Accelerating EMR Adoption in America

Summary
The administration can help spur electronic medical record (EMR) adoption by promoting policies that drive development of health metrics and pay-for-performance programs, while building a health information exchange backbone, thus realizing the promise of a lower cost, higher quality American health system.

Despite its promise to transform American health care, only a minority of physicians has adopted an EMR
The US health care system is the world’s largest, accounting for 16.6% of GDP at ~$2.3 billion spend in 2008. EMRs are capable of helping our health system achieve higher quality, lower cost care. However, only ~14% of physicians have adopted EMRs, driven largely by three groups: 1) large practices realizing cost benefits 2) early technology adopters and 3) practices adopting due to employer requirements.
Current EMRs provide little economic benefit to the health system, while burdening physicians with complicated technology with little return.

EMR adoption will grow as the market evolves from a productivity tool to performance and connectivity tool
Current EMR vendors offer products that provide clinical documentation and results management. In order to become attractive to the remainder of health care providers, EMRs will need to develop two core features:
-Performance EMR: Data warehousing and mining technologies that improve care protocols through clinical decision support and reporting mechanisms to payers
-Connectivity EMR: Clinical information readily shared with all entities within health information exchange networks

The performance and connected EMR links payments to quality outcomes, reduces replication of rendered services and medical errors while easing administrative burden, thus driving down health care costs while improving quality.

The administration can help drive adoption by facilitating the evolution of EMR

Current proposals to drive adoption focus on direct subsidies to providers to assist in the purchase of EMRs. However, given current barriers to adoption, the administration should facilitate EMR evolution to make it a product necessary and desired by providers. The administration can do this by undertaking the following initiatives:

The administration should drive performance EMR through funding the development of metrics and pay-for-performance programs
- Have HHS convene public and private stakeholders in order to develop standardized outcome metrics for both the effectiveness of clinical care and the incidence of medical errors
- Provide more direct support for development of pay-for-performance programs through CMS, and work with HHS to convene private payers to understand and promote best practices in pay for performance

The administration should drive connectivity EMR through greater support of government HCIT bodies
- Increase funding for the Nationwide Health Information Network to create a set of information exchange standards and specifications
- Provide greater support for Regional Health Information Organizations to spur regional health IT architecture and tools
- Establish a formal Health IT privacy committee to ensure the protected free flow of protected, de-identified information necessary to improve health care quality while addressing privacy advocate’s concerns

By pursuing these recommendations, the administration will help the EMR market evolve, driving adoption, and in turn improve the health system’s quality while containing costs.

Patients don't know who is their inpatient doctor

One surprising finding here -
Most Hospital Patients Unable to Identify Their Physicians, Survey Finds - NYTimes.com

To summarize: Some 75 percent of the patients were unable to name a single doctor assigned to their care. Of the 25 percent who responded with a name, only 40 percent were correct.

This is not surprising:
*Family members are not there during rounds when we come by the patient room
*Work hour restrictions force numerous resident physician handoffs at academic hospitals, making it difficult to know who is the primary resident
*Reimbursement forces division of labor, thus PCPs don't see their admitted patients and have brought about the rise of hospitalists (arguably, hospitalists provides better care for patients so this is a good thing from a quality standpoint - another topic for another post)

But the one thing that was surprising was that patients able to name one of their physicians also were more likely to be unsatisfied with their care. Now that's one finding that I have no explanation for...

End-of-life costs - Do they matter?

End of life care reportedly consumes a quarter of health care costs - (see the much quoted JAMA article from a decade ago).

Revisiting this issue because this week's NEJM has an article - NEJM -- Fighting On: Intercede about caring for a woman who's family wishes to push on with care, despite her wishes. As all of us on this blog know, these are one of the most painful situations as a provider to be in - navigating the treacheries of generations and subtleties of culture and tradition so that you can broker a frank discussion about death of a loved one. (as a side note, should the residents get first authorship here? give 'em a break!)

Ok, so what's the health policy angle here? Two quick ones that I see:

1- Health care costs DO NOT account for a majority of health care spend. If you look at the data since that JAMA article, you can see a decreasing amount of spend in end of life care. Current estimates are around 2% of costs are for end of life care. What's happened is that with the increasing prevalence of chronic diseases, and the overwhelming use of advanced medical techologies to manage chronic diseases, a greater and greater portion of health care costs are accrued in the outpatient setting - not at end of life, or in the inpatient setting, as many think. For further explanation see this McKinsey report, figure 2 which references Hogan et al, Health Affairs 2001, Riley and Lubitz, NEJM 1993, Strunk and Ginsburg, Health Affairs 2003.

2. The best way to reduce end of life costs (and to add dignity to death) is to have frank discussions with your loved one on goals of care BEFORE you or they get sick - if you look back at the JAMA article from above, that advanced directives can save between 25% to 40% of end of life costs. I'm sure the data has progressed since the publication of this paper, but still - it makes sound financial sense, and it's the right thing to do as a family. Having seen the turmoil that families go through when they haven't had these discussions, I can argue for cost savings up the wazoo, but in the end, it just adds dignity to death that we all deserve.

Drug Discovery for the Poor

That pharmaceutical companies invest heavily on so-called “cosmetic” therapies for industrialized nations is no secret. An hour’s worth of ESPN quickly reveals two commercials for erectile dysfunction, four for nasal steroids, and three for enlarged prostates. But what about drugs for the global poor? Tuberculosis, filariasis, and schistosomiasis (among others) remain major causes of worldwide morbidity and mortality, yet there hasn’t been a new treatment for these illnesses in decades. The reason is pretty obvious: without the hope of a recouping a return on investment, Big Pharma is unlikely to pour money into lead compounds and accept the associated risk. Put simply, poor people can’t afford to pay premium prices for more effective treatments, and poor people live in poor countries that can’t do the research themselves. The black heart of pharma is no blacker than any other company with a fiduciary responsibility to its shareholders.

I think the case of Coartem (artemether-lumefantrine), a potent treatment for malaria, is instructive. As far as I know, it's the only new, on patent, single-manufacturer drug to treat a disease of the poor to come out in the past 10 years.

Artemesinin, the most potent part of Coartem, was discovered in the late 50’s by Chinese scientists who realized that grinding up leaves of an indigenous plant was a cure for fever. Lumefantrine, also discovered in China, was another drug which killed malaria in another way. The combination drug, Coartem, was overlooked by the West who predominantly focused on vector control. Once the mosquito population was quelled in developed nations, interest in new treatments for malaria was stifled for 40 years. Ciba-Geigy ultimately acquired the sole worldwide manufacturer of artemesinin as a strategic maneuver to enter the Chinese market. At the time of the Ciba-Geigy/Sandoz merger in 1996, artemesinin found its way to the chopping block as a small, unprofitable, and therefore expendable compound for the new company, Novartis. If not for an intense interest by the CEO, Daniel Vasella, Coartem would have been lost. Dr. Vasella felt that Coartem had the possibility to save lives, and he therefore launched large-scale clinical trials at a high cost to Novartis. These demonstrated efficacy of > 95%.

Coartem was initially marketed, at a cost of 60 dollars a course, to European travelers and represented about 2 million dollars in sales. By 2004, Coartem was becoming recognized as a miracle drug. There were very few side effects, and the combination drug had no known resistance, whereas monotherapies like chlorquine were becoming widely ineffective. Vasella realized there were many more patients who needed the drug, but the plant was only grown in one place, and the people who needed it could not afford 60 dollars per treatment. A complex deal was brokered between the WHO, the Global Fund for AIDS, TB, and Malaria, and Ministries of Health. Under the arrangement, the WHO would predict the number of needed doses and add the drug to the essential medicines list, Novartis would manufacture and ship the drugs, and MOH’s would place orders paid for by GFATM. In the span of 3 years, Novartis increased its production of Coartem for 10,000 doses to 60 million doses, one of the greatest scale-up operations ever.

Novartis lost boatloads of money on the operation. Some estimates suggest they lost 80 cents a dose on the deal. Why? They planted acres and acres of artesia annua around the world, tied up working capital in factories in China and New York, and worst of all, the country orders fell way short of WHO estimates, which left millions of Coartem doses to expire on warehouse shelves. With no guarantee of purchases, Novartis was left with piles of inventory, detonating an already break-even business plan, not to mention the opportunity cost of not producing more Diovan, their blockbuster antihypertensive. So, why’d they do it? Vasella argues that that ethically they had no choice. Withholding the treatment would be tantamount to killing millions of people. Further, he points out, employees feel (and work) better if they’re working at a malaria company instead of an evil pharmaceutical company. Coartem, after all, is the number one drug by volume that Novartis makes. Keeping factories running 24/7 leverages economies of scale, sops up excess manufacturing capacity, and creates jobs. Finally, Coartem could be a way to develop relationships with big pockets like the Bill and Melinda Gates Foundation, USAID, and middle income countries like Brazil, India, and ironically, China. At Novartis, Coartem is a loss leader - the millions they lose on one drug for the poor pales in comparison to the amount of money they stand to make on say, chemo.

A number of questions are still outstanding. Are there other drugs collecting dust on remote scientists’ shelves? How do we get pharmaceutical companies to invest in treatments for diseases that disproportionately affect poor folks? Are pharmaceuticals even the right people to create these therapies? How is the partnership between funders, manufacturers, distributors, and the people taking the drugs worked out? How has the landscape changed with the light of multilaterals shining not just on procurement but drug discovery and delivery? The Coartem story can be read as a success and as a dismal failure. Only time will tell if other companies will take Novartis’ lead or use Coartem as an example that R&D for diseases of the poor only eats into the bottom line.

Can Obama's Economic Plan actually stimulate health care?

Jeff - great point, and one that has not fallen on deaf ears. Obama has heard you loud and clear and proposes to use a portion of the stimulus package to health care jobs stimulation.

When you dive into the stimulus package - it seems to break down currently into the following buckets:

• $39 billion in subsidies to health insurance for the unemployed; providing coverage through Medicaid
• $90 billion to shore up state Medicaid programs
• $20 billion for health-information technology systems
• $4 billion for preventative care

Infusion of capital into the insurance markets will help preserve jobs, but I think the real jobs creation is in the $20bb for HCIT. The question is how does a technology solution that conceivably kills jobs (less need for transcriptionists, filing and admin support) create other types of jobs?


Halamka - the CIO and an ED doc from the BI has outlined how his organization has created jobs through EMR implementation . The link is here

The Health Care Blog: Electronic Medical Records and Obama's Economic Plan

The meat of the post is as follows:

"In 2009, we will implement 150 physicians in 75 practices, or 13 physicians in 6 practices per month. The direct staff we'll need are:

Massachusetts eHealth Collaborative: 6 FTEs (5 practice consultants plus a project manager)

Concordant: 9 FTEs (5 on-site assessment/design/deployment/support, 2 technical lead/system architect, 2 project management)

eClinicalWorks: 4 FTEs (3 on-site trainers, plus part of a product specialist and a project manager)

At BIDMC, the project is run by 3 FTEs (Project Director, Technical Lead, Senior Practice Consultant)

Thus we've created 22 jobs for the rollout and support of our EHR project. Multiply this by the number of clinicians needing EHRs in the country and you'll see that the Obama plan will create tens of thousands of new high tech jobs."

I don't disagree with the numbers of people required. At approximately $25K / physician install costs, with ongoing annual service costs of approximately $8k - $20bb will not cover the remaining 86% of physicians who do not have an EMR office solution. Also, part of the reason that EMR hasn't taken off (in addition to a whole host of reasons I'll post at some point) is that the install process requires too many people and disrupts the office operations to an unacceptable degree. So for EMR install gain acceptance, we will need to find solutions that require less people. That means engineering jobs to develop the lower footprint install. But will the stimulus go directly to providers or to HCIT vendors?

Anyways, not a structured argument - but essentially I think Obama's proposed jobs creation program should theoretically focus on health care - but it's not really clear that the program will really create jobs directly.

Regardless, the stimulus is the right steps towards increasing access to health care while driving down costs and raising quality.

Stimulate health care

Much has been written about the need for a large government stimulus to boost spending (and make up for reduced spending by businesses and individuals) and raise employment. The focus has been on infrastructure and construction, and on "shovel ready" projects. While many regions of the U.S. certainly do need improved roads and bridges, I would argue that focusing a stimulus primarily on infrastructure ignores the shift in our economy over the last half century from a manufacturing-based to a service-based one. More specifically, health care is a huge source of employment in the U.S., and a driver of well-paid, highly-trained employment. According to the 2002 U.S. economic census (the last economic census published), "health care and social services" was the largest employer of any segment in the economy. A quick survey of major cities shows that in many cases, a health system is the largest private employer: NY-Presbyterian in NYC (Crain's), Kaiser Permanente in LA (LA Almanac), Partners in Boston (Dept. Labor and Workforce Dev.). I would bet the data is similar in most MSAs.

Why not focus the stimulus on health care? Instead of shelving his health care reform efforts because of the recession, shouldn't Obama make it even more of a priority? Improving health coverage boosts demand for care (this has clearly been the case in MA), which helps some of the largest regional employers across the country. It will boost demand for good jobs (RNs, PAs, medical assistants, medical technologists, among many others) which should stimulate more people to train in these fields (come to think of it, a good stimulus program should probably pay for these training programs). Of course, hospitals and clinics still need secretaries, coffee shops, and janitors. And, lest we forget, better health care is an inherently good thing (unlike more pick-up trucks).

A Tactic to Cut I.C.U. Trauma - Get Patients Up

Contrary to popular belief, many people do survive their stay in the ICU - the issue for them is recovering from their critical illness as quickly as possible.

See this week's widely circulated nytimes article on tactics to do exactly that:
A Tactic to Cut I.C.U. Trauma - Get Patients Up - NYTimes.com

The actual engineering behind the walker devices for ICU patients is incredible:

ICU Walker

Many technologies drive the cost of health care - this one at least seems to drive down in-hospital costs of health care. Paradoxically, it increases out-of-hospital costs of health care, but that's a debate for another post.