I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).
I wrote this piece in March 2006.
Information Technology Can’t Easily Fix Health Care System Gaps
By Mr. HIStalk
A New England Journal of Medicine study last week found that ethnicity, income, insurance status, and geographic area do not influence the preventative care received by Americans. Great news! Well, not entirely — we’re collectively getting only about half the care we should. The embarrassing gap just isn’t prejudicial, that’s all.
The study used a RAND Corporation list of several hundred medical care standards that are hardly controversial, with common-sense items like, “Providers should reassess the alcohol intake of patients who report regular or binge drinking at the next routine health visit.” So, if the standards make universal sense, why aren’t they being followed? Unless you know of doctors who wake up vowing to harm their patients, it must be something else.
I can think of only two reasons: (a) command and control is so fragmented within our episode-based system of revolving door specialists that everyone assumes that someone else is watching the big picture, or (b) providers are too busy to do anything more than patch and mend, buried in piles of disjointed facts that are difficult to comprehend and act upon.
The authors recommend IT as the solution. Why not? No judgment is required, just analysis of discrete data elements with specific combinations of values. It’s a piece of cake compared to fly-by-wire electronics on a jet.
Sounds good, but I’m seeing red flags all over the place. Can your clinical information system or practice management application detect the following situations?
- Patients <75 years old presenting with an acute myocardial infarction who are within 12 hours of the onset of MI symptoms and who do not have contraindications to thrombolysis or revascularization
- Patients with major depression who have medical record documentation of improvement of symptoms within six weeks of starting antidepressant treatment
- Patients under age 75 with preexisting coronary disease who have an LDL level >130 mg/dl after six months of dietary cholesterol-lowering treatment
You don’t have to go far to find out. If your database person can’t do it in SQL, it probably can’t be done.
AHRQ and other groups have observed for years that we collect a lot of data, but often in unusable forms (paper, free text, or scanned documents), in scattered locations, entered too late to be actionable (diagnoses, surgical records), and with logic and structure better suited for creating bills than delivering care. Reading these standards makes that obvious. We IT folks are on the hook to solve the problem, but current systems (and use of them) are going to be a problem.
RAND was kind enough to make its standards freely downloadable as a public service at . If you’re a CIO, vendor executive, or system user, evaluate your system’s capabilities to capture and repose the necessary data elements. Then, look at how many are actually available.
How many of the standards are you managing by automation today? How many are you working to add? Think competitive advantage since it’s unlikely that this kind of scrutiny will just go away.
I maintain that most hospitals, even those using advanced clinical functions like CPOE and clinical decision support, still are missing much of the electronic data needed to make clinical decisions. While the NEJM article wasn’t written to make that observation, I think it ends up doing exactly that.