The Reason Why: Cheap & Easy Connected Health Tools Should Come Before EMRsBy Joseph C. Kvedar, M.D.
Within the administration's health reform agenda, its strategy for modernizing the healthcare system by sponsoring a widespread implementation of EMRs is admirable, and necessary, but also terribly insufficient.
There are several reasons for this, not least is the practical reality that the bulk of physicians who would benefit most from this technology -- independent doctors working in small practice groups of two or fewer – cannot afford to implement a modest $300,000 EMR system, even with the administration’s $40,000 subsidy. This is especially problemtatic because at least 33% of the nation’s roughly 820,000 licensed physicans work in such small practice groups.
According to a report from The Center for Studying Health System Change, physicians are now migrating away from small practice groups, but they are not moving into “large, multispeciality practices, the organizational model that may be best able to suppost care coordination, quality improvement and reporting activities, and investments in health information technology.”
The very ugly truth is that even where physicians can afford to implement an EMR, evidence that an EMR alone can improve population health or cost-efficiency is lacking. In fact, the evidence suggests that without concomitant payment reform, an EMR roll-out will merely increase the cost of care. (Absent payment reform, expanding coverage to the uninsured will also spike costs, without any guarantees of improving quality.) While payment reform is being pursued vigorously at the state level, most notably in Massachusetts, it is not top of mind in DC right now.
So this begs some questions: 1) How big a contribution to our reform effort can an EMR roll-out have if only specialists, large practices and hospital systems can afford to particpate? 2) At a time when federal resources are scarce, is this the best use of $36 billion in taxpayer funds? 3) If EMR adoption or universal coverage are pursued without payment reform, how will we decrease our overall cost of care?
The good new is that there are alternatives to a full scale EMR implementation, like “connected health” tools. I am thinking of tools like blood pressure cuffs, glucometers and smart pedometers. Each uses electronic sensors to allow patients to collect their own health data easily, and as-needed, and then upload their data to the Internet. Physicians can track their patients’ status remotely, intervening when necessary and in a just-in-time manner. Patients possessed of their own health data are also empowered for “self-care.”
How does this contribute to reforming the system? The continuous data stream gives the doctor an opportunity to deliver higher quality care. Patients being monitored remotely from their homes spend less time in a doctor’s office. This cuts costs—measured in hours and dollars—for the patient and the physician. Best of all, connecte health tools are cheap. Doctors (or employers and payers) pay little as $20 per patient, per month to use them. You don’t need advanced math to see the cost-effective ness of the value-added here when compared with a seven-digit EMR installation.
Other connected health tools include:
Hypertension Connect is a program being implemented in primary care practices at Partners Healthcare that requires patients with newly diagnosed or difficult to control hypertension to upload blood pressure readings several times a week and allows a clinician to make rapid therapeutic changes achieving control quicker – thus the connection to meaningful use. In a clinical trial this intervention was associated with significantly lower blood pressure than a control group. This program delivers further value in a setting where the provider is in a pay for performance contract or a capitated payment arrangement. The cost is less than $50 per patient per month.
Diabetes Connect is a similar program where newly diagnosed diabetics, or folks starting insulin are asked to upload their glucometer readings. They are able to see the readings in the context of other variables (diet, exercise, stress) on a website which is also available to a provider (usually a nurse) in their primary care doctor’s practice. We’ve had good early success with this program being associated with dramatic lowering of A1c, which is both a component of meaningful use and associated with lower cost of care.
In a perfect world, connected health tools will be integrated into an EMR. Doctors will also have the option to choose from a palate of simple EMR modules that can be combined to meet their unqiue needs. (One such emerging concept is known as Clinical Groupware.) But until such time as EMRs become cheaper and more accessible to individual physisicans, doesn’t it make sense to leverage these connected health alternatives, to help us begin to meet some of our reform goals – for less money and in less time?
The very good news is that doctors can use these “connected health” alternatives to achieve “meaningful use”, the administration’s new standards for measuring quality improvements from electronic tools. Criteria for meaningful use include such things as ‘percent of diabetics with HbA1c under control’ and ‘percent hypertensive patients under control’. Better still, as physicians focus on performing to “meaningful use” standards, they inch closer to a framework where they are being paid for outcomes, rather than volume of procedures.
It’s time to begin investing in patient self-management tools, to give some responsibility for improving health and lowering costs to our citizens. This would offer some balance, at least, to the administrations $36 billion investment in EMRs.
Joseph C. Kvedar, M.D., is Founder and Director of the Center for Connected Health, a division of Partners Healthcare that is applying communications technology and online resources to increase access and improve the delivery of quality medical services and patient care outside of the traditional medical setting. He is internationally recognized for his leadership and vision in the field of connected health and the application of communications technologies to improve healthcare to patients. Dr. Kvedar is co-editor of Home Telehealth: Connecting Care within the Community. |
发表于 2009-10-30 16:06:27
