Betting $19 Billion on Digital Docs

What will it take to drive doctors to go digital with electronic health records (EHRs)?

The government is putting down at least $19 billion to start. $2 billion is slated for health IT grants, training and state programs. Starting in 2011, the remaining $17 billion is planned for Medicare/Medicaid incentives that encourage doctors and hospitals to use EHRs. If that doesn't work, penalties would begin in 2015.

The influx of billions of dollars is essential, but not enough to overcome major obstacles. It will take unprecedented participation, cooperation and ingenuity for most patients and America's health system to reap the benefits of EHRs. We have a lot to overcome.

A long path. A 2007-08 NEJM study found that only 4 percent of physicians had adopted a fully functional EHR system. Likewise, a 2009 study found that only 1.5 percent of non-federal U.S. hospitals had a comprehensive EHR system.

A checkered past. Initial forays into EHR did not go well. Many of the first systems were expensive and difficult to use. Many physicians rebelled and then surrendered.

A challenging puzzle. Dozens of vendors have already placed proprietary systems that are not compatible. Setting standards and connecting them into a shared network is a daunting task. 

A fragmented landscape. Getting competing interests to cooperate across shared geography can be difficult. Issues arise around where the data is stored and who has access. 

 A difficult sell. Overtaxed, underpaid physicians say that any EHR that doesn't save them time and help earn them money isn't going to get their attention, let alone the dedication needed to master it.

Betting $19 billion is not enough to win, but it keeps the digital revolution in play.

Expanding successes. Some hospitals are already using EHRs in a powerful way. Regional Health Information Organizations are in the works. A government spotlight will accelerate progress.

Encouraging innovation. Technology companies, large and small, will get a boost to provide solutions demanded by the government. Entrepreneurs will fill the gaps.

Setting a national agenda. If only establishing a nationwide EHR had the cache of landing a man on the moon. Maybe once its benefits are more broadly demonstrated and understood, the whole idea will capture the public's imagination.

The benefits of EHRs are priceless. Connecting our hospitals, physicians offices and other provider sites with a common EHR system that readily shares medical information will revolutionize care. It will take a lot of time and money, but the government is off to a good start. EHRs and healthcare reform could have been off the table in these times of uncertainty. Instead, we're betting on future success. 

—Tom DeSanto

Image: www.gamblingplanet.org

Denied Healthcare Coverage

The flaws in our healthcare system are hitting home. More of us will see it personally in these times of job losses and economic strain. Some will lose coverage; others will be denied.

I recently applied for a family health insurance plan in the individual market. Despite excellent health, I was denied. The reason? Too many prescriptions, plus chiropractic follow-up from an automobile accident.

Okay, I'll confess. For many years, I've been taking two prescriptions to correct minor, long-term conditions. Both prescriptions are generics and not expensive. Never before has it affected my insurability.

The third prescription was Lipitor®. Without it, my cholesterol level was 210 and wouldn't decrease despite a careful diet and frequent exercise. My doctor put me on Lipitor as a preventive measure against heart disease—after trying another medication that caused side-effects. It worked well for years.

The chiropractic care was to loosen my neck muscles after an automobile accident. (I was a passenger and the driver was not at fault.) No emergency treatment was required. I simply wanted to restore my natural balance. None of the billing went through my health insurer and treatment was ending.

The remainder of my family was accepted. What's wrong with this picture?

- Two family members spend much more annually on healthcare than I do.

- Now accepted, my family members can be covered under three separate individual plans for a lot less money. So, the insurer gets to triple the administrative costs and receive lower premiums.

- I'll have to find coverage elsewhere, so the insurer loses my business. And, by the way, I've been insured by this company since birth.

- My efforts to prevent future problems actually worked against my insurability.

Obviously, the health insurance company would have done much better by simply accepting my entire family under one plan in the individual market. It's a wonderful company. Why couldn't it do better?

- Lack of complete medical data for decision-making

- Bureaucratic complexity of the healthcare system

- Lack of regulation that would preserve an optimal risk pool

- Ineffective methodologies for reimbursement

The flaws of our healthcare system are moving from being someone else's problem to becoming our own. And that's the best impetus for sweeping change.

— Tom DeSanto

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Embryonic Stem Cells Multiply and Divide

Many restrictions on federal funding for human embryonic stem-cell research are now history. Research and profits will multiply. Ethics and oversight will divide.

Research. At the signing ceremony, President Obama proclaimed, "we will vigorously support scientists who pursue this research. And we will aim for America to lead the world in the discoveries it one day may yield." We have a new mandate.

Profits. The embryonic stem cell market is projected to reach $1 billion per year with 10 percent growth annually.* When the restrictions were lifted, stock in leading  stem cell companies spiked. California, with a $3 billion taxpayer-funded stem cell research program in place since 2004, is among the first in line for the gold rush.

Ethics. Proponents expressed hope that it will lead to therapies that will help the more than 100 million Americans with diabetes, cancer, spinal cord injuries, Parkinson's, Alzheimer's and other conditions. Opponents expressed moral objection over research that "exploits living members of the human species as raw material for research."**

Oversight. President Obama gave the NIH 120 days to draft ethical guidelines for government-funded research using embryonic stem cells. Creating policies that foster innovation while defining appropriate human embryo sources, ensuring proper FDA regulation, protecting intellectual property and ensuring adequate reimbursement is a tall order.

Congress still must act to remove a final barrier. It must overturn the Dickey-Wicker Amendment that prohibits federal funding for the actual extraction of stem cells from human embryos. The debate over use of re-engineered adult (pluripotent) cells versus embryonic cells is sure to boil over.

Pursuing the research application of human embryonic stem cells is much like the cells themselves. Opportunities multiply. Issues divide. And the debate will continue over what makes us human.

—Tom DeSanto

*Michael West, CEO, BioTime in The Scientist; **Douglas Johnson, National Right To Life Committee; Stem cell image: CIRM

Uncle Sam, Medical Expert?

How much of a role should the U.S. government assume in ensuring the quality and safety of medical care?

Recent events are sure to unleash a new round of debate.

Yesterday, the U.S. Supreme Court ruled that patients injured by a drug can sue its manufacturer for damages even if the drug was granted FDA approval. Consumer advocates applauded. Drug manufacturers lamented. Lawyers smiled. No longer was the FDA deemed to be the final authority on drug safety. A precedent was set, affirming the check and balance of  the tort system and Federal regulation.

Two weeks ago, the $787 billion stimulus bill provided $1.1 billion to the Health and Human Services Department to research the comparative effectiveness of drugs, medical devices, surgery and other treatments for specific conditions. Consumer advocates, labor unions and large employers applauded. Lobbyists, minority groups and conservative lawmakers expressed concern. Would the government-sponsored research truly improve quality and efficiency by eliminating ineffective care? Or would insurers and Medicare use the data to ration care and drive down costs?

New treatment guidelines from HHS, developed over broad population groups, could run the risk of producing bad outcomes in certain individuals. If that happens, would HHS, the new authority on medical effectiveness, find itself in the same boat as the FDA—with regulators wringing their hands and lawyers licking their chops?

We've cast Uncle Sam in the role of medical expert. Is he truly up to the task?

—Tom DeSanto