Saturday, April 30, 2005

From The Economist

- AN ARTICLE FOR YOU, FROM ECONOMIST.COM THE NO-COMPUTER VIRUSApr 28th 2005 The inability, and reluctance, of doctors and hospitals to useinformation technology more widely is killing thousands of people"WHETHER or not a treating doctor has Alex's full medical recordavailable can literally mean life or death," says Cynthia Solomon ofSonoma, California. Her son Alex, now in his 20s, grew up withhydrocephalus, a rare and life-threatening condition in which fluidaccumulates in the brain and needs to be drained through specialshunts. So Ms Solomon had no choice but to become a walking filingcabinet of records on allergies, pituitary-gland problems, brain scansand "every piece of paper a doctor ever wrote about Alex's case." Sheworried constantly. There were close calls, such as the time that Alexwent on a trip and ended up, unconscious, in some distant hospital. MsSolomon could not get his paper records to the new doctor and had topray that Alex would not get the wrong antibiotics or be laid on hisback, which might have killed him.To Ms Solomon the information problem with health care today is soglaring that she eventually took matters into her own hands, as bestshe could. She took out a second mortgage, hired software programmersand developed a computer system, called FollowMe, for online medicalrecords that any doctor can, in theory, access anywhere and anytime.FollowMe will not fix the world's health-care industry--only about 400families now use it--but Ms Solomon has correctly identified thewoeful, even scandalous, failure of the health-care industry worldwideto adopt modern information technology (IT). The solution seems obvious: to get all the information about patientsout of paper files and into electronic databases that--and this is thecrucial point--can connect to one another so that any doctor can accessall the information that he needs to help any given patient at any timein any place. In other words, the solution is not merely to usecomputers, but to link the systems of doctors, hospitals, laboratories,pharmacies and insurers, thus making them, in the jargon,"interoperable". This may be obvious, but today it is also a very distant goal.According to David Bates, the head of general medicine at Boston'sBrigham and Women's Hospital and an expert on the use of IT in healthcare, the industry invests only about 2% of its revenues in IT,compared with 10% for other information-intensive industries.Superficially, there are big differences between countries. In Britain,98% of general practitioners have computers somewhere in their offices,and 30% claim to be "paperless", whereas in America 95% of smallpractices use only pen and paper. But, says Mr Bates, this obscures thelarger point, which is that even the IT systems that do exist cannottalk to those of other providers, and so are not all that useful.It shows. People on the right side of the digital divide increasinglytake for granted that they can go online to track their FedEx package,to trade shares, file taxes and renew drivers' licences, and to doalmost anything else--unless, of course, it involves their own health.That information, crumpled and yellowing, is spread among any number ofhanging folders at all the clinics they have ever visited, and probablylong since forgotten about. The most intimate information is, ineffect, locked away from its owners in a black box.Many IT bosses find this baffling. John Chambers, the chief executiveof Cisco Systems, the world's largest computer-networking company, saysthat health care is down there with mining as the most technophobicindustry. Jeff Miller, a manager at Hewlett-Packard, a largecomputer-maker, calls health care "one of the slowest-adoptingindustries", which is especially surreal because hospitals oftensplurge on the latest CAT-scan or MRI equipment, but are stingy withtheir back-office systems. It is, he says, like "Detroit putting outfuturistic hydrogen cars but using paper processing and manual labourfor the manufacturing."This has perverse consequences. According to the Institute of Medicine,a non-governmental organisation in Washington, DC, preventable medicalerrors--from unplanned drug interactions, say--kill between 44,000 and98,000 people each year in America alone. This makes medical snafus theeighth leading cause of death, ahead of car accidents, breast cancerand AIDS. "It's like crashing two 747s a day," says Mark Blatt, who wasa family doctor for 20 years before he joined Intel, the world'slargest semiconductor-maker, to manage its health-care strategy. Thereshould, he says, be more outrage.RICH PICKINGSImproving computer systems, of course, would not eliminate all medicalerrors. But most researchers believe that they would reduce themdramatically. One study in America estimates that IT could prevent 2madverse drug interactions and 190,000 hospitalisations a year. Anotherstudy reckons that electronic ordering of drugs can reduce medicationerrors by 86%. By contrast, research published in March in the JOURNALOF THE AMERICAN MEDICAL ASSOCIATION warns that IT, if the software isbadly designed, could actually increase errors. But almost everybodyagrees that well-designed IT is essential to improving quality inhealth care.The same goes for its cost, an increasing burden to ageing societies inthe rich world and even in poor countries such as China. HP's Mr Millerreckons that redundancy and inefficiency account for between 25% and40% of the $3.3 trillion the world spends on health care every year,and could be eliminated with proper IT. A study from a clinicalresearch centre at Dartmouth College in New Hampshire reaches a similarconclusion, estimating that a third of America's $1.6 trillion inannual health-care spending (as of 2003) goes to procedures thatduplicate one another or are inappropriate. Estimating how much IT could save, after taking account of theconsiderable cost of applying it widely, is not easy. Writing in HEALTHAFFAIRS, an American journal, in January, Jan Walker and fivecolleagues (including Mr Bates) at the Centre for InformationTechnology Leadership in Boston concluded that a fully interoperablenetwork of electronic health records would yield $77.8 billion a yearin net benefits, or 5% of America's annual health-care spending. Thisincludes savings from faster referrals between doctors, fewer delays inordering tests and getting results, fewer errors in oral orhand-written reporting, fewer redundant tests, and automatic orderingand re-fills of drugs. It does not include, however, perhaps thebiggest potential benefit: better statistics that would allow fasterrecognition of disease outbreaks (such as SARS or avian flu). The key word in all such estimates is always "interoperable", says MrBates, pointing to the differences between two pilot programmes inAmerica. In one, the Californian city of Santa Barbara set up acity-wide peer-to-peer network (in which the computers of differentpractices and clinics can talk directly to one another). This allowsdoctors, say, to pull up portable-document-format (PDF) files from oneanother. But the information in them--text, with numbers buried init--is "unstructured" and so not very useful. It is the equivalent offaster faxing, and not what people mean by interoperability.The other American pilot, located in Indianapolis and managed by theRegenstrief Institute, a non-profit medical-research organisation,comes closer. It has created a city-wide network in which physicianscan, with the patient's permission, log on to a complete medicalhistory that includes all previous care at the 11 participatinghospitals. Already, the database contains 3m patient records, 35mradiology images, 1.5 gigabytes of diagnoses, 20m order-entries byphysicians, and so forth. The key difference is that, whereverpossible, the data is entered in a structured and formatted form. Testresults are in neat rows and columns and tagged in a way that everyother computer can recognise and compare against other appropriatenumbers. This is the sort of IT solution that not only cuts waste anderrors, but also helps physicians to make better decisions.What, then, would the ideal IT architecture of health care in futurelook like? It would start, says Intel's Mr Blatt, with wireless dataentry by nurses and doctors. Practices and clinics would have secure"Wi-Fi hotspots"--using a radio technology called 802.11--and staffwould walk around with small handheld devices that transmit all inputsto the database in the back office. Another source of input might betiny radio-frequency identification (RFID) chips that are attached topatients and send basic information when they come in range of a radiofield. Patients could also add inputs themselves. A firm called HealthHero, for instance, makes a cute little device called a Health Buddythat patients take home and plug into their telephone lines. A coupleof times a day, it asks them basic questions or takes their heart rate,and sends the data to the doctor.Behind the scenes, all this data would be formatted and storedaccording to recognised standards. Contrary to widespread concerns,this does not require a single central repository or any otherparticular hardware architecture. Instead, it relies on common softwareprotocols and formats so that individual computer applications can findand talk to one another across the internet. Most of these standards,such as XML, SOAP and WSDL, already exist and are used by manyindustries. Others, such as HL7, LOINC or NCPDP (spelling them outmakes them sound no less obscure) are unique to the health-careindustry and govern data interchange between hospitals, laboratoriesand pharmacies. On top of these, there need to be hacker-proof layersof authentication and password protection so that only the right peopleget access. There is still some work to do to refine these technologies. InJanuary, eight of the world's largest IT companies--Microsoft, Oracle,IBM, HP, Intel, Cisco, Accenture, and Computer Sciences--teamed up toform an "interoperability consortium" for that very purpose. Ingeneral, however, "the technology is very, very ready," says RobertSuh, the technology boss at Accenture, a consultancy that is helpingBritain's National Health Service (NHS) and regional governments inAustralia and Spain to implement electronic health records. In fact, Britain's--or rather England's--NHS is among the pioneersworldwide. This year, it will begin rolling out a GBP6.2 billion ($12billion) project in which five regions in England will form networkedIT"clusters" so that 18,000 NHS sites, including all family doctors andacute-care hospitals, can share standardised information on patients.These clusters will eventually be linked through a "spine" (called theN3 and run by BT) with huge bandwidth to create, in effect, onenational network. Scheduled to be completed by 2010, the plan, likemost IT projects, has had some early hiccoughs and has been greetedwith cynicism by some doctors. But other countries will be looking toit as a model.Another pioneer is Denmark, which began rolling out a similar networkfor the region around Copenhagen in 2001 and expects to complete it by2007, before covering the rest of Denmark. Torben Stentoft, the boss ofHvidovre Hospital in Copenhagen and the head of the city's network,says that his main concern is the nitty-gritty of dealing with all ofhis legacy computers which need to be tweaked or replaced. But he feelsthat he has his society's full support. "Nobody is against this.Everybody is asking for it," he says. In particular, the Danes findnothing terribly controversial in the idea of a national healthidentification number, which they already have, and spend little timeworrying about how to fund the new systems, since their tax kroner aredoing that. AMERICAN EXCEPTIONALISMMr Stentoft is in an enviable situation, especially if viewed fromAmerica, which has the world's largest and costliest health-caresystem. America is as enthusiastic as any country about electronichealth records. President George Bush has embraced the idea, and hespoke about it publicly some 50 times last year. He has even appointeda "national co-ordinator for health information technology" to create afully interoperable, nationwide network within ten years. But America'shealth-care system is so different from others that it faces somespecial complications. The first big difference is that, whereas most other rich countrieshave "single-payer" (ie, government-run) health-care systems, Americahas a highly fragmented industry with many private providers andinsurers doing business alongside large government programmes (such asMedicare, for old people). This means that in funding a new ITinfrastructure "the financial incentives are not exactly aligned," saysMr Bates. In single-payer systems, the expenditures come out of thesame pocket--the taxpayer's--that the savings go into. But in America,he estimates, the practices and hospitals that pay for the IT only get11% of the cost savings, with the rest going to insurers and employers(who buy the insurance). The resulting mismatched incentives, says MrBates, could derail the entire project: "It's a situation where Americacould end up far behind."This calls for some combination of government subsidies andprivate-sector financial incentives, argues the Markle Foundation, acharity in New York that is dedicated to the proper use of IT in healthcare and national security. Over half of all doctors in America work insmall practices. And, say Markle's researchers, a typical practice(defined as five doctors handling 4,000 patient-visits a year) wouldmake losses if it had to pay the estimated $15,000 a year for threeyears that it costs to install an interoperable IT system and to learnhow to use it. The practices, Markle concludes, therefore need incentives of $3 to $6per patient-visit, or $12,000 to $24,000 a year, which comes to $7billion-14 billion a year for three years, or between 1.2% and 2.4% oftotal ambulatory-care revenues. The trickier question is how toadminister this largesse, whether it is provided by insurers andemployers or the government. The money could be disbursed directly andspecifically for the IT systems. Or it could be given indirectly insome sort of pay-for-performance arrangement.The other big difference between America and countries such as Denmarkis public perception of the robustness of privacy laws. The EuropeanUnion has stricter privacy laws than America, and Europeans haverelatively more confidence in them. For information sharing, "ours is amuch more porous environment," says Alan Westin, a professor atColumbia University who has written several books on privacy issues.This is not primarily an IT issue, although the internet does seem toraise the stakes. In February, one database broker, ChoicePoint, had toinform some 140,000 people that it had accidentally sold sensitiveinformation about them. Also in February, a statistician of the healthdepartment in Palm Beach County, Florida, inadvertently e-mailed a listof more than 6,000 HIV carriers to all employees of the department. This makes many Americans suspicious of plans that involve sharingsensitive health information. Although opinion polls in Europe showoverwhelming support for interoperable medical databases as long asthese are properly regulated, a February poll by Harris Interactivefound that Americans are currently evenly split, with 48% saying thatthe benefits outweigh the privacy risks, and 47% saying the opposite.Some 70% of Americans in the poll worried that sensitive data (onsexually transmitted diseases, say) might leak. This is unfortunate, says Michael Callahan, a health-care lawyer atKatten Muchin Zavis Rosenman, a law firm in Chicago, since a weightytome of legislation was passed in 1996 precisely to prevent such leaks.Called HIPAA (short for "health insurance portability andaccountability act"), the law defines strict codes for sharing medicaldata and takes effect in stages, with a large chunk of compliancefalling due this month. HIPAA creates a national "floor", says MrCallahan, with some states following even stricter statutes, andinvolves the federal government in enforcement and prosecution. HIPAAis not quite as strong as equivalent laws in Europe, he thinks, butstrong enough.Mr Westin disagrees. The HIPAA rules are "not at all adequate" forshared medical records, he says. So the only way to sell such recordsto the American public, he says, is to design the whole system withprivacy as a priority. This rules out any form of medicalidentification card, to which Americans would be hostile (even thoughthey think little of giving their social-security numbers, a de factoID, when renting DVDs). It also means avoiding a central database thatcould be hacked. The best approach, says Mr Westin, is to emulate the"locators" used by American police. Cops in California who arrest a NewYorker cannot access information about that person directly, but canview a directory of such information and request it from theauthorities in New York. Finally, rather than allowing sceptics to optout of the new system, says Mr Westin, the system should from the startrequire patients actively to opt in.As the Markle Foundation puts it, the technology must be designed insuch a way that "decisions about linking and sharing are made at theedges of the network" by patients in consultation with their doctors,and never inside the network. This goes to the very heart of thematter. For even though it is fine to start hoping for the day wheninteroperable electronic health records create vast pools of medicalinformation that could be used to find new cures and battle epidemicsin real time, their ultimate purpose is to make one simple andshockingly overdue change: to enable individuals, at last, to haveaccess to, and possession of, information about their own health. See this article with graphics and related items athttp://www.economist.com/science/displayStory.cfm?story_id=3909439Go to http://www.economist.com/ for more global news, views and analysis fromthe Economist Group.- ABOUT ECONOMIST.COM -Economist.com is the online version of The Economist newspaper, anindependent weekly international news and business publication offeringclear reporting, commentary and analysis on world politics, business,finance, science & technology, culture, society and the arts. 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