Health Care Anew

IT Priorities 

As an inveterate critic of how hospitals have gone about applying information technology, I enjoyed during the latter of my working years pointing out that while we were spending untold numbers of dollars and man hours trying to create an electronic medical record, we had not proved ourselves able to computerize our internal telephone directory.   And so at considerable expense we would issue an updated print version of the phone book every year or so. 

So it was with both amusement and interest that I noted a small story in the May 11 issue of the New York Times reporting that the government of the City of New York was for the first time publishing its official directory in digital form, available on the Internet at www.nyc.gov/greenbook.   

What this reveals, I believe, is that the internal structure of hospitals and governments is to a large extent political in nature, with decisions and priorities being affected more by the relative clout of the proponents than by the content of the matter under consideration.  In the case of hospitals, the people interested in medical records are more powerful than the people interested in telephone books and so when it comes to allocating information technology resources, medical records has a big leg up.   A modest investment in computerizing the phone book could save some money right away, whereas it is by no means clear that the enormous investment in developing the electronic medical record has ever yet produced a financial return.  But the priority goes to where the power is. 

I’ll still keep looking for the hospital that follows the example of the City of New York, but I’m not holding my breath.

Moving health care into the computer age continues to be a popular cause among health care gurus, pundits and policy wonks. 

The April 30, 2012 issue of The Boston Globe had quite a long article on the subject, titled Goodbye, Paper.  The subhead read “Electronic health records are being used in hospitals and doctors’ offices.  So how are they doing?  Do the e-records protect and promote patient safety?” 

The answer was equivocal.  Some studies suggest that they do while others claim to identify adverse unintended consequences, like ordering more expensive tests (presumably because computers make it easier to do so). 

In my opinion, the wrong question was asked.  The question should have been “Do providers who seriously try to improve patient safety find e-records helpful?” 

Surely the answer to that question would be a resounding ‘yes.”  Collecting data, massaging it and making it widely available is an integral part of safety improvement efforts and is what computers do well. 

The bulk of the effort to expand the use of computers in health care continues to be based on the belief that doing so will result in better care at lower cost.  Eventually that may happen, but it will take a long time and the cost will be enormous. 

The right way is to insist that providers get serious about improving quality and containing cost.  Once they do, they will quickly learn that computers can make the job a lot easier.

I have long been fascinated by the subject of how culture changes.  Along the way I have observed one process of change.  When doing a particular thing violates a cultural norm, people will sometimes just quietly start doing it with cultural acceptance coming later.

A current example is the salaried practice of medicine. 

When I began my career in the 1950’s, medical culture considered salaried practice to border on the unethical.  Group practices got away with it so long as they were controlled by physicians.  A few teaching hospitals employed faculty members and used their academic role for cover.  But for the rest of the profession, salaried practice was strongly frowned upon. 

One expression of that disapproval was the prohibition against so-called “corporate practice,” which says basically that a corporation may not hire a physician, charge for his or her services, and keep the money.  Several states have laws on the books that make that practice illegal. 

A feature called “datadig” in the March 2012 issue of Hospitals and Health Networks, the journal of the American Hospital Association, reported that twenty per cent of all practicing physicians in the US are now employed by hospitals.  And by all indications, that number continues to rise. 

While the prevalence of salaried practice is well along, the cultural opposition to it remains largely untouched.  I hear no talk of repealing the anti-corporate practice laws. The obvious form for the Accountable Care Organizations now being encouraged is the community hospital with a salaried medical staff, but it is hard to find anyone who will say that.   Organized medicine no longer talks about it.

At first thought, it would seem that this kind of change would go faster if we were able to talk about it.  But maybe talking about it would actually slow it down.

The rate of cost escalation in health care seems to be slowing down but nobody knows why. 

A front page article in the Sunday New York Times of April 29 reports that health care costs rose at a rate of less than four per cent during 2009 and 2010.  This is close to a sustainable rate and much lower than had been the case in previous years. 

When asked what had caused the change, the standard answer from the academics and gurus quoted was that they had no idea. 

I take that to be a sad commentary on the performance of the intellectual community.  After all the attention that has been given to health issues during recent years, after all of the concern expressed over the high and rising cost of health care, and despite the millions spent annually on research in the field of health care, the level of understanding of the economics of health care remains at such a primitive level that when there is a significant change in economic trends, no one can come up with so much as a plausible theory to explain what is going on. 

I attribute this to the intellectual community’s obsession with single payer; i.e., national health insurance.  Single payer would pretty much cancel out any operation of market forces in health care and individuals in academia apparently have been afraid to explore the subject of how those forces work for fear that such exploration would be seen as a lack of dedication to the single payer idea. 

I call that intellectual nonfeasance.