Clinical costs or clinical care? Which will it be?
The web these days seems to be full of the talk around EHRs, health IT and the stimulus bill – you can tell by our blog posts that this question over whether more technology is really the cure for an ailing health care system and improving patient care is indeed controversial. There is also a larger question here however, and that is about the cost of health itself and whether a population’s health is a public good. That is, shouldn’t we dedicate time and energy and, therefore money, to focusing on the key components of health care and clinical practice – more time in interaction to construct clinical knowledge, than to continue to ‘automate’ health, to ‘reduce time and reduce costs etc’. It seems to be a cost vs. care issue.
Recently the New York Times reported in their section on Bits, that Kaiser Permanente’s research in its Hawaii division shows that a combination of EHRs, secure e-email and a web portal acted to reduce the number of patient visits by 26% from 2004 to 2007. This reduction was an unintended consequence of the IT deployment however. The secure email tool was used for non-urgent situations, which allowed, interestingly, physicians more time to spend with other patients in addressing their problems as their offices were less crowded. However, the Times points out that the ‘less visit’ result may not be received as positively outside of an integrated delivery system like Kaiser where physicians are paid salaries and patients are covered by Kaiser health plans. What do you think?
Right on the back of the ‘what do you think?’ question, several physicians have come out against one of the technological tools used in the Kaiser study – the EHR. In the Washington Post, two physicians from different universities, Stephen Soumerai, professor of ambulatory care and prevention at Harvard Medical School, 
and Sumit Majumdar, associate professor at the University of Alberta’s Department of Medicine, argue that health IT is “the wrong investment to make at this time.” While they conceded that computerized records may improve care in some settings in terms of reducing medical errors, repeat prescribing and inappropriate treatments, these tools are still unproven in the US and that perhaps, as has been suggested for medical devices and pharmaceuticals, there should be some effectiveness research conducted on their deployment in office practices. Indeed, elsewhere, such gold standard research studies have shown that EHRs do not improve the quality of care for those with chronic conditions nor do they save money. In some cases, these authors suggest that there have been increases in medical errors and deadly automated prescribing, particularly with pediatric patients. Many of these issues, the authors contend, lie with the fact that the multitude of small clinical practices found in the US are not ready for the time - and critical thinking intensive work that comes with interconnected health information. Large, integrated systems like Kaiser or national health plans such as those found in Europe fare better as physicians are required to use and trained to use the national systems. Without these systems in place, the authors feel the extensive funds earmarked for health IT could be better spent improving the physician-nurse practitioners teams that support the well-being of vulnerable patients.
In our orthopedic corner of the world, Scott Haig, MD, based in New York states in Time Magazine that while EHRs may just cut costs (and remember, that is debatable), “[m]any of us in medicine are concerned that the greatest cost will be in the quality of medicine we practice.” We’re back to the old ‘automate or informate’ argument made about databases in the 1980s by Shoshana Zuboff. In many ways, EHRs seem to take the romance out of medicine Haig contends, as physicians begin to upload all medical judgment. Not only that, but the kinesthetic experience of medicine is reduced to typing on a keyboard. As Haig says, “I still don’t see the profit-maximizing, cost-controlling physician with his nationwide computer treating patients any better than the great physicians I’ve known have. With pen and paper, personal commitment to each patient and judgment born of practical experience. None of which I have found in a machine” . So more information might mean less redundancy, greater research etc but how is this improving clinical decision making? That is, how are the EHRs informating medicine, if they are at all?
Just in time to answer that question, IBM has been hard at work testing a 3-D patient record in Denmark, Healthcare IT News reports. 3-D???? Yes, I was astounded too! And guess what, you get an avatar which you can rotate and zoom in and out to get the level of detail needed from a 3-D representation of human anatomy accompanied by a patient’s EHR!! Doctors can look specifically at organs or more broadly at the circulatory, muscular and nervous systems and health providers can access medical data by selecting an arrow that indicates information is available.
Just in case you were wondering, the need for this technology did not emerge out of the blue, rather out of an extremely large and busy hospital practice. When Hardy Christoffersen, MD, head of the hospital’s surgical outpatient clinic, sees a patient, he has 15 minutes for an interview, examination and diagnosis, including decisions about what kind of additional treatment may be required. “The IBM tool gives me a fantastic, graphic view of the patient’s status. I can see much more information than just what the patient tells me is bothering him or her that day – information for which I would otherwise have to spend considerable time searching through our current records system,” Christoffersen said. “With this medical information hub, I have all the information I need at my fingertips.” Again, in Christoffersen’s account we hear the arguments of efficiency and patient care, but interestingly, he also adds that the IBM solution supports the hospital’s desire to be paperless and that future generations of digital native doctors will approach EHRs naturally.
Naturally. I am reminded of the last time I was down in a lecture with medical students (digitally native ones) and they were discussing their experiences with ‘old school’ docs. How they appreciated the time these docs took with their patients. How they healed them physically as well as emotionally and how they were reminded of medicine (the romantic, non computerized one) and why they decided to go to med school. I wonder what these EHR naturals will make of these discussions. I wonder what you make of them too!
With thanks to AIDG, and rosefirerising for their wonderful images!
Good things happen when we connect!
Kirsten Broadfoot
Tags: 3D patient record, automate, Bits, clinical costs, clinical decision making, digital native doctors, effectiveness research, EHRs, Hardy Christoffersen, health IT, healthcare, IBM, informate, Kaiser Permanente, medical errors, medical students, old school medicine, research, Scott Haig, Shoshana Zuboff, Stephen Soumerai, Sumit Majumdar, Washington Post
