Among the challenges faced by our nation's health care system are the continual struggles between all of the stakeholders over insurance premiums, reimbursement rates, administrative requirements, health plan rules, appropriate levels of patient care management, quality of care improvements, patient privacy, and myriad other debacles. They contribute to the total cost of health care in the US, which now exceeds $2 trillion annually, which accounts for over 16% of GDP. Each stakeholder's interests are legitimate, and it has been very difficult to find ways to respond to one problem without creating another. Solutions are analogous to a balloon: if you push it back into place in one area, it is sure to pop out in another.
There is, however, a watershed opportunity for progress. Information technology can be harnessed to create win-win-win health situations. Currently, only about 20% of physicians rely on health information technology (HIT) such as electronic medical records in their offices, which underscores the potential for savings and efficiencies that will come with greater adoption. But with about 35% of the nation's practices having three or fewer physicians, strong incentives and catalysts are necessary to facilitate the transition.
In recent years, various bills in Congress have called for greater use of "e-Health", and a major bipartisan bill passed the Senate in 2005. President Bush appointed a "National Coordinator for Health Information Technology" at the Department of Health and Human Services to lead the transition to e-health. However, most of the efforts focused on transitioning the nation toward electronic medical records (EMR), by developing standards for interoperable systems and data sharing, ensuring that systems meet appropriate levels of quality, and ensuring patient privacy and system security. In a few cases, particularly in a some states, efforts promote telemedicine, whereby a patient can be remotely examined by a health care professional a great distance away, by use of Internet connections and high-resolution cameras. But these initiatives are few and far between, helping only limited numbers of patients.
The Federal emphasis on EMR is only the first step. Much broader, more comprehensive innovations are possible, providing greater benefits to all parties. In 2007, the Oregon Office for Health Policy and Research and the Oregon Health Care Quality Corp. released a report estimating that a half-billion dollar investment in HIT would result in a potential savings of as much as $1 to $1.3 billion annually. Savings would result from electronic processing of information (e.g., prescriptions, x-ray results, warnings to doctors about complicated treatment issues, etc.) and by eliminating unnecessary services. The recent American Recovery and Reinvestment Act of 2009, passed with President Obama's leadership, allocates billions of dollars for HIT, through a number of programs to modernize the health care system by 2014, with an anticipated reduction in costs to the Federal government of $12 billion over ten years.
Ideas / Solutions
While not a panacea for all of our health care delivery woes, HIT is a key to stabilizing each leg of the "three-legged health care stool" -- access, cost, and quality -- all of which need to be stabilized to keep the system from toppling over. By combining a number of HIT innovations:
- patients can be regularly monitored for specific health conditions,
- continuity of care between providers can be enhanced,
- complications from chronic diseases can be prevented,
- medical errors resulting from fragmented patient records and illegible pharmaceutical prescriptions can be reduced,
- unnecessary office and hospital visits can be decreased,
- patient and provider education will be increased and more accessible,
- duplication of data entry, collection, and reporting can be averted,
- administrative procedures can be simplified and streamlined,
- more providers will convert from paper processing to electronic processing of claim forms, reports, x-ray reports, prescriptions, etc.,
- health plan claims processing can be accelerated with reduced costs,
- government regulators can receive health plan reports promptly,
- public health officials can receive more and better data for improving public health and enhancing disease prevention efforts,
- health care researchers can receive more and better data for developing treatment protocols or guidelines, and
- costs will be decreased for ALL of the above.
To effectively harness the power of HIT, Federal and State governments must collaborate through coordinated efforts on many fronts and establish a true partnership with the private sector. Some health plans have begun adopting and reaping the benefits of HIT. For example, Kaiser Permanente has employed the Archimedes Model for health data management to provide HIT access, treatment protocols, clinical trials guidance, outcomes-based reporting, etc. Yet, the impact of HIT innovations can be maximized by coordinating and integrating the structures and uses of HIT by a broader range of providers, health plans, researchers, and regulators.
The first initiative which should be fully developed is "electronic disease management", or "eDM". Patients can be remotely monitored from home, work, or elsewhere. It is ideal for patients with disabilities or with diabetes, asthma, or chronic heart conditions. While genetic profiling for use in coverage decisions is offensive, it can be useful in deciding who could most benefit from eDM. Patients can either have continual monitoring, such as by wearing a heart monitor all the time, or periodic monitoring, such as by taking a daily blood sample. By using digital devices, the results can then be transmitted over the Internet to the patient's doctor or hospital. A blood-sampling device could be connected via cable to a computer. A wearable device could either be periodically connected via cable to a computer, or, better still, equipped with a wireless device to continually transmit data whenever it is within range of a WiFi hot spot, wireless LAN connection, or similar wireless network.
The doctor or hospital would receive this information regularly and be able to quickly and easily observe conditions that are cause for concern.
They can contact the patient for an immediate appointment, or provide guidance on at-home treatment. Sharing the data with patients motivates them toward healthier behavior and adhering to regimens. Where there are no patterns that give rise to concern, countless office visits can be avoided, saving time, money, and administrative paperwork and processing. Devices could be programmed with reminders so that patients are prodded to obtain and transmit their data.
For providers, in cases where they are paid on a "capitation" basis (payment of a set amount based on the number of patients they serve regardless of how much treatment is provided), providers can function much more cost-efficiently, and stretch their reimbursement dollars. In other payment situations, payment rates can be set so that a provider can still be compensated for their consultative time, though at a level lower than for a full office visit, commensurate with their brief interaction via phone or email, or in reviewing patient data.
For health plans and insurers, the influx of data on health conditions and treatment procedures will help them to structure their services, both in terms of their existing patient loads, and in forward planning of the number of providers that they need to satisfy demand in each locality. In cases where they reimburse on a "fee for service" basis (i.e., pay-as-you-go, for each service provided), they will save money by avoiding reimbursement to providers for unnecessary visits. They can compensate providers at lower levels that still reflect the amount of time spent reviewing patient data that is transmitted or emailing a patient.
For health care researchers who track data of specific conditions and public health trends, or are developing cures for diseases, the new volume of aggregated data on clinical practices and patient outcomes will be a treasure trove. This data will also be of great value in identifying the most urgent and appropriate needs for spending governmental and private sector health care funds, both for patient care and research into treatment and cures.
The Federal government must spearhead this initiative, both through government-paid health care and support to the private sector, as eDM's success is dependent on the use of standardized systems and a national effort. National standards are essential for data to be aggregated, and for monitoring devices to have universal utility. Otherwise, if a patient relocates or changes providers, their devices might be useless. Both the Medicare and Medicaid programs should be amended to allow coverage of the costs of these devices in appropriate circumstances, to save money in treating their sickest patients, since the sickest 10% of patients account for approximately 70% of services and costs,.
The second innovation, which neatly complements eDM, focuses on saving time and money through administrative simplification. It would replace the current system in which each health plan or insurer, and each hospital chain, has its own forms to which providers must adhere when documenting each patient interaction. Standardized e-forms would alleviate the staggering burden that is now placed on doctors, nurses, clinicians, and other providers by the multiple coverage plans of their patients. Administrative simplification would ease the costly and time-consuming headache for offices that are forced to continually hire more support staff to process all of their claims. It would decrease the costs that are passed through to patients, health plans, government funders, and others.
A unitary, standardized set of electronic health care claims and treatment forms, for treatment documentation and reimbursement, would benefit all parties. Providers and hospitals would use one set of forms in dealing with health plans, freeing up much of their own time, and reducing their need for claims processing staff. Health plans and insurers that operate in more than one state would be able to simplify their state reporting efforts, as all of the states would request their information in the same format. State regulators would receive health plan and insurer data in a single format, enabling them to compare activities throughout the industry in an apples-to-apples manner, and better identify the strengths and weaknesses of health care delivery in their state. The Federal government could improve its health care system planning, identification of systemic shortcomings, public health strategies, medical research efforts, practice guidelines, and health care funding formulas. By virtue of the forms being electronic, cost savings would result by avoiding the time and errors inherent in repetitive data entry.
Standardized treatment and claims forms could easily be integrated into the plethora of software suites that are currently available to practitioners. There would still be ample opportunity for companies to differentiate their software products that offer case management, practice management, and back-office management all in one system. Only the forms that need to be transmitted to external stakeholders (i.e., hospitals, health plans and insurers, government regulators) would need to be standardized. Software packages could still integrate decision support modules, scheduling, referrals, imaging, lab orders and results, pharmacy services, patient billing, and a long list of other features.
The Federal government, the States, and the National Association of Insurance Commissioners, would have to collaborate for this to come to fruition. The Federal government, as a user of the data and the pivot point for broadest standards, would have to take the lead, as all parties would need to adhere to one system. But since the States have jurisdiction over insurance, in order to compel cooperation among health insurers, the States have to be on board and have an equal voice in crafting the forms to meet their needs, too.
The third initiative for optimal use of HIT is to integrate these innovations with telemedicine, to fill the gaps in health care for our nation's children. We know where to find a whole lot of them during the day: at school. School nurses are the key to reaching many students whose families may lack health insurance, or have only meager coverage. With an active school nurse program, many health conditions can be caught at early stages, the spread of communicable diseases can be minimized, preventive medicine can be practiced, and children with disabilities or specific health needs can receive better care.
Telemedicine can be used to maximize the reach of school nurses. Since many schools do not have a nurse, and some school districts have only a few nurses -- if that many -- who are expected to satisfy the needs of students at dozens of schools, telemedicine is the key to extending the reach of nurses. With telemedicine, a school nurse can see many student-patients from many different schools during the same day without even leaving his or her office.
Almost all US schools are now connected to the Internet. For example, in California, all educational institutions, K-through-20, are connected on the same network, often with high speeds. This enables difficult health conditions to be escalated to doctors or other specialists elsewhere for further review and attention. Referrals can be made to practitioners at community colleges, or even to doctors at university teaching hospitals, giving student-patients with severe health conditions access to advanced medical facilities, if necessary.
This system would require use of an inexpensive high-resolution digital camera in each school. By diagnosing student-patients' conditions remotely, without wasting travel time, a nurse could rotate among schools at a moment's notice. Use of the standardized, unitary set of electronic forms, as discussed above, would save the nurses' time and the schools' money, with further savings if the case needs to be escalated to another practitioner, who would also use the standardized forms. The school telemedicine system could be further enhanced by using eDM devices for remote testing, as described earlier, e.g., to ascertain and report the student's blood pressure, pulse, and blood characteristics. This would be vital for students with special medical conditions, such as diabetes.
The Federal and State governments would need to collaborate on this initiative, as it would involve allowing funds of either or both to be used for these purposes, and it would require a deployment strategy within the State. It could be anticipated that the Federal government would struggle with whether this program should be funded as a health care program, which it most essentially is, or as a schools-based program via education funding. This institutional debate is a reminder that resolve will be necessary to overcome organizational resistance to change, in order for new systems of this type are to be implemented.
The fourth initiative would build upon the principles of telemedicine in the schools, and the process of escalating and referring problematic health conditions. The initiative would be to connect, via telecom networks, all health care facilities that receive Federal assistance. While protocols would need to be established so that cases are escalated only when necessary and appropriate, it would be a great advance for public health, and begin to expand the reach of quality health care. The facilities would need to be allowed to spend a small amount of their Federal funding on cameras, networks, and digital diagnostic equipment, in order to establish the integrated telemedicine system.
By linking all health care facilities that receive Federal funds, the result is that university teaching hospitals, the National Institutes of Health (NIH), Community Health Centers (CHCs), and most other hospitals would be connected. A patient who comes to a CHC with a standard case of the flu would be treated there. But if the CHC practitioner observed symptoms that required resources or expertise beyond what the CHC had, then the patient could have an electronic visit with a specialist at a hospital, who might even be in another state. The patient would be brought to the room at the CHC with a telemedicine camera and network connection, and the remotely located doctor could observe the patient and their medical records over the network. The data from encounters that originate at a CHC could also aid the NIH in their research on indigent care treatment. The Federal Center For Disease Control and Prevention could be alerted immediately if there was a public health concern. It would amount to a win-win situation.
The fifth component is to focus Federal HIT resources on physician practices that have three or fewer doctors, which are estimated to account for 35% of all physician practices. Whereas large HMOs and hospitals are more likely to be able to finance conversion to HIT from their operating budgets, and have the IT staff to do so, small practices usually do not have resources to do so. They are therefore likely to be the laggards in conversion. Yet, because they service so many Americans, particularly in rural, remote, and underserved communities, they are the key to establishing a seamless system throughout the country. They are the most in need of Federal assistance for the hardware, software, installation, and training that HIT require.
The net results of combining:
- administrative simplification with standardized electronic forms,
- the school nurse telemedicine program,
- an integrated telemedicine system among Federal aid recipients, and
- support for small medical practices,
would be profound. The combination would benefit each stakeholder group, save time and money, extend access to care especially for children, improve quality of care, and enhance public health.
Studies have shown that the initial investment for developing and converting to HIT systems would pay for itself over time. The only real argument against it is that it requires the health care industries to change the way they do business. But that is a pretty flimsy reason for resisting change that would have such tangible, meaningful, and cost-effective results for all Americans.