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Higher quality health care, lower cost

MANY SIGNIFICANT TRENDS ARE affecting health care in the United-States: costs are increasing at a rate that is more than twice the rate of inflation; individuals are living longer, requiring more health care during their lives; on average, people are wealthier than they were just a few years ago, demanding better health care, and are willing to devote more of their discretionary income to staying well and having a better quality of life; patients are becoming much more knowledgeable about their problems, thanks to the Internet, and expect to be treated according to what they read; and finally, patients and health care providers are subject to increasing time pressures. Those trends are placing enormous pressure on the health care system. With premium costs rising rapidly, patients, health plans and employers are looking for creative solutions that will provide higher quality care at an overall lower cost.

A major solution is to use electronic clinical decision support systems that aid physicians in delivering the best medicine to their patients. Solving patient problems early results in better quality care delivered at a lower cost. Also, fewer medical errors will occur as a result of "just-in--time" medical guidelines (i.e., when the doctor needs it for the presenting patient). Today, technologies exist to help solve this problem.

Health care costs-row at a double-digit pace in the early 1990s. In response to the outcry by employers, employees and dependents, many health plans and Medicare held down reimbursement levels in an attempt to control the cost increases. This helped in the short run, and the rate of increase of health care costs in the mid- 1900s dipped to just over the rate of inflation. However, the fix was short-lived. As the decade . waned, health care costs began rising eventually reaching today's double-digit, pace.

How have other industries solved similar problems? In the 1980s, America's automobile industry was under attack by Japanese companies delivering higher quality cars at lower prices. American auto manufacturers had become complacent about producing quality products. Once the industry acknowledged this new competitive environment, it realized that it had to deliver a much higher quality product at a. lower price.

After wrestling with making manufacturing processes more efficient, the industry realized that it would have to first of all design more innovative, stylish, and better quality products, and solve any manufacturing issues to bring those products to market. In addition, design would have to be done electronically, with the digital design handed to manufacturing. The result was a cheaper, easily repeatable manufacturing process that produced letter quality, less expensive products. Other industries have learned the same lessons.

What is .the analogy for the health care industry? To have all patient records available electronically during all phases of diagnosis and treatment and to diagnose patients early. It is estimated that only 5 percent of patient records are maintained in an electronic format today, and there are very few standards for saving, retrieving, and communicating patient data. That suggests that immediate cost savings can be generated through the use of electronic patient data. However, diagnosing and treating patients earlier also holds great promise in producing immediate benefits.

A good example of how this approach already is working in the health care industry can be found in the May 23, 2000, edition of The Wall Street Journal, which profiled the Merrill Lynch health plan. The paper reported, "By just about any standard, the financial-services giant is generous in what it covers." And what is the result of this generosity? "The company says its approach appears to be saving money." How does Merrill Lynch achieve lower-cost health care while treating patients generously? By focusing on "the quality of care and early detection" of patient problems. The company has developed electronic systems to track patients and the treatment of their problems. Merrill Lynch tracks misdiagnoses, mistakes and potential disasters to better adjust procedures. The company usually covers 100 percent of a patient's- medical expenses, as long as the treatment is :prescribed by a doctor. The total focus is on quality, not cost. The result has been. better patient care and medical costs, that are 25 percent lower per employee than they are at 54 companies of similar size. Large claims (over $50,000) have declined from 3.3 per 1,000 persons in 1995 to 2,2 per 1,000 persons in 1999.

Anecdotal evidence also comes from Sage Health Management Solutions and its implementation of the RadWise service, which combines the features of electronic order entry for imaging procedures with clinical decision support. In a trial involving mainly primary care physicians, doctors used RadWise at the conclusion of their encounters to order procedures, and were given an imaging recommendation based on the selected clinical diagnosis. The diagnostic positivity was 57 percent in those cases in which physicians accepted the RadWise recommendation (60 percent is the theoretical "high-water mark"). This performance is in stark contrast to the 24 percent positivity in cases when physicians chose change the order recommended by RadWise. Clearly, the RadWise decision support feature not only provided the referring physicians with appropriate imaging recommendations, but also encouraged best medicine, facilitating: high quality care and the savings it yields.

To examine the issue of medical errors, one leas only to look at the National Academy of Science's Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System, published in 1999. The IOM study found that approximately 100,000 deaths per year occur as a result of medical errors - more than the number of deaths from motor vehicle accidents, breast cancer, and AIDS combined. Most of the publicity about the IOM study highlighted that 10 percent of the errors were prescription related. But little mention was made of the finding that 17 percent of the errors were due to improper or incorrect diagnoses.

One of the reasons diagnostic errors occur is the large variation in training, experience and skills of the nation's physicians. The medical body of knowledge is so large and is growing so quickly that it is difficult for medical schools and medical professionals to keep up. Another reason for diagnostic errors is that medical professionals are not rewarded for identifying and solving medical errors. In fact, just the opposite occurs: doctors and other medical professionals often are the target of lawsuits and other punitive actions for mistakes or errors in judgment. Therefore, the health care system finds it difficult to document errors, learn from past errors and correct procedures to limit future errors.

In its second report, "Crossing the Quality Chasm: A New Health System for the 21st Century," the IOM recommended ways not only to reduce medical errors but also to improve health care quality for all patients. "Greater emphasis should be placed on systematic approaches to analyzing and synthesizing medical evidence for both clinicians and patients," reads the report. That is a major theme of the study. Additionally, the report cited the significant potential for "more complex applications, such as computer-aided diagnosis, ... to contribute to evidence-based practice and consumer-oriented care ...."

Another proponent of evidence-based decision support systems is the President's Information Technology Advisory Committee. In its 1999 report, Transforming Health Care Through Information Technology, the committee found that "decision-support tools can provide critical links between a current patient's condition and previous clinical studies:" The real challenge is how to collect past studies, synthesize them and have this information available to doctors at the point-of-care.

In terms of technologies available to help solve these problems, the less expensive and most ubiquitous method that can be used to achieve clinical-based, decision-support systems is the Internet. New applications and databases should all be developed to run on the Internet (or an internal intranet). That will go a long way toward implementing communication and data standards. As we have seen, the demands on the health care system are increasing as patients become wealthier, desire a better quality of life and live longer. We have also seen that electronic processes and evidence-based clinical decision support systems have the potential to decrease costs through more efficient means of documentation and communication, and enhanced productivity and accuracy. The health care community should move forward and implement standards for defining and implementing electronic patient record systems. This is a huge task, but it will have a tremendous impact on the cost to deliver health care. Secondly, more attention should be given to developing evidence-based decision support systems in order to enhance the physicians' productivity and accuracy. Clinical decision support systems have an excellent near-term potential to decrease costs, improve the quality of health care and increase patient satisfaction.

Harley Feldman, M.B.A., is chief technology officer at Sage Health Management Solutions in Golden Valley.