Our fragmented, disconnected, crisis-based medical system where doctors bear no consequence for cost, but liable for everything, is a wasteful money pit.
In a recently published study, "Emergency Physician Perceptions of Medically Unnecessary Advanced Diagnostic Imaging," physician Hemal Kanzaria and co-authors uncovered that 97 percent of the over 700 responding ED physicians admit that nearly one in four advanced diagnostic imaging studies they personally order are "medically unnecessary." Worse yet, most in-hospital diagnostic imaging studies cost about five times more than their independent counterparts for the same work.
"The main perceived contributors were fear of missing a low-probability diagnosis and fear of litigation," according to the study abstract. The real contributor is that emergency physicians, and virtually every other consulting physician, is being forced to treat immediate crisis in the blind under looming threat of litigation, a callously perverse system that costs Medicare and Medicaid hundreds of billions of dollars each year, and the overall healthcare system arguably close to a trillion dollars per year in waste.
Emergency physicians, hospitalists, specialists, and even primary-care doctors, which pretty much covers anyone with a prescription pad, order lots of unnecessary or redundant tests not because the vast majority are intentionally wasteful but, because they, with rare exceptions, have no idea of what has or has not been done before them and must treat patients in the moment of crisis, not in the continuum of care.
This does not mean that ED doctors are bad at their jobs. It's just that doctors working in teams are proven to provide better care at lower cost. Much lower cost. As much as 30 percent.
Doctors work best if they can work in teams using the same information. Unfortunately, EHRs do not provide the kind of information that doctors need to be effective. They need information that helps them make informed decisions and they need to be responsible for all care and costs. When this happens, the quality of care improves. People get and stay healthier, and, costs go down.
So, has spending $24.6 billion in taxpayer dollars on EHR systems been a bad idea? Not irreversibly. Some conflicts of interest that strongly inhibit the flow of data need to be addressed first:
1. It's good for EHR vendors to make it as hard as possible to move data to a competing system, denying the healthcare system as a whole.
2. It's good business for hospitals and their sub-specialist employees, whose stability relies on a steady stream of people in medical crisis, to keep data within their own walls and away from competitors.
3. It's good business for the industry as a whole because a free-flow of data means price, quality, and effectiveness transparency, forcing healthcare to compete like the rest of the economy.
And, the federal government obliges everyone with a cloak to hide behind: HIPAA.
The public is the only stakeholder in healthcare that restricting access to data is not good for.
The key to saving our healthcare system is to achieve a free flow of data and to convert that data into actionable clinical, price, and quality information for primary-care physicians, called interoperability.
Interoperability is the ability for different information technology systems and software applications to communicate, exchange data, and use the information that has been exchanged. It solves three of the most vexing problems the healthcare system and its providers face:
1. It unites a fragmented healthcare delivery system;
2. It streamlines and standardizes communication among providers; and,
3. It eliminates duplication of services.
Three Solutions to Move Forward
Karen DeSalvo, a physician and the former national coordinator for health information technology, set a goal to get the basic infrastructure in place by 2017 and to have a fully interoperable national system by 2024. That deadline has since been moved to 2017.
Considering that literally hundreds of thousands of doctors do not have or cannot afford EHR systems, nor can they afford to jump through the annual labyrinth of regulatory hoops to meet the federal government's definition of "meaningful use," and over 150 EHR manufacturers fighting for the only thing that keeps them in business - proprietary data - this goal is not only unrealistic, it is disingenuous.
But, there are companies already operational and their population health, analytics, and quality measurement systems combined with primary-care practice operational transformation, best practices training, and support that unleashes the power of that information, already generating high quality care and superior clinical outcomes at lower cost.
They do this by cutting waste and managing chronic disease effectively, which keeps patients out of the hospital. As a result, they must be independent of hospitals to avoid the conflict of interest.
Hospitals and their unions, whose lament you are already hearing, realize their vulnerability, and will fight unless you change the system to protect them. Hospitals are necessary to the public welfare and our national security.
Three simple actions can accelerate the process:
1. Funding the expansion of our interoperability capabilities and use of a common population health and analytics system with practice transformation, and requiring EHR companies to format their data in the same way and put it in the same place;
2. Limiting "out-of-network" payments to a reasonable percentage of Medicare to protect both patients and providers to protect patients and shared savings and risk programs from predatory practices; and,
3. Indemnifying doctors that use and document best practices from frivolous lawsuits.
With the kind of savings programs like these can deliver, investing the savings from just four or five Medicare beneficiaries per year for each enabled primary-care practice, the return on investment generates savings of 100 times or more.
The hardest part is mentally disengaging from the misperception that hospitals are healthcare providers. They are not. Hospitals are medical crisis treatment and rehabilitation facilities. Hospitals cannot so much as dispense an aspirin without a doctor's approval, and doctors need to be clear of conflict of interest.