When Connecting Our Country's Health IT, Let's Take Our Own Hippocratic Oath to "Do No Harm"

Every day, meetings and hearings take place in Washington as lawmakers, insurers, vendors to the medical community, hospitals, and occasionally practicing doctors debate the best way to computerize and connect our HealthCare Economy. The stakes are gigantic, to be sure. At $2.6 trillion dollars a year and 15% of GDP, Health Care is our nation's biggest industry, and one of the least effective. Ranked 37th place in efficacy by the World Health Organization on simple measurements like lifespan and infant mortality, we are spending a lot and not getting much. We still have some of the best doctors, hospitals, research and treatment centers in the world, to be sure, but those are bright spots in an ineffective system.

The good news is that no one disputes the system is broken. It doesn't work for anyone. Doctors, nurses, hospitals, insurers, employers and patients are all unhappy with the status quo. But why did it get this way? And what can we do to change it?

The first part of the Obama plan to fix the health economy revolves around Health IT. The American Recovery Act of 2009 has set aside $36B ($20B net) to compensate doctors who show "meaningful use" of electronic health records from "certified" systems. The sooner practitioners comply (2011 is the earliest date), the more of an incentive a doctor is eligible for -- somewhere in the range of $40k-$60k. Those words in bold have created a flurry of lobbying, testimony and opinions that cover a range of possibilities from the grandiose (every doctor will have a fully implemented system that checks everything in the patient's record, and comments as to its appropriateness) to the very simple -- the ability to keep an electronic file on a patient and submit prescriptions -- electronically.

There's even a website http://www.meaningfuluse.org/, courtesy of the Association of Medical Directors of Information Systems (not sure who they are), where vendor after vendor keeps praising and posting on "meaningful use". Ironically, despite the impassioned posts, the poll on the professional's website asks the following question

Peer Insight Poll

ARRA is most likely to result in: Spending $20B without significant benefit Transform healthcare to be higher quality and cost effective

Guess what! Two-thirds of the IT professionals polled answered "A"...they believe the government will spend $20B without significant benefit. The very people that will likely benefit from the money don't think it will have significant impact on healthcare.

So, being America, I'd like to get my opinion in here as well. It's not too late to make this money a down payment on a system that works. So for those of you setting policy on this subject, be it Capitol Hill, HITSP, the Department of Health and Human Services, please all vow to take your own Hippocratic Oath and "do no harm". The reality is that somewhere between 5-9% of American doctors have adopted some form of clinical electronic health systems, meaning a whopping 91% haven't. So we need to get real about what is possible, and focus on a standard that most doctors can comply with and benefits the doctor /patient relationship in the process.

1) First, we need to focus on finishing and clarifying the standards needed to code and deploy these systems. While huge movements have been made, especially in the last three years through a variety of organizations, there are still too many standards and definitions, and inconsistencies between them. Whittle down the list that matters, focusing on the basics, the Continuity of Care Document and those elements like lab reports, images, and medicines that populate the documents. Networks work so well because the standards are simple, but exacting. The same can't be said for Health IT standards.

2) Second - take all "non-essential" requirements off the certification list for the time being. The hardest part about technology use is adoption, and feature bloat will make it nearly impossible for doctors and their staffs to adopt some of the more ambitious ideas. Right now, the average doctor in America sees a patient for 8 minutes. And if they are typing into a keyboard, speaking notes into a mike, or doing anything else, they are not paying attention to you! How many of you can type or do data input of any sort while really paying attention to someone else? If any of you have doctors that use tablets today, you know they don't look you in the eye, and are paying attention to the keyboard. The already too short patient-doctor interaction will be less effective, thus breaking the "do no harm" rule.

3) Interoperability is what really matters, so make sure the systems talk to each other (see standards, above). Can the labs results get to the doctors in a timely fashion with notification? Can the patient be sent to a specialist with their complete profile and tests included? Can the pharmacy get a legible prescription? Can the patient look up their own information? These connections will help deliver quality care with lower error rates and less redundancy.

4) Privacy and Security should be restored to the system. Just as importantly as having their own information, can a patient see who has looked at their information? Can they grant requests and deny requests to share health information? Right now, the first thing we all do when we go to the doctor is sign away our privacy, when we agree to let the doctor and the health insurer get information as necessary to pay the claim. We have no idea where the information goes. Insurer collect information to calibrate rate (read-raise) and employers, who self-insure have the ability to find out who is driving their cost up when someone has a premature baby, or a spouse with cancer. I have heard horror stories where parents have had their prescription medicine usage used against them in custody cases (against the law, yes, but the penalties are so weak, it happens)

5) Knowledge is power, so share it appropriately. Since the average American has to work until the end of March to pay their insurance and health care costs, they do want to take care of themselves. Doctors don't like patients cruising the internet, since there is a lot of misleading information out there. So suggest good information, links and organizations where a patient can educate themselves. Let them know the likely costs of their treatment, and if costs can be lowered through better diet, exercise and sticking to their medical regime.

6) Improve the quality of the time with the doctor by prior check-in. One of the simplest things you can do with the computer is let the patients fill out their clipboard information at home before the appointment. How many of you can't remember the dosage you are taking of your medications when you are sitting in the doctor's office? Or how often do you forget a symptom or an issue due to lack of time or proper organization? This not only gives the patient a chance to make sure they are presenting all their information, but a chance for the doctor to skim the information and know your issues so the time together can be spent discussing them.

Health IT interoperability is a baseline on which a better healthcare system can be built. But make sure the foundation is strong before too much weight is added on.

Joanne Rohde