Stanley Feld M.D.,FACP,MACE
President Obama’s goal for healthcare reform is to increase the quality of medical care, increase efficiency of medical care and decrease the cost of care. The goal is admirable. The route he is taking is wrong. In the process he might destroy the medical workforce.
The route the electronic medical record (EMR) stimulus package should take should be flexible and educational for patients and physicians. It should use modern software technology instead of subsidizing old inflexible technology that is set up to be punitive to physicians and patients to the advantage of the government and the healthcare insurance industry.
The term "quality medical care’ is used loosely. It has not been appropriately defined. The practice of evidence based medicine has been used to define quality medical care. The problem is evidence based medicine is changing daily.
A better definition should be the best clinical outcome with the most efficient financial outcome. It is assumed that practicing evidence based medicine will lead to the best clinical outcome at the most efficient cost.
Some guidelines are essential and should be inflexible. Others are ever changing and must be flexible. In bureaurocratic systems it is difficult to create flexible rules. Also, all patients are different. Clinical judgment plays an important role in treatment.
Physicians should not be penalized for using clinical judgment. Nonetheless, physicians are penalized in a pay for performance evaluation for deviating from inflexible clinical guidelines. Since some clinical guidelines are always changing the weakness of the approach is obvious.
An example of an inflexible clinical guideline is the need for rules to have a sterile operating room with sterile gowns and tools to avoid surgical infection.
An example of a need for a flexible clinical guideline should be a physician’s approach to a patient with hypertension. The goal should be to normalize the blood pressure. The goal for lowering the blood pressure to normal is to avoid heart attacks and stroke. However, if the patient’s blood pressure was elevated for a long period of time and was severe enough to compromise the renal (kidney)) blood flow, lowering the blood pressure too quickly could result in the patient having a stroke from a relatively low blood pressure. This is an example of the value of clinical judgment.
Physician performance should not be evaluated on static measurements. It must be evaluated on physicians’ medical judgment. Clinical judgment is a function of a physician’s ability to relate to his or her patients. (patient physician relationship)
On the other hand, if a patient felt poorly as a physician tried to lower the blood pressure to normal the patient might stop his medication without telling the physician. The physician’s workup might have been perfect and his choice of medication may have been excellent. This physician might get an excellent mark on his performance but the patient had a stroke because the patient did not comply with treatment. The patient might not have complied because he was not taught to be a professor of his disease. Healthcare is a team sport. The patient physician relationship failed but was not measured. .
The poor performance was missed by the static digital healthcare evaluation imposed by an inflexible EMR. The importance of the patient physician relationship and not including patient responsibility in the clinical outcome should be part of any performance measurement. A performance measurement should be a measurement of both the patients’ and physicians’ performance.
Now that the federal government plans to spend $50 billion to spur the use of computerized patient records, the challenge of adopting the technology widely and wisely is becoming increasingly apparent.
There is no question we should have universal electronic medical records. It should be a teaching tool for patients and physicians. The EMR should be inexpensive and flexible. It should not a tool to judge and penalize clinical performance. President Obama is being ill advised. His EMR stimulus program is going to result in a waste of $50 billion dollars.
“In a “perspective,” Dr. Kenneth D. Mandl and Dr. Isaac S. Kohane portray the current health record suppliers as offering pre-Internet era software — costly and wedded to proprietary technology standards that make it difficult for customers to switch vendors and for outside programmers to make upgrades and improvements.”
The software the government is going to spend $50 billion dollars on is going to be too expensive, inflexible and not widely distributed.
“Instead of stimulating use of such software, they say, the government should be a rule-setting referee to encourage the development of an open software platform on which innovators could write electronic health record applications”.
EMR software platforms in the cloud should be developed. This link by Christopher Barnatt is an excellent utube explanation of cloud computing. I suggest all watch it.Amazon uses the cloud to sell books. www.Salesforce.com’s business model tracks sales force activity at a minimal cost to the company. It is flexible and maintenance free.
“Such an approach, they say, would open the door to competition, flexibility and lower costs — and thus, better health care in the long run. “If the government’s money goes to cement the current technology in place,” Dr. Mandl said in an interview, “we will have a very hard time innovating in health care reform.”
The rules can be immediately changed. The cost to a medical practice could be minimal. Its effectiveness is maximal. The cost to the government using modern software technology could be between 1-10 % of what the stimulus is proposing to spend. If it is fashioned as an educational tool to patients and physicians the payback will be maximal, quality of care will improve and the cost of care will decrease.