I supervise junior gastroenterology doctors in the hospital on Friday mornings where the sound of my clinic is mainly of doctors typing. The typing is new in recent years after the clinic implemented electronic medical records (EMR) systems and required that my colleagues use them “meaningfully” (specified in federal regulations) so my healthcare system can obtain financial incentives provided under The Health Information Technology for Economic and Clinical Health (HITECH) Act.
My colleagues must also carefully interpret relevant patient test results and prior evaluations, and communicate their diagnosis and management plans to other doctors, while documenting the patient encounter carefully, not only to have an accurate record but to ensure proper billing and compliance with a variety of regulatory requirements
{mosads}EMR systems have not made these tasks easy as their work-flow and functionality are substantially less than ideal. It is no wonder that doctors currently spend about two hours in front of a computer for every one hour in front of their patients, some of it at home.
Unwieldy information systems are not the only cause of frustration. Worry about malpractice, increasing financial pressure from revenue-focused administrators, and new and changing regulatory and compliance requirements added to the already high-pressure stakes of clinical care have created a toxicity that has led doctors to have increasing scorn with the contemporary practice of medicine. Nearly one-half of my colleagues are experiencing burnout according to various surveys.
Yet, despite the frustration, the digitization of healthcare represents an untapped opportunity that could help solve many of the challenges that our healthcare system faces, the greatest of which is the trajectory of healthcare costs.
The U.S. is currently spending more than $3 trillion a year on healthcare (about the entire GDP of France). The rate of growth on healthcare spending (about 5.8 percent) is about 1.3 percentage points higher than the rate of growth of our GDP. At current rates of growth, healthcare will represent about 20 percent of our total economy by 2025. This is not sustainable.
Equally disturbing is the relative value we get from our spending compared with other nations. The U.S. spends far more than any other country on healthcare but we lag behind other countries on a variety of quality and outcomes measure as well as in our ability to provide access to care and achieve healthy lives for all of our citizens.
On the other hand, we also have much to be proud of. Citizens of the U.S. fare better than citizens of many other countries in access to new, potentially life-saving medications, specialty care and rescue care for a variety of serious conditions. However, such benefits are available only to those who are well-insured.
The last decade has brought a blizzard of new healthcare policy including the HITECH Act, the Affordable Care Act (ACA), MACRA, PAMA, and 21st Century Cures.
One objective of these policies has been to chisel away at the costs of care while improving quality and other measures of the effectiveness of our healthcare system. Such outcomes are achievable when considering the magnitude of waste, which has been estimated to be $476 to $992 billion per year in various analyses. A mixture of factors contributes to the waste; part of it stems from variability in the clinical approaches and decisions made by healthcare professionals and patients.
The care we receive should not be entirely different for the same condition based solely on what doctor we see or where we are seen when there is evidence supporting specific approaches to optimize health and reduce costs.
However, such unwanted clinical variability has been documented repeatedly for more than forty years. If you are a 70 year old man with early-stage prostate cancer, for example, your chance of having a doctor recommend a prostatectomy (surgical removal of the prostate) is up to four times higher if you happen to see a doctor in some regions of the country compared with others in which observation may be recommended.
Both approaches can achieve the same outcome but prostatectomy, in addition to being much more expensive, is associated with a risk of serious complications including urinary incontinence and impotence.
There is substantial variability in costs across regions in the U.S. and even within narrow geographic regions. The cost of a knee-replacement in Massachusetts, for example, varies from about $18,000 to $53,000 depending on where it is performed even when the outcomes are the same.
Similarly, rates of growth of healthcare spending vary across regions. We could save more than $1 trillion if we could nudge regions with high rates of growth of Medicare spending more toward the national average.
How can we address these challenges, which are deeply rooted in clinical decisions that should best be made by healthcare professionals and patients and not policy-makers? A solution that is yet mainly untapped lies in achieving the wide adoption of technologies that can help doctors and patients arrive at best clinical decisions that reflect contemporary knowledge and are cost conscious.
As we consider a successor to the ACA we should continue to put a punctuation mark on payment policies that reward the healthcare ecosystem for delivering the most value for our healthcare dollars. However, in addition to policies that reward value-based care we must put sharp focus on work-flow and the burden we have placed on our providers aiming instead to give them tools they need to help them consistently achieve high quality care at sustainable costs.
The clinical recommendations that healthcare professionals offer their patients can be right or wrong and they may be followed or ignored. One thing we know for sure is that our lives depend on the quality and outcome of that interaction. If my colleagues and I have to keep typing, let’s make every key click count.
Peter Bonis, MD is the chief medical officer for clinical effectiveness at Wolters Kluwer Health as well Adjunct Professor of Medicine, Tufts University School of Medicine. Bonis trained in gastroenterology and health services research, and prior to joining UpToDate in 1998, he was a full-time faculty member at Yale University School of Medicine.
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