Electronic Health Records and Prospective Health Care

Last week Don Berwick announced his resignation as Administrator of CMS. In his parting speech, Dr. Berwick listed his top 5 reasons as to why there is so much waste in the US health care system.

These five reasons were as follows:
1. The over treatment of patients
2. The failure to coordinate care
3. The administrative complexity of the health care system
4. Burdensome rules
5. Fraud

In a post on this week’s Health Care Blog, Dr. John Halamka argues that a common solution which would at least in part address each of these issues is the electronic health record. I think the point he is making is on the right path but that it would be better served taking it one step further: an electronic health record in the context of Prospective Health Care. Prospective Health Care is a coordinated approach to health care and wellness which involves personalized health risk assessment and the development of a personalized health care plan to ensure maximum patient involvement and engagement in their care. IN this model, the personalized health plan is coordinated between the patient, a health coach when appropriate, and the provider system.

By focusing on an electronic health record itself, we risk missing its necessary precursor – a strategic approach which addresses the needs of each patient by tailoring their health care plan to meet their individual needs. An electronic health record is a tool which would help implement and optimize this type of approach, but would be insufficient on its own.

In the context of each of Dr. Berwick’s five reasons for waste, Dr. Halamka suggests that electronic health records would mitigate each of these factors.

To address over treatment of patients, Dr. Halamka suggests that EHRs could automate alerts and reminders as to what his patients need. If such alerts and reminders are not tailored to the specific health and wellness needs of individual patients in the context of their personal health plan, one could see how these types of systematic alerts and reminders could potentially exacerbate over treatment rather than curb it.

In terms of coordinated care, EHRs will certainly allow multiple providers greater ease of access to a patient’s health and treatment information and provide the opportunity for improved communication between different providers working with the same patient but unless the patient in question has a personal health plan in place to drive the strategic approach to their individual care, there can be no guarantee that these different providers are working with the patient towards a common goal. If providers are not working in tandem the opportunity to reduce waste is missed.

Dr. Halamka also gives examples as to how the next three contributors to waste, complexity, rules, and fraud, could be mitigated by EHRs as well – mainly by streamlining some of the administrative complexities of the health care system by having EHRs that automate care plans, provide feedback at the point of care, and process payments based on measured outcomes. He also suggests that the data generated by ERHs would allow analysts to look for patterns of care that are outliers and thus potential indicators of fraud. For each of these instances it would still be important for EHRs to be utilized in the context of personalized health planning to ensure that patients are receiving and providers are being reimbursed for providing patients optimal care for their individual health and wellness goals.

While EHRs are an important tool to help drive appropriate treatment of patients, coordination of care, and reductions in administrative burdens and the potential for fraud to help eliminate waste, they can only do so optimally in the context of prospective health care.

To fix our economy, we must reform health care delivery

The dominant political debate of the day regards the form of tax legislation needed to prevent major tax increases beginning in January 2011. Underlying this debate is the weakness of our economy and the loss of employment for so many Americans. There were many drivers of the economic "melt down" in 2008 but one that has gone out of focus recently is the tremendous burden of health care costs. And with the passage of last year's health care reform legislation (PPACA), costs will increase even more. Regardless of the outcome of new tax legislation and potential stimulus spending, deficit reduction remains a necessary yet menacing challenge. What needs to be discussed more rationally and addressed quickly is how we stem the continued escalation of health care expenditures, particularly with the passage of PPACA and the increased coverage of many more Americans.

In an editorial in this Sunday's New York Times, this issue is discussed with a primary focus on reducing costs by cutting Medicare expenditures and increasing the costs borne by individuals. Neither of these approaches gets to the root of the problem. Lowering overall expenditures for
health care must be addressed as our current weakened economy is straining under this burden. Importantly, it is feasible to both lower costs and improve care! PPACA, while monumental in its scope, focuses largely on insurance coverage but deals lightly, and in my view ineffectively, with the root problem of health care delivery in the US. Our health care delivery "system" is uncoordinated, reactive, and focused on the expensive treatment of disease events associated with late-stage preventable chronic illness. Physicians and providers are currently rewarded economically for interventions, particularly invasive ones. It is recognized that coordinated care which emphasizes prevention and, when needed, interventions over time, and is focused on a motivated and involved patient, provides the most cost effective outcomes. Reimbursement for prevention and coordinated care to minimize disease is insufficient to cover costs. Yet reimbursement must be structured to reward such care. PPACA addresses these issues, but the solutions require the establishment of new bureaucracies, many years, and changes that will be subject to intense political debate. The type of care needed to improve health, outcomes and decrease costs is well understood today, but little is being done to foster its adoption. Care must be coordinated, personalized, preventative, and involve an engaged patient. Unfortunately, current incentives work against such models of care being established. I don't see a timely solution, given the current approaches.

To foster change, I propose highlighting the imperative to do so along with the establishment of a bipartisan Presidentially-appointed committee charged to recommend new models of coordinated care delivery and reimbursement strategies. The Bowles-Simpson Committee is an example of a bipartisan approach to recommend solutions to knotty problems. The report of a Health Delivery Improvement Committee could be expected within six months. Both private insurance and CMS could provide reimbursement incentives to foster recommended changes rapidly. The answer to our current wasteful approach to health care will be far easier to find than overall solutions to a tepid economy, but the former will provide strong support to make the latter solution easier.