Sunday, February 1, 2009

My Obama Wish List

One of the few bright spots in the current economic climate is the funding of healthcare IT as part of the recent stimulus package approved by the United States Congress. As both an educator and consumer of healthcare IT, I have a couple of pet peeves with the current U.S. system I'd like to share.
  1. Stringent adherence to standards. My chiropractor complained that he sometimes receives patient images via CD that take him up to 30 minutes to sort through because of the limited viewing capabilities of the software supplied with the CD. No wonder many physicians love film and hate PACS. If technology only hinders access to information instead of facilitating it, who can blame them? What can we do about this? First of all, anyone creating non-standard CD’s should be penalized; perhaps the FDA can mandate IHE compliance from all diagnostic imaging vendors. Second, it would help if vendors would at least construct simple DICOM viewers for CD embedding that allow side-by-side display of different MR pulse sequences. A minimum standard for image display, similar to what is done for digital mammography in IHE, would be a great help.
  2. Universal patient record and format. I recently went to a neighborhood clinic to get antibiotics prescribed for a sore throat and all of my medical history and personal information had to be re-entered. Most U.S. consumers of healthcare have had to go through this process and most struggle (in vain) to provide a complete history of every procedure, vaccination, and physician encounter they’ve had. I did not have to manually fill in the form, as a receptionist was doing the interview and entered it as I gave her information. On my comment that this was all entered about two years before, she answered: "That’s true, but we recently changed our patient software." I am sure this is common; what a waste of time, energy, and money. And let’s not forget the medical errors that are possible as a result of an incomplete medical history. Again, stringent standards would be a great benefit and probably would have allowed for a simple migration from the legacy to the new patient software.
  3. Patient portal. I believe that we would greatly benefit from a personal portal, such as This would comprise the best toolset from personal health records (PHRs) such as Google Health, Microsoft HealthVault, WebMD, and others. This capability would eliminate the re-entering of patient histories as I would be able to authorize physician access to my information. I believe PHRs will see their greatest advocates from major employers and healthcare systems seeking to lower healthcare costs, such as Wal-Mart Stores and the Cleveland Clinic, who have PHR initiatives. In the meantime, I suggest you check out the PHRs available now
  4. Physician buy-in. One of our friends is a primary physician who just started a new practice. She is overwhelmed by the amount of work that’s required to establish a patient-record system which is, surprise... paper-based, as it is with about 80%-90% of all physicians. When I asked why she didn’t select an electronic health record (EHR) system, I was told that it was too expensive ($50-$100k). The macro-economic impact of all patients having a PHR to share with a physician EHR, in terms of overall cost, could be huge. Because there is no incentive for a physician to spend the extra money on an EHR system, the government should provide some. For example, one incentive could be higher reimbursement rates for all Medicare and Medicaid patients when a physician uses an EHR and lower rates when they do not.
  5. The unique patient ID for each citizen. This has been proposed in the past, was shot down by privacy advocates, and did not seem to get any further. Here is what the U.S. could learn from other nations that seem to be able to do this successfully: In the Netherlands, every citizen has an insurance card with a unique patient ID. (Note that “everyone” brings us to the topic of universal health coverage but that is the subject of another article). If, as can happen, a person breaks their leg when skiing in Austria, this same unique ID is used at the Austrian clinic to access the information system in the Netherlands which authorizes treatment. If existing healthcare IT systems can cross country borders, languages and cultures in Europe, I am amazed that we can’t cross states, cities, or even exchange information between two hospitals that are across the street from one another in the U.S. Images from a CD from one hospital have to be imported to the other and patient ID’s have to be changed using a Mater Patient Index system. Compounding the confusion, many hospitals are not able to issue the same patient ID in radiology as is issued in pathology or other specialties within the same facility. A unique patient ID would provide a major benefit to healthcare IT.
These topics are all related, because they all deal exchanging patient health information in a standard manner, which should be a requirement of every healthcare provider. Some of these proposals might make it into legislation; others, such as the unique patient ID, may run into the entrenched fears of “big-brother government” and privacy advocates. My hope is that the new administration will fully and completely consider the benefits and drawbacks of healthcare IT reform and then wisely allocate our money.