When I speak to clinicians and other healthcare professionals, an important part of our discussion relates to the driving forces behind new policy, payment, and programs that, to some, seem to come out of nowhere. Whether it’s the medical home, medical home neighbor, EHR incentive program, ICD-10, ACOs, Comprehensive Primary Care, Bundled Payments, or other initiatives, fundamentally these are all about trying to address accelerating healthcare costs, mediocre quality indicators, and highly variable access to care. Access, Quality, Cost: Achieving a balance between these three factors is a major challenge, and the data suggest that the United States can certainly do better. Consider this:
- The U.S. spends almost twice per capita on healthcare than the nearest OECD country (Organization for Economic Cooperation & Development).
- By 2018, national health expenditures are projected to reach $4 trillion and 18.7% of the U.S. gross domestic project.
- In 2009, 10% of the U.S. population accounted for approximately 65% of U.S. health expenditures.
For all that we spend on health care in the U.S., the results are not stellar. Here are a few statistics:
- Nearly 2 million Medicare patients are readmitted within 30 days each year; many of these could probably have been avoided.
- Approximately 33% of emergency department visits among Medicare beneficiaries are likely avoidable.
- The U.S. was last in amenable mortality in 2006–2007 with a rate of 96 deaths per 100,000 compared to 55/100,000 in the best country (France).
- In 2007, the U.S. had the worst rate of lower extremity amputations related to diabetes among OECD countries: 36/100,000 versus 9/100,000 in the United Kingdom.
Source: The Commonwealth Fund
In a survey of healthcare opinion leaders in 2011, (subscription required) 89% rated the U.S. healthcare system’s performance as unacceptable/very unacceptable with regard to efficiency (defined as avoidance of overuse or inappropriate use of services, preventable hospitalizations and readmissions, regional variation in quality & cost, administrative complexity, and use of information systems). I suspect many of you would likely agree with that assessment given your day-to-day experiences providing healthcare.
Since the AmericanEHR community is focused on health IT, how could technology support improvements in quality, cost, and access? Given the recent criticism of the RAND report from 2005, it is important not to overstate the potential impact of health IT on access, cost, and quality. However, if appropriately designed, implemented, and used, most clinicians would likely agree that health IT should be able to positively influence outcomes in at least some situations. Consider the potential effects of the following uses of health IT & EHRs:
- Patient portals allowing a patient or family to request an appointment that aligns with the availability of their chosen clinician. (Access)
- Emergency Departments and discharge nursing staff being able to access schedules for primary care clinicians to make follow-up appointments to assure appropriate transitions in care and clinical follow-up. (Access; Quality)
- Population management features/functions that identify patients in need of appropriate follow-up based on clinical indicators, laboratory tests, and appropriate screening protocols. (Quality; Cost)
- Clinical decision support that, in real-time, identifies gaps in care so that patients and clinicians can engage in shared decision-making and develop a care plan that is actively followed by both the patient/family and the clinical team. (Quality)
- Dashboards that provide quality snapshots of specific patient sub-groups within a practice for targeted interventions and follow-up such as those recently discharged from the hospital; patients recently started on complex medication regimens or high risk medications; patients belonging to specific vulnerable populations. (Cost, Quality)
These are just a few ways in which health IT can help address the challenge of maximizing access and quality while controlling costs. Attaining Meaningful Use (MU) objectives & measures is important for practices to receive incentive payments. However, it may take a narrower focus on those health IT functions that can reasonably be assumed to result in a direct effect on access, quality, & cost before major improvements in outcomes will be realized.
What do you think?
This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP).