As new models of health information technology are unveiled and more federal support is committed to their promotion, we gain a clearer vision of what health care could and probably should look like in the not-so-distant future:
- Our complete medical records, including recent test results, will be accessible electronically at every doctor's office and hospital we visit, eliminating the need to complete a set of forms every time we walk into a new practice.
- Instant communication between the specialists who serve us will negate multiple, redundant tests and appointments.
- More efficient medical facilities will be able to focus on the prevention of health problems and the maintenance of our chronic conditions, rather than harried aid only in the case of emergency and illness.
But what has also become clear is that for all the hopes of leading thinkers in medicine, government and the tech industry, the road to health-care nirvana is going to be bumpy — and expensive.
From the Fax Machine to the Cloud
Consider the case of electronic health records. A core piece of any blueprint for more efficient health care, such portable records — stored in the data cloud — are expected to improve doctors' ability to diagnose patients correctly, speed up care and reduce costly and time-consuming redundant testing.
The high-tech transition, however, won't be seamless. Last week Jessie Gruman, founder of the Center for Advancing Health and author of Aftershock: What to Do When You or Someone you Love Is Diagnosed with a Devastating Diagnosis, wrote about a snag she encountered when she went for an echocardiogram. Gruman reported on Dr. Kevin Pho's popular medical website, KevinMD.com, that her cardiologist asked her to fax the name, address, affiliation, phone number, fax number and email address of her primary care physician, oncologist and two other specialists so the office could forward her test results. But Gruman has no fax machine and her cardiologist doesn't accept email from patients. So she had to send the information by snail mail — not exactly a 21st-century transaction.
"I wish I could tell you that this little tangle was a one-time glitch in otherwise smooth care-coordination by my clinicians. But it's not," Gruman wrote. "For me and for millions of others with chronic conditions who are treated by multiple doctors in different settings, this is normal."
The Obama administration's $800 billion 2009 stimulus program devoted money to the creation of a uniform standard for electronic health records and created incentives within the Medicare reimbursement system to push doctors and hospitals to begin using the records more widely. A recent survey found that about 70 percent of doctors now use electronic health records in some form, which many experts see as a tipping point. Federal officials predict that, despite the significant upfront cost of technology, wider adoption of electronic health records will eventually reduce fees for providers and patients alike.
But that efficiency is thwarted when a provider with a state-of-the-art records program can't communicate with other clinics. (At many large hospital systems and medical centers, doctors can't even communicate efficiently with other offices in the same complex.) The average doctor in the United States still receives 1,100 faxes a month, according to Jonathan Bush, chief executive of the health information technology company Athenahealth.
"I'm aware that if I don't coordinate my information, it's not going to happen," Gruman wrote, "and I'm resigned to unraveling the different rules for transmission of each practice and hospital and testing site. But many people just assume that test results will be automatically and magically sent to the right doctors and don't bother to request that it be done. Most of us don't track the fast-changing relationships among entities within health care. Indeed, how would we know whether or how our cardiologist is connected to our primary care provider or to a specific hospital, especially since this may have changed since our last visit and may or may not involve a shared electronic health record?"
A recent study on the adoption of information technology in health care settings, published in the journal Health Affairs and cited by Gruman, bemoaned the lack of progress. Adoption by clinics has been sluggish. Some software chosen by providers is difficult to manage. And even when good systems are in place, too few practices realize the benefits of fully integrating technology into patient care. The study's authors, representing Harvard Medical School and the RAND Corporation, called for "more-standardized systems that are easier to use, are truly interoperable and afford patients more access to and control over their health data."
When electronic health records systems can't communicate with one another, it often leaves patients with the responsibility of arranging for key records to be shared among offices. But as Gruman points out, we may not realize which doctors need to see our test results and may not have the time — or if we're ill, the energy — to fulfill the task.
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"The current lag in information technology undermines the quality of our care, costs us and the system money and requires a considerable investment of our time," she writes. To avoid redundant testing and flawed diagnoses made on the basis of incomplete information, Gruman recommends that all clinics, practices, hospitals and testing sites provide patients a standard, printed statement at each visit, detailing how (and whether) its staff will transmit records to other physicians and specifying what procedures, if any, patients need to take on their own to facilitate transfers.
"I just want my clinicians," Gruman writes, "to tell me whether they are going to do this for me. And then I want them to either do it or make it easier for me to do it myself.
"This is not my job and I'm not good at it."
What Could Possibly Go Wrong?
There are some concerns across the industry that even when electronic health records become more widespread, companies and consumers may not see their costs drop. The New York Times recently reported that Kaiser Permanente, one of the nation's most technologically integrated health care providers, still has not realized hoped-for savings.
In the cover story of the current issue of The Atlantic, "The Robot Will See You Now," Jonathan Cohn explores the development of new, computer-based diagnostic systems. They're based on technology developed for IBM's Jeopardy!-playing Watson program and meant to help doctors speed up diagnoses and avoid errors. His article also touches on the potential pitfalls of an era when doctors can access patients' complete histories, test results and range of possible diagnoses with the touch of a finger.
Citing a separate Health Affairs study from 2012, though, Cohn writes that doctors who had instant access to patients' test results actually tended to order more tests, not fewer, seemingly because they knew they could see the results immediately and, ideally, make a more informed diagnosis. "If new tools allow providers to process far more information than they do now," he wrote, "providers might respond by trying to gather even more information."