Fascinating and timely article from the Economist on health care & IT<\/p>\n
The inability, and reluctance, of doctors and hospitals to use information technology more widely is killing thousands of people<\/i><\/p><\/blockquote>\n
IT is strategic – when used wisely.<\/p>\n
\nTHE NO-COMPUTER VIRUS
\nApr 28th 2005
\nThe inability, and reluctance, of doctors and hospitals to use
\ninformation technology more widely is killing thousands of people
\n“WHETHER or not a treating doctor has Alex’s full medical record
\navailable can literally mean life or death,” says Cynthia Solomon of
\nSonoma, California. Her son Alex, now in his 20s, grew up with
\nhydrocephalus, a rare and life-threatening condition in which fluid
\naccumulates in the brain and needs to be drained through special
\nshunts. So Ms Solomon had no choice but to become a walking filing
\ncabinet of records on allergies, pituitary-gland problems, brain scans
\nand “every piece of paper a doctor ever wrote about Alex’s case.” She
\nworried constantly. There were close calls, such as the time that Alex
\nwent on a trip and ended up, unconscious, in some distant hospital. Ms
\nSolomon could not get his paper records to the new doctor and had to
\npray that Alex would not get the wrong antibiotics or be laid on his
\nback, which might have killed him.
\nTo Ms Solomon the information problem with health care today is so
\nglaring that she eventually took matters into her own hands, as best
\nshe could. She took out a second mortgage, hired software programmers
\nand developed a computer system, called FollowMe, for online medical
\nrecords that any doctor can, in theory, access anywhere and anytime.
\nFollowMe will not fix the world’s health-care industry–only about 400
\nfamilies now use it–but Ms Solomon has correctly identified the
\nwoeful, even scandalous, failure of the health-care industry worldwide
\nto adopt modern information technology (IT).
\nThe solution seems obvious: to get all the information about patients
\nout of paper files and into electronic databases that–and this is the
\ncrucial point–can connect to one another so that any doctor can access
\nall the information that he needs to help any given patient at any time
\nin any place. In other words, the solution is not merely to use
\ncomputers, but to link the systems of doctors, hospitals, laboratories,
\npharmacies and insurers, thus making them, in the jargon,
\n“interoperable”.
\nThis may be obvious, but today it is also a very distant goal.
\nAccording to David Bates, the head of general medicine at Boston’s
\nBrigham and Women’s Hospital and an expert on the use of IT in health
\ncare, the industry invests only about 2% of its revenues in IT,
\ncompared with 10% for other information-intensive industries.
\nSuperficially, there are big differences between countries. In Britain,
\n98% of general practitioners have computers somewhere in their offices,
\nand 30% claim to be “paperless”, whereas in America 95% of small
\npractices use only pen and paper. But, says Mr Bates, this obscures the
\nlarger point, which is that even the IT systems that do exist cannot
\ntalk to those of other providers, and so are not all that useful.
\nIt shows. People on the right side of the digital divide increasingly
\ntake for granted that they can go online to track their FedEx package,
\nto trade shares, file taxes and renew drivers’ licences, and to do
\nalmost anything else–unless, of course, it involves their own health.
\nThat information, crumpled and yellowing, is spread among any number of
\nhanging folders at all the clinics they have ever visited, and probably
\nlong since forgotten about. The most intimate information is, in
\neffect, locked away from its owners in a black box.
\nMany IT bosses find this baffling. John Chambers, the chief executive
\nof Cisco Systems, the world’s largest computer-networking company, says
\nthat health care is down there with mining as the most technophobic
\nindustry. Jeff Miller, a manager at Hewlett-Packard, a large
\ncomputer-maker, calls health care “one of the slowest-adopting
\nindustries”, which is especially surreal because hospitals often
\nsplurge on the latest CAT-scan or MRI equipment, but are stingy with
\ntheir back-office systems. It is, he says, like “Detroit putting out
\nfuturistic hydrogen cars but using paper processing and manual labour
\nfor the manufacturing.”
\nThis has perverse consequences. According to the Institute of Medicine,
\na non-governmental organisation in Washington, DC, preventable medical
\nerrors–from unplanned drug interactions, say–kill between 44,000 and
\n98,000 people each year in America alone. This makes medical snafus the
\neighth leading cause of death, ahead of car accidents, breast cancer
\nand AIDS. “It’s like crashing two 747s a day,” says Mark Blatt, who was
\na family doctor for 20 years before he joined Intel, the world’s
\nlargest semiconductor-maker, to manage its health-care strategy. There
\nshould, he says, be more outrage.
\nRICH PICKINGS
\nImproving computer systems, of course, would not eliminate all medical
\nerrors. But most researchers believe that they would reduce them
\ndramatically. One study in America estimates that IT could prevent 2m
\nadverse drug interactions and 190,000 hospitalisations a year. Another
\nstudy reckons that electronic ordering of drugs can reduce medication
\nerrors by 86%. By contrast, research published in March in the JOURNAL
\nOF THE AMERICAN MEDICAL ASSOCIATION warns that IT, if the software is
\nbadly designed, could actually increase errors. But almost everybody
\nagrees that well-designed IT is essential to improving quality in
\nhealth care.
\nThe same goes for its cost, an increasing burden to ageing societies in
\nthe rich world and even in poor countries such as China. HP’s Mr Miller
\nreckons that redundancy and inefficiency account for between 25% and
\n40% of the $3.3 trillion the world spends on health care every year,
\nand could be eliminated with proper IT. A study from a clinical
\nresearch centre at Dartmouth College in New Hampshire reaches a similar
\nconclusion, estimating that a third of America’s $1.6 trillion in
\nannual health-care spending (as of 2003) goes to procedures that
\nduplicate one another or are inappropriate.
\nEstimating how much IT could save, after taking account of the
\nconsiderable cost of applying it widely, is not easy. Writing in HEALTH
\nAFFAIRS, an American journal, in January, Jan Walker and five
\ncolleagues (including Mr Bates) at the Centre for Information
\nTechnology Leadership in Boston concluded that a fully interoperable
\nnetwork of electronic health records would yield $77.8 billion a year
\nin net benefits, or 5% of America’s annual health-care spending. This
\nincludes savings from faster referrals between doctors, fewer delays in
\nordering tests and getting results, fewer errors in oral or
\nhand-written reporting, fewer redundant tests, and automatic ordering
\nand re-fills of drugs. It does not include, however, perhaps the
\nbiggest potential benefit: better statistics that would allow faster
\nrecognition of disease outbreaks (such as SARS or avian flu).
\nThe key word in all such estimates is always “interoperable”, says Mr
\nBates, pointing to the differences between two pilot programmes in
\nAmerica. In one, the Californian city of Santa Barbara set up a
\ncity-wide peer-to-peer network (in which the computers of different
\npractices and clinics can talk directly to one another). This allows
\ndoctors, say, to pull up portable-document-format (PDF) files from one
\nanother. But the information in them–text, with numbers buried in
\nit–is “unstructured” and so not very useful. It is the equivalent of
\nfaster faxing, and not what people mean by interoperability.
\nThe other American pilot, located in Indianapolis and managed by the
\nRegenstrief Institute, a non-profit medical-research organisation,
\ncomes closer. It has created a city-wide network in which physicians
\ncan, with the patient’s permission, log on to a complete medical
\nhistory that includes all previous care at the 11 participating
\nhospitals. Already, the database contains 3m patient records, 35m
\nradiology images, 1.5 gigabytes of diagnoses, 20m order-entries by
\nphysicians, and so forth. The key difference is that, wherever
\npossible, the data is entered in a structured and formatted form. Test
\nresults are in neat rows and columns and tagged in a way that every
\nother computer can recognise and compare against other appropriate
\nnumbers. This is the sort of IT solution that not only cuts waste and
\nerrors, but also helps physicians to make better decisions.
\nWhat, then, would the ideal IT architecture of health care in future
\nlook like? It would start, says Intel’s Mr Blatt, with wireless data
\nentry by nurses and doctors. Practices and clinics would have secure
\n“Wi-Fi hotspots”–using a radio technology called 802.11–and staff
\nwould walk around with small handheld devices that transmit all inputs
\nto the database in the back office. Another source of input might be
\ntiny radio-frequency identification (RFID) chips that are attached to
\npatients and send basic information when they come in range of a radio
\nfield. Patients could also add inputs themselves. A firm called Health
\nHero, for instance, makes a cute little device called a Health Buddy
\nthat patients take home and plug into their telephone lines. A couple
\nof times a day, it asks them basic questions or takes their heart rate,
\nand sends the data to the doctor.
\nBehind the scenes, all this data would be formatted and stored
\naccording to recognised standards. Contrary to widespread concerns,
\nthis does not require a single central repository or any other
\nparticular hardware architecture. Instead, it relies on common software
\nprotocols and formats so that individual computer applications can find
\nand talk to one another across the internet. Most of these standards,
\nsuch as XML, SOAP and WSDL, already exist and are used by many
\nindustries. Others, such as HL7, LOINC or NCPDP (spelling them out
\nmakes them sound no less obscure) are unique to the health-care
\nindustry and govern data interchange between hospitals, laboratories
\nand pharmacies. On top of these, there need to be hacker-proof layers
\nof authentication and password protection so that only the right people
\nget access.
\nThere is still some work to do to refine these technologies. In
\nJanuary, eight of the world’s largest IT companies–Microsoft, Oracle,
\nIBM, HP, Intel, Cisco, Accenture, and Computer Sciences–teamed up to
\nform an “interoperability consortium” for that very purpose. In
\ngeneral, however, “the technology is very, very ready,” says Robert
\nSuh, the technology boss at Accenture, a consultancy that is helping
\nBritain’s National Health Service (NHS) and regional governments in
\nAustralia and Spain to implement electronic health records.
\nIn fact, Britain’s–or rather England’s–NHS is among the pioneers
\nworldwide. This year, it will begin rolling out a GBP6.2 billion ($12
\nbillion) project in which five regions in England will form networked
\nIT”clusters” so that 18,000 NHS sites, including all family doctors and
\nacute-care hospitals, can share standardised information on patients.
\nThese clusters will eventually be linked through a “spine” (called the
\nN3 and run by BT) with huge bandwidth to create, in effect, one
\nnational network. Scheduled to be completed by 2010, the plan, like
\nmost IT projects, has had some early hiccoughs and has been greeted
\nwith cynicism by some doctors. But other countries will be looking to
\nit as a model.
\nAnother pioneer is Denmark, which began rolling out a similar network
\nfor the region around Copenhagen in 2001 and expects to complete it by
\n2007, before covering the rest of Denmark. Torben Stentoft, the boss of
\nHvidovre Hospital in Copenhagen and the head of the city’s network,
\nsays that his main concern is the nitty-gritty of dealing with all of
\nhis legacy computers which need to be tweaked or replaced. But he feels
\nthat he has his society’s full support. “Nobody is against this.
\nEverybody is asking for it,” he says. In particular, the Danes find
\nnothing terribly controversial in the idea of a national health
\nidentification number, which they already have, and spend little time
\nworrying about how to fund the new systems, since their tax kroner are
\ndoing that.
\nAMERICAN EXCEPTIONALISM
\nMr Stentoft is in an enviable situation, especially if viewed from
\nAmerica, which has the world’s largest and costliest health-care
\nsystem. America is as enthusiastic as any country about electronic
\nhealth records. President George Bush has embraced the idea, and he
\nspoke about it publicly some 50 times last year. He has even appointed
\na “national co-ordinator for health information technology” to create a
\nfully interoperable, nationwide network within ten years. But America’s
\nhealth-care system is so different from others that it faces some
\nspecial complications.
\nThe first big difference is that, whereas most other rich countries
\nhave “single-payer” (ie, government-run) health-care systems, America
\nhas a highly fragmented industry with many private providers and
\ninsurers doing business alongside large government programmes (such as
\nMedicare, for old people). This means that in funding a new IT
\ninfrastructure “the financial incentives are not exactly aligned,” says
\nMr Bates. In single-payer systems, the expenditures come out of the
\nsame pocket–the taxpayer’s–that the savings go into. But in America,
\nhe estimates, the practices and hospitals that pay for the IT only get
\n11% of the cost savings, with the rest going to insurers and employers
\n(who buy the insurance). The resulting mismatched incentives, says Mr
\nBates, could derail the entire project: “It’s a situation where America
\ncould end up far behind.”
\nThis calls for some combination of government subsidies and
\nprivate-sector financial incentives, argues the Markle Foundation, a
\ncharity in New York that is dedicated to the proper use of IT in health
\ncare and national security. Over half of all doctors in America work in
\nsmall practices. And, say Markle’s researchers, a typical practice
\n(defined as five doctors handling 4,000 patient-visits a year) would
\nmake losses if it had to pay the estimated $15,000 a year for three
\nyears that it costs to install an interoperable IT system and to learn
\nhow to use it.
\nThe practices, Markle concludes, therefore need incentives of $3 to $6
\nper patient-visit, or $12,000 to $24,000 a year, which comes to $7
\nbillion-14 billion a year for three years, or between 1.2% and 2.4% of
\ntotal ambulatory-care revenues. The trickier question is how to
\nadminister this largesse, whether it is provided by insurers and
\nemployers or the government. The money could be disbursed directly and
\nspecifically for the IT systems. Or it could be given indirectly in
\nsome sort of pay-for-performance arrangement.
\nThe other big difference between America and countries such as Denmark
\nis public perception of the robustness of privacy laws. The European
\nUnion has stricter privacy laws than America, and Europeans have
\nrelatively more confidence in them. For information sharing, “ours is a
\nmuch more porous environment,” says Alan Westin, a professor at
\nColumbia University who has written several books on privacy issues.
\nThis is not primarily an IT issue, although the internet does seem to
\nraise the stakes. In February, one database broker, ChoicePoint, had to
\ninform some 140,000 people that it had accidentally sold sensitive
\ninformation about them. Also in February, a statistician of the health
\ndepartment in Palm Beach County, Florida, inadvertently e-mailed a list
\nof more than 6,000 HIV carriers to all employees of the department.
\nThis makes many Americans suspicious of plans that involve sharing
\nsensitive health information. Although opinion polls in Europe show
\noverwhelming support for interoperable medical databases as long as
\nthese are properly regulated, a February poll by Harris Interactive
\nfound that Americans are currently evenly split, with 48% saying that
\nthe benefits outweigh the privacy risks, and 47% saying the opposite.
\nSome 70% of Americans in the poll worried that sensitive data (on
\nsexually transmitted diseases, say) might leak.
\nThis is unfortunate, says Michael Callahan, a health-care lawyer at
\nKatten Muchin Zavis Rosenman, a law firm in Chicago, since a weighty
\ntome of legislation was passed in 1996 precisely to prevent such leaks.
\nCalled HIPAA (short for “health insurance portability and
\naccountability act”), the law defines strict codes for sharing medical
\ndata and takes effect in stages, with a large chunk of compliance
\nfalling due this month. HIPAA creates a national “floor”, says Mr
\nCallahan, with some states following even stricter statutes, and
\ninvolves the federal government in enforcement and prosecution. HIPAA
\nis not quite as strong as equivalent laws in Europe, he thinks, but
\nstrong enough.
\nMr Westin disagrees. The HIPAA rules are “not at all adequate” for
\nshared medical records, he says. So the only way to sell such records
\nto the American public, he says, is to design the whole system with
\nprivacy as a priority. This rules out any form of medical
\nidentification card, to which Americans would be hostile (even though
\nthey think little of giving their social-security numbers, a de facto
\nID, when renting DVDs). It also means avoiding a central database that
\ncould be hacked. The best approach, says Mr Westin, is to emulate the
\n“locators” used by American police. Cops in California who arrest a New
\nYorker cannot access information about that person directly, but can
\nview a directory of such information and request it from the
\nauthorities in New York. Finally, rather than allowing sceptics to opt
\nout of the new system, says Mr Westin, the system should from the start
\nrequire patients actively to opt in.
\nAs the Markle Foundation puts it, the technology must be designed in
\nsuch a way that “decisions about linking and sharing are made at the
\nedges of the network” by patients in consultation with their doctors,
\nand never inside the network. This goes to the very heart of the
\nmatter. For even though it is fine to start hoping for the day when
\ninteroperable electronic health records create vast pools of medical
\ninformation that could be used to find new cures and battle epidemics
\nin real time, their ultimate purpose is to make one simple and
\nshockingly overdue change: to enable individuals, at last, to have
\naccess to, and possession of, information about their own health.
\nSee this article with graphics and related items at http:\/\/www.economist.com\/printedition\/displayStory.cfm?Story_ID=3909439<\/p>\n","protected":false},"excerpt":{"rendered":"Fascinating and timely article from the Economist on health care & IT The inability, and reluctance, of doctors and hospitals to use information technology more widely is killing thousands of people IT is strategic – when used wisely.<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[18],"tags":[],"_links":{"self":[{"href":"http:\/\/www.zmetro.com\/index.php?rest_route=\/wp\/v2\/posts\/1321"}],"collection":[{"href":"http:\/\/www.zmetro.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/www.zmetro.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/www.zmetro.com\/index.php?rest_route=\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"http:\/\/www.zmetro.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1321"}],"version-history":[{"count":0,"href":"http:\/\/www.zmetro.com\/index.php?rest_route=\/wp\/v2\/posts\/1321\/revisions"}],"wp:attachment":[{"href":"http:\/\/www.zmetro.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1321"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/www.zmetro.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=1321"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/www.zmetro.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=1321"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}