Dr. Theodore A. Praxel, Marshfield’s director of quality improvement and care management.
Darren Hauck for The New York TimesClaire Critelli, 6, and her mother, Marilee, left, with Dr. Edna O. DeVries at the Marshfield Clinic in Wisconsin.
December 27, 2008
The Evidence Gap
Health Care That Puts a Computer on the Team
By STEVE LOHR
MARSHFIELD, Wis. — Joseph Calderaro, 67, is one of health care’s quiet success stories. Over the last four years, he has carefully managed his diabetes by lowering his blood sugar, blood pressure and cholesterol with diet, exercise and medication.
To keep on track, Mr. Calderaro visits his doctor, attends meetings for diabetes patients and gets frequent calls from a health counselor. It is a team effort, orchestrated by the Marshfield Clinic here. And it is animated by technology, starting with Mr. Calderaro’s computerized patient record — a continuously updated document that includes his health history, medications, lab tests, treatment guidelines and doctors’ and nurses’ notes.
To visit the Marshfield Clinic, a longtime innovator in health information technology, is to glimpse medicine’s digital future. Across the national spectrum of health care politics there is broad agreement that moving patient records into the computer age, the way Marshfield and some other health systems have already done, is essential to improving care and curbing costs.
A paper record is a passive, historical document. An electronic health record can be a vibrant tool that reminds and advises doctors. It can hold information on a patient’s visits, treatments and conditions, going back years, even decades. It can be summoned with a mouse click, not hidden in a file drawer in a remote location and thus useless in medical emergencies.
Modern computerized systems have links to online information on best practices, treatment recommendations and harmful drug interactions. The potential benefits include fewer unnecessary tests, reduced medical errors and better care so patients are less likely to require costly treatment in hospitals.
The widespread adoption of electronic health records might also greatly increase evidence-based medicine. Each patient’s records add to a real-time, ever-growing database of evidence showing what works and what does not. The goal is to harness health information from individuals and populations, share it across networks, sift it and analyze it to make the practice of medicine more of a science and less an art.
The Bush administration has left it mainly to advocacy and the private sector to introduce digital medicine. But President-elect Barack Obama apparently plans to make a sizable government commitment. During the campaign, Mr. Obama vowed to spend $50 billion over five years to spur the adoption of electronic health records and said recently that a program to accelerate their use would be part of his stimulus package.
The Marshfield Clinic, a large doctors’ group in Wisconsin, shows that computerized records can indeed improve the quality and efficiency of medicine. Yet the Marshfield experience suggests that the digital record becomes truly useful only when patient information is mined to find patterns and answer questions: What treatments work best for particular categories of patients? What practices or procedures yield the best outcome?
The Marshfield Clinic “understands that it’s a system of improvement that technology makes possible that really matters, and the electronic health record itself is no silver bullet,” said Dr. Carolyn M. Clancy, director of the federal Agency for Healthcare Research and Quality.
For the Obama presidency and the administrations that follow it, the challenge will be to somehow link electronic medical islands into a network that begins to approach on a national scale what organizations like Marshfield have achieved regionally. Ideally, a lone physician in a rural community could tap into the national health information network and be as well informed on treatments and research for patients with certain conditions as a specialist at Marshfield.
Some experts caution that such a broad capacity for record-sharing could take decades to achieve — if it is even possible in the decentralized American marketplace of medical competitors.
Marshfield Clinic, a nonprofit organization founded in 1916, has a long history of using information technology to further research and improve care. In the 1960s, the clinic bought the digital breakthrough of its day — a mainframe computer — and used punched cards to feed it information on diagnoses and procedures. In 1985, the clinic introduced its first basic electronic health records, kept refining them and by 1994 mandated that its doctors all use them. In 2003, it introduced wireless tablet computers, whose screen can written on like digital paper or flipped up, exposing a keyboard, and used as a conventional laptop PC.
Today, Marshfield’s 790 doctors and their support staff at 43 locations in Wisconsin all use the tablet PCs. At the end of last year, the group eliminated paper charts for the more than 365,000 patients its doctors see each year, freeing up storage space the size of a football field at the main clinic in Marshfield. At each step toward a fully digital system, physicians were consulted and involved in the design process.
“It’s been a fabulous journey from physicians being reluctant to now being unable to live without this technology,” observed Dr. Karl J. Ulrich, the clinic’s chief executive. Marshfield is one of a few dozen medical groups across the country that are aggressively embracing information technology. The organizations tend to be big — ranging from providers with thousands of physicians like Kaiser Permanente and the Department of Veterans Affairs to ones with hundreds like Marshfield and Geisinger Health Systems in central Pennsylvania. They are typically responsible for most or all aspects of a patient’s care. They are often insurers, as well.
Those groups, in other words, have the scale and economic incentives to invest in information technology to capture the gains from improved quality and efficiency. In that regard, they lie outside the mainstream of America’s health care economy, a fee-for-service system in which providers are typically paid for doing more, not necessarily doing better. It is a system that encourages more doctor visits, more tests, more surgical procedures, more pills.
For most doctors, who work in small practices, an investment in electronic health records looks simply like a cost for which they will not be reimbursed. That is why policy experts say any government financial incentives to use electronic records — matching grants or other subsidies — should be focused on practices with 10 or fewer doctors, which still account for three-fourths of all doctors in this country. Only about 17 percent of the nation’s physicians are using computerized patient records, according to a government-sponsored survey published in The New England Journal of Medicine.
Even for the large doctor groups, there is no crisp, conclusive cost-benefit arithmetic. Marshfield can point to various measurable savings, but has scant proof they outweigh the millions spent in the past and the $50 million-a-year technology budget.
“People ask about return on investment, but that’s the wrong question,” said Dr. John W. Melski, the medical director of clinical informatics at Marshfield. “This requires the usual leap of faith that knowledge will yield good things — better care, doing things smarter and, yes, saving money in the long run.”
Aided by their growing database, Marshfield’s physician-researchers are working on ambitious projects in personalized medicine that use genetic markers to tailor drug dosages. For example, the clinic recently began a clinical test on 250 patients that uses three gene markers to personalize their doses of Coumadin, or warfarin as the generic drug is known. The blood-thinning drug is widely prescribed for heart patients. But it is often difficult to calibrate the right dose for individuals, and the consequences of internal bleeding or blood clots can be life-threatening. In this case, the electronic health record is the starting point for research, feeding information into the database from which the clinic’s scientists appropriate patients. The digital record holds the patient-specific information used in the Coumadin calculation of tailored doses for individuals.
Marshfield is also researching “predictive” medicine that combines genetics, family histories and lab tests to warn patients about looming health risks. It has a voluntary DNA database on nearly 20,000 people, whose health care information goes back 30 years on average — and the electronic record is the vehicle for collecting and conveying that information. The researchers are looking for patterns in family history, lifestyle, environmental factors, lab test results and selected genetic markers that might predict the onset of conditions like diabetes and Alzheimer’s disease years in advance.
“Better health information technology is needed every step of the way,” said Catherine A. McCarty, director of Marshfield’s center for human genetics and principal investigator for its personalized medicine research project. “We could not do this without the electronic health record.”
The more immediate target, though, is harnessing the digital technology to help manage chronic illnesses like diabetes, heart disease, cancer and asthma. Seventy-five percent of America’s health care spending goes to people with one or more chronic conditions. And as the population ages that percentage is rising.
Marshfield’s progress in recent years with its more than 18,000 diabetes patients, including Mr. Calderaro, points to the potential. The gains are a byproduct of being able to constantly measure and manage health outcomes, a process of efficiently gathering and monitoring patient information that is made possible by the electronic health record. Besides the doctor visits, group meetings and monthly calls from a diabetes counselor, Mr. Calderaro has used all the information to take responsibility for controlling his diabetes. He not only monitors his blood sugar and blood pressure readings, but he could recite the carbohydrate grams in each of the foods he ate one day recently. A three-mile walk is often part of his daily regimen. He was never really heavy, but he has a sister with diabetes and had a maternal grandmother who suffered from the disease.
“If I had known when I was 40 years old what I know now, I would have done things differently,” Mr. Calderaro said.
From mid-2004 through the third quarter of this year, the percentage of the clinic’s diabetic patients with blood cholesterol at or below the recommended level rose to 61 percent, from 40 percent earlier. The percentage with satisfactory blood pressure increased to 52 percent, up from 32 percent.
Over the same span, hospital admissions among Marshfield’s diabetic population fell — to 311 per 1,000 patients a year, from 360. Because a hospital stay for a diabetes patient ranges from $8,000 to $22,500, according to national statistics, Marshfield’s results translate into an annual cost saving of $7.3 million to $20.5 million.
More important may be the suffering avoided. Complications from diabetes include kidney failure, blindness and amputations. “Those are the things that really scare you,” Mr. Calderaro, the patient, said. “But it doesn’t have to be. You can manage it.”
Marshfield is striving to help more of its diabetes patients to do as well as Mr. Calderaro, and the federal Medicare agency has recognized Marshfield’s progress.
In a continuing pilot project, Medicare has selected the clinic and nine other large doctor groups and arranged to pay them for the quality of care they deliver. Last year, on the basis of how well diabetes patients had fared, by various measures, Marshfield was one of only two groups that did well enough to earn bonus payments.
The Medicare pilot prompted Marshfield to take a fresh look at how it cares for various chronic conditions, including heart disease and hypertension. That led to a new software tool, called the iList, which has proved a big help, said Dr. Theodore A. Praxel, Marshfield’s medical director of quality improvement and care management.
The iList (for “intervention list”) culls the patient records of a primary care physician, and ranks and flags patients by conditions not met, including uncontrolled blood pressure and cholesterol, overdue lab tests and vaccinations missed. Nurses and medical assistants then “work the iList,” calling patients with reminders and scheduling them for exams and lab work.
In medicine, the computer is to memory what the X-ray machine is to vision — a technology that vastly surpasses human limitations. The benefits of a computer-helper, doctors say, become quickly evident in everyday practice.
When a doctor electronically prescribes a new drug, for example, an on-screen warning appears if the medication is on the patient’s allergy list or could cause a potentially dangerous interaction with another drug the person is taking. In the New England Journal of Medicine survey, 71 percent of physicians using electronic health records with that feature said they had received a computer alert that helped them avoid a harmful prescription mistake.
“It absolutely happens,” said Dr. Edna O. DeVries, a pediatrician at Marshfield. “You’re distracted and talking to the parents. You’re on autopilot.”
Dr. DeVries, who joined the clinic in 1989, was the medical director nearly a decade ago on a database, created by Marshfield, to track early childhood immunizations in central Wisconsin. Over the next two years, the immunization rates for children in the area rose to 93 percent, from 67 percent, as a result of the tracking and follow-up reminders.
“The quality of care goes up dramatically just by having information instantly,” Dr. DeVries said. Yet, as her colleague and veteran of computer medicine Dr. Melski notes, there is no payoff to technology alone — only in people using technology wisely.
“We have to restructure our medical culture,” he said. “We have to promote a culture that believes in the evidence and is trained in analyzing the evidence. It’s the only long-run answer to the challenges we face in health care — evidence-based medicine.”
Past Coverage
A Towering To-Do List (November 6, 2008)
Most Doctors Aren't Using Electronic Health Records (June 19, 2008)
Kaiser Endorses Microsoft's Health Records Plan (June 10, 2008)
New York City to Help Doctors Track Patients' Records Electronically (February 26, 2008)
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