Discovering Precision Health. Lloyd Minor
in the form but is needed to process a claim. The form gets faxed back to the doctor’s office, which amends it and faxes it back. The payer then must pay someone to transcribe the information into the system.
These kinds of inefficiencies drive up the cost of transactions. There are also health consequences. The absence of shared medical records makes it nearly impossible to get a longitudinal view of a patient’s health care history. This is striking, particularly when compared with other products, such as one’s car, where a comprehensive maintenance history is often easily accessible.
THE UNFULFILLED POTENTIAL OF ELECTRONIC HEALTH RECORDS
During my time as a resident, I remember far too many nights when I was on call and would need to contact hospital security in the middle of the night. The reason? I needed them to open the door to the office of a faculty member so that I could track down a chart or a radiology study on a patient who was having surgery at 7 a.m. I also remember taking care of patients in the Emergency Department who had received all their care in the health system in which I was training, but I did not have the benefit of any of this information because the chart with their medical history could not be located.
My experience was much more the rule than the exception in U.S. health care. Indeed, as recently as 2008, only 10 percent of doctors kept digital records on their patients. The other 90 percent made notes on paper and stored them in manila folders on shelves and in filing cabinets. Paper records had some obvious disadvantages. They took up space, and they were difficult to share with other physicians, hospitals, and insurance companies. Patients switching doctors, hospitals, or places of residence could not easily bring their records with them.
In 2009, in the wake of the financial crisis, the federal government acted to remedy this situation. The Health Information Technology for Economic and Clinical Health (HITECH) Act set aside $27 billion of federal funds to encourage health care providers to adopt electronic health records (EHR) systems, and more money was subsequently made available for training and assistance. All told, the federal government spent about $35 billion on bringing the U.S. health care industry into the electronic age. The program was highly successful in that it made EHRs commonplace. Today, nine in 10 doctors have adopted them. We have made a colossal transformation in a relatively short period of time.
It is also true that the potential benefits of the data that exist in electronic health records have not been realized. But with some changes in technology, regulations, and attention to training, EHRs may soon serve as the backbone of an information revolution in health care—one that will transform health care the way digital technologies are changing banking, finance, transportation, navigation, internet search, retail, and other industries. Regulations are being implemented that will put patients in control of their own health records and facilitate the sharing of data among health care organizations. Engineers are developing artificial intelligence technology that can take notes for physicians, summarize the important points from a patient’s record, and assist in medical decision‐making. Apple’s recent app for medical information, which gives third‐party developers the ability to pull information from health records, is expected to be the first of many developments that bring health care data to patients’ fingertips. There are a lot of reasons to be optimistic that we will be able to have both high‐tech and high‐touch medicine.
Despite these obvious benefits of EHRs, their true potential to improve the way health care is delivered has not been realized. As implemented today, EHRs have too many of the drawbacks of paper records. The promise of being able to send them easily from one office to the next has been hampered by a lack of standards and perverse incentives in the health care marketplace to hoard information. Worse, EHRs, with their cumbersome user interfaces and onerous billing requirements, have become a burden to doctors and nurses, contributing to burnout and information overload among physicians and degrading patient care. “A clinician will make roughly 4,000 keyboard clicks during a busy 10‐hour emergency‐room shift,” writes Abraham Verghese, professor for the theory and practice of medicine at Stanford. “In the process, our daily progress notes have become bloated cut‐and‐paste monsters that are inaccurate and hard to wade through” [20].
While the design of EHRs is a topic of considerable criticism from physicians, much of the data entry is driven by regulatory considerations. The authors of a 2018 article published in the Annals of Internal Medicine described their experience of helping to launch EHR software (Epic Systems) in health systems throughout the world. (The same software is used widely in the United States.)
We noted a significantly different interpretation of the EHR abroad: Physicians were more likely to report satisfaction with its use and cite it as a tool that improved efficiency. We also found that clinical documentation differs from that in the United States. In other countries, it tends to be far briefer, containing only essential clinical information; it omits much of the compliance and reimbursement documentation that commonly bloats the American clinical note. In fact, across this same EHR, clinical notes in the United States are nearly 4 times longer on average than those in other countries.
The authors also noted that since enactment of the 2009 HITECH Act, clinical notes in the United States have doubled in length, thus supporting their conclusion that simplifying regulations “would benefit the health care system and patients alike” [21].
It’s clear that transforming EHRs into sophisticated clinical tools depends on reforming the technology that underlies them and the regulations that govern them. But it’s also clear that radical changes will be required at many different levels, and physicians in particular are going to need to reexamine their role in shaping the future. In 2018, Stanford Medicine published a white paper that contained several recommendations (see box on next page) [22]. A long‐form article in the April 2019 issue of Fortune also provides a detailed overview [23].
WHAT HANDICAPS THE U.S. HEALTH CARE SYSTEM
Fax machines and electronic health records are far from the biggest issues facing U.S. health care, but their prominence in the health care system is a painful reminder of the system’s many shortcomings. Many thoughtful and often provocative books have been written documenting those shortcomings, such as The Innovators Prescription: A Disruptive Solution for Health Care, by Clayton Christensen and Jerome Grossman; The American Health Care Paradox: Why Spending More Is Getting Us Less, by Elizabeth Bradley and Harvey V. Fineberg; More Than Medicine: The Broken Promise of American Health, by Robert M. Kaplan; and An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, by Elisabeth Rosenthal. My intent here is to briefly highlight a few of the fundamental problems that handicap the system, since they underscore the need for the kinds of new approaches represented by Precision Health.
Reactive
In the United States, the term health care, as it’s commonly thought of, is a misnomer. It’s really sick care—people tend not to use health care unless they are responding to an injury, illness, or disease diagnosis—and there are few financial incentives in the system for providers to focus on prevention.
One Size Fits All
Every person with a given diagnosis tends to receive the same treatment, regardless of his or her age, sex, and other medical conditions, even though all those variables dramatically influence the responses to treatment.
Fragmented
When an individual enters the medical system, there is often very little coordination among all the different health care providers. Their communication can be haphazard, and they may not have access to the same pieces of patient information, which can lead to inadequate or incorrect treatments.
Medical Practices
Invest in adequate EHR training when onboarding clinicians and bring them up to speed when incremental changes are made.
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