 billion a year - if the communications standards were not fully open, the study found.

Under a less open system, doctors, hospitals, insurers and patients could still share information, but doing so would require costly software changes to permit information-sharing outside a proprietary network. With employers changing insurers frequently and individuals often referred to several doctors, those costs could be daunting.

Many medical groups are starting to make sizable investments in creating local networks that connect electronic patient records. But without moving swiftly to establish open communications standards between those networks, the study's authors said, a large opportunity for savings may be lost.

"If we're not careful, we'll have little islands of excellence that don't talk to each other," Jan Walker, the lead author of the article in Health Affairs, said in an interview.

President Bush has spoken frequently about the need to move to electronic health records and last May appointed Dr. Brailer to the new post of health information technology coordinator. But last November, Congress eliminated a seemingly modest $50 million request for Dr. Brailer's office for technology demonstration projects.

"More aggressive leadership at the national level is needed, and time is of the essence," Dr. Blackford Middleton, chairman of the Center for Technology Leadership and an assistant professor at Harvard Medical School.

In a commentary accompanying the Health Affairs article, Laurence Baker, an associate professor at Stanford Medical School, questioned the authors' assumptions about savings from reduced labor costs and redundant tests eliminated. He called the study's conclusions "a very optimistic assessment."

The study did not try to measure improvements in health care because of better access to patient information.

Dr. Brailer, who also wrote a commentary for Health Affairs, said the improvement in reduced medical errors and better care would be significant, along with cost savings. He also endorsed the call for open standards.

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