Illustration by Neil Donnelly
Health Care Prognosis Improves With Digital Law: Peter Orszag
Even with the all-too- depressing illustrations of political paralysis we’ve seen recently, government can still act to improve our lives. A good case in point: The U.S. health sector is rapidly digitizing, and federal legislation from early 2009, passed well before the health-care reform act, is an important reason why.
Just five years ago, only 12 percent of doctors and 11 percent of hospitals had comprehensive information- technology systems in place. With no digital records to measure patient progress and guide doctors on best practices, it’s not surprising that cost and quality of care have varied wildly, not only across the U.S. but even within a single hospital.
The Health Information Technology for Economic and Clinical Health (HITECH) Act, a little-noticed component of the 2009 economic-stimulus bill, is helping to change all that. As a result, over the next five years we will experience a substantial expansion in health IT. That digital revolution, in turn, is central to improving value in health care.
Consider the experience of Partners HealthCare System Inc., an early adopter of health IT at Brigham and Women’s Hospital and Massachusetts General Hospital in Boston. In 2006, more than two-thirds of its doctors used electronic health records and, by 2009, all of them did. The system includes integrated clinical-decision support, which gives doctors computerized help in assessing the best tests and treatments for their patients. (Can you imagine how difficult it would be for a doctor to keep up with the increasing complexity of modern medicine without such tools?)
Partners HealthCare has used its health IT to be more selective about which patients should have diagnostic imaging tests, such as MRIs and CT scans. The cost to Medicare for imaging tests nationwide roughly doubled from 2001 to 2009. And such tests are not only expensive but potentially dangerous. Frequently imaged patients face an increased risk of cancer because of exposure to excessive radiation.
Doctors at Partners now order imaging scans through the computer system and are automatically queried about the patients’ characteristics. For each case, the software then provides an “appropriateness” score, reflecting evidence- based protocols for the image requested. And in some cases, the program suggests an alternative to imaging.
The system is also used to compare doctors to one another, so they know if they use imaging tests more or less than their peers do.
From 2006 to 2009, imaging rates at Partners flattened, and in some specialties even started to decline, sometimes significantly. The number of outpatient images per patient, for example, fell 25 percent in that period, even after adjusting for patient characteristics such as age, ethnicity, gender, medical history and medications.
The Partners HealthCare data suggest that doctors who use imaging a lot in one year will tend to do the same in subsequent years. They also indicate that imaging rates vary by doctor. In 2006, a doctor at the 90th percentile (meaning he ordered more images per patient than 90 percent of doctors) ordered about 28 images for every 100 patients, almost four times as many as a doctor with rates at the 10th percentile. To make a meaningful dent in the use of imaging tests, the doctors who use them the most need to change their behavior.
The IT interventions appear to have been effective at reducing imaging rates across the board, including among the doctors who ordered the tests most. By 2009, that doctor at the 90th percentile ordered 20 images per 100 patients, a decline of almost 10. This one doctor’s net decrease in scans was larger than the total number of scans ordered by the doctor at the 10th percentile even in 2006. And the low-use doctor reduced his rate, too, by about two images per 100 patients.
The experience has likewise been encouraging at other health-care centers, even some that are much smaller than Partners HealthCare. Stellaris Health, for example, a four- hospital network based in Armonk, New York, has used its IT system to reduce instances of venous thromboembolism. This cardiovascular condition is a precursor to pulmonary embolism -- a blockage of an artery in the lungs -- which is the most common preventable cause of hospital deaths.
Stellaris coded into its electronic medical-record system the risk factors for venous thromboembolism, and taught its doctors evidence-based practices to minimize those risks. Today, 99 percent of Stellaris doctors follow the practices, up from about 80 percent in 2007.
Better Health Care
More broadly, health IT is a necessary but not by itself sufficient step toward improving value in health care. A review of the health IT studies by the Congressional Budget Office, published in 2008, while I was the director of that agency, concluded that it “has the potential to significantly increase the efficiency of the health sector by helping providers manage information.” The CBO also found, however, that health IT couldn’t realize this potential without a supportive health-care delivery system that uses it aggressively. The most auspicious examples of IT use were in relatively integrated systems, such as Veterans Affairs, Partners HealthCare, Kaiser Permanente and Group Health Cooperative in Seattle.
In places where the technology is used to compare doctors’ practices, bolster adherence to evidence-based medicine, examine what techniques are working best and reduce error rates, it can be quite beneficial.
So what has changed to increase the use of health IT? First, like all computer technology, health IT keeps advancing, so that it has become somewhat less intrusive to the practice of medicine. Many doctors find tablet computers, for example, more convenient than laptops or desktops in the examination room.
Just as important, and perhaps more so, under the first stage of the HITECH Act, doctors who adopt electronic health records can receive incentive payments of as much as $44,000 from Medicare or $63,750 from Medicaid; hospitals can qualify for payments of $2 million or more. As of early August, Medicare providers had received $400 million in incentive payments for health IT, and much more is in the pipeline. Surveys suggest that while the first-stage incentives are available, at least two-thirds of American hospitals will adopt new systems.
Starting in 2015, the Medicare subsidies for adopting health IT systems are to be replaced by penalties for not doing so.
To be sure, investments in information technology are only part of what’s needed to improve value in U.S. health care. Still, in this summer of despair over politics in Washington, the early success of the HITECH Act is a refreshing reminder of what sensible policy can accomplish.
(Peter Orszag is vice chairman of global banking at Citigroup and a former director of the Office of Management and Budget in the Obama administration. The opinions expressed are his own.)
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