Backstage at the Medical Revolution
Behind-the-scenes technologies are transforming medicine -- but who's gonna pay?
By Neil Osterweil
Reviewed By Charlotte Grayson
Hurry up and wait.
Soldiers know that mantra well, and until recently, so did patients who visited the department of orthopaedic oncology at Massachusetts General Hospital in Boston.
The drill used to be:
Today patients don't wait for their X-ray films. In fact, there aren't any films to wait for.
"It's similar to a digital camera," explains Giles Boland, MD, director of teleradiology at Massachusetts General and associate professor of radiology at Harvard Medical School in Boston.
"The light is put on a light-sensitive plate and the image is recorded digitally. The advantage of that, aside from saving money on the film and processing is that you can tweak the contrast levels like you can with a digital camera, so that if you don't get a good exposure you can make it into a good exposure."
The hospital uses a picture-archiving and communications system that allows digital storage and display not just of X-rays, but also of CT scans, MRI images, and ultrasound pictures, all of which can be digitally enhanced -- magnified, brightened, or with contrast added -- or manipulated to improve their usefulness. Orthopaedic surgeons, for example, can turn CT images into 3-D pictures that can be visually rotated to show how all the bones fit together.
"Certainly it has enhanced the ability of radiologists to make an accurate diagnosis; there's no question about that," Boland tells WebMD.
Because it's digital, the system also allows doctors in another building, city, or even another country to can call up images on computers in their office or examining room for ready reference or consultation. "You can be in the operating room, you can be on the floor in the patient's room, you could be doing a biopsy and you can see these images anywhere, he says.
Big deal, you say? It is if you're the one trying to clutch an envelope full of X-rays while maneuvering hospital corridors balanced on crutches.
Not too long ago, only Superman had X-ray vision, but now every Dr. Tom, Dr. Dick, or Dr. Harriet with a computer terminal, the right software, and security authorization can peer into the inner workings of his or her patients to see whether the hip bone's connected to the thigh bone.
It's the flashy stuff in medicine -- the latest miracle surgery or wonder drug -- that gets all the rave notices these days, but what goes on behind the scenes is also making subtle but important changes in how doctors practice medicine and how patients and physicians communicate.
Barring Drug Errors
Everybody makes mistakes, but when mistakes come in the form of the wrong drug or the wrong dose, they can be very costly indeed. In 1994, a mistake in the dosing of a chemotherapy drug for treatment of breast cancer cost Boston Globe health reporter Betsy Lehman her life.
According to a 1999 report from the Institute of Medicine, an independent organization associated with the National Academy of Science, medication errors account for more than 7,000 deaths in the United States each year; another study estimates that "adverse drug reactions" (such as breathing failure caused by narcotics or anesthesia drugs) cause more than 100,000 patient deaths annually.
The Institute of Medicine report, titled "To Err is Human: Building a Safer Health System" says that in most cases medical errors aren't the fault of a single person or group, but instead are caused by system failures.
"[T]his is not a 'bad apple' problem," the IOM report says. "More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. For example, stocking patient-care units in hospitals with certain full-strength drugs, even though they are toxic unless diluted, has resulted in deadly mistakes."
To reduce the chance of fatal or harmful drug errors, the FDA in March 2003 proposed widespread adoption of a barcode scanning system for use with all prescription drugs and select over-the-counter medications as well.
When John Q. Patient is admitted to the hospital, he is given a bar-coded ID bracelet that links him directly to his computerized medical record. Before Nurse Nancy gives him a drug, she scans the bracelet, which calls up John's medical record, and then scans the code on the drug package. The information is whisked electronically to the hospital pharmacy, and the computer whirs into action, comparing the drug, dose, and time of administration with the prescription information already on file. If there's a discrepancy, such as the wrong drug, wrong dose, or a change in the patient's chart, the computer sends an error message to Nancy, who looks for the source of the problem.
The FDA estimates that uniform adoption of the barcode system will result in a 50% increase in the chance that a drug error will be caught before the drug is administered, leading to a drop in "adverse" drug events of more than 400,000 over the next two decades.
In addition to saving lives and preventing drug-related health problems (and the lawsuits that inevitably follow), a barcode system offers benefits that would warm the cockles of any managed-care Scrooge's heart, including greater health-care-worker efficiency, more accurate billing, inventory control, and reduced malpractice insurance premiums.
For the Record
Another innovation that's found a niche in a few leading hospitals -- such as Boston's Beth Israel Deaconess Medical Center -- is the online medical record. The OMR, as initial-loving doctors call it, is an electronic version of the old paper folders bulging with notes, lab test results, copies of prescription orders, letters between doctors and patients, referral slips, etc.
But imagine if every time you went to a new doctor, all you had to do was give him or her a password granting access to all of your medical records instantaneously.
"The online medical record is an electronic health record. It has a place for doctors and nurses to enter the medication list and the problem list, keep track of blood pressures and store their notes and so on," explains Daniel Z. Sands, MD, MPH, assistant professor of medicine at Harvard Medical School, and clinical systems integration architect at Beth Israel Deaconess Medical Center in Boston.
He says the online medical record grew out of a need to impose order on the chaos of modern medical life.
"Medicine is increasingly complex, and we don't have a lot of time to spend with you in the exam room. We're dealing with an incredible amount of information and keeping track of this information isn't really manageable using paper. Having a computer system there is a very important safety net for us, and it really makes it possible to provide quality health care," Sands tells WebMD.
"We know from doctors who've left the organization, one of the things they miss the most is that computerized patient record system."
Who Wants the Tab?
So with all this wonderful technology promising to make things more efficient, reduce workload, and improve delivery of services to patients, why aren't more hospitals using it?
"We live in two worlds: the world of the possible and the world of reality," says Jerome H. Grossman, MD, senior fellow and director of the Harvard/Kennedy Health Care Delivery Policy Program, at the Kennedy School of Government at Harvard University in Cambridge, Mass.
"All of this technology is possible and exists, and we know it's possible because it exists in at least one place. But scaling it up has proven to be an absolute, insurmountable barrier."
Despite more than 30 years of rapid development in computer technology, less than 5% of patient medical records are currently automated. The problem is that the people who hold the purse strings at hospitals tend to be interested in one thing, Grossman says, and that's ROI, or "return on investment." Information systems call for a big cash investment upfront and on uncertain benefits down the line.
But Brent C. James, MD, executive director for Intermountain Health Care at the Institute for Healthcare Delivery Research, and adjunct professor of family and preventive medicine at the University of Utah School of Medicine in Salt Lake City, tells WebMD that electronic record systems can work when health-care systems are large enough and have the cash, brains, and will to make them work.
The Intermountain Health Care system, which comprises 22 hospitals and more than 100 outpatient facilities, has been working toward an electronic medical information system for more than 35 years. "We passed a point, just in the last couple of years, where it's showing a net return on investment," James tells WebMD.
The keys to success, he says, were designing a system that wouldn't make the jobs of doctors and nurses harder than they already were, and making sure that the system was part of overall efforts to improve the quality of health-care delivery.
"These types of systems, which we call advanced clinical systems, are still only in a minority of hospitals," acknowledges David Classen, MD. "Somewhere between 5% and 8% of hospitals have these advanced clinical systems that can provide lots of clinical information to doctors and to patients and provide the platform to act on that clinical information through things like computerized physician order entry."
Classen, who is vice president of the First Consulting Group in Salt Lake City, tells WebMD that about 40% of hospitals will have such systems in place over the next five years.
In addition to the high initial acquisition cost -- about $8 million per hospital -- health-care systems have been reluctant to invest in advanced clinical systems because early versions of these systems weren't flexible enough to meet the complex needs of individual hospitals or physician groups, and those systems that were tested tended to make more rather than less work for harried doctors and nurses.
But the tide of negative opinion about advanced clinical systems is beginning to turn, Classen says, because employers and health insurers are beginning to demand them, and because hospital administrators and doctors are beginning to realize that "these systems can really reduce a lot of errors, and improve the quality and safety of patient care, " Classen says.
Back to Wired Health -- At Your Fingertips.
Published September 2003.
SOURCES: Giles Boland, MD, director of teleradiology, Massachusetts General Hospital, associate professor of radiology, Harvard Medical School in Boston. Institute of Medicine. Daniel Z. Sands, MD, MPH, assistant professor of medicine, Harvard Medical School, and clinical systems integration architect, Beth Israel Deaconess Medical Center, Boston. Jerome H. Grossman, MD, senior fellow and director of the Harvard/Kennedy Health Care Delivery Policy Program, Kennedy School of Government, Harvard University, Cambridge, Mass. Brent C. James, MD, executive director for Intermountain Health Care at the Institute for Healthcare Delivery Research, and adjunct professor of Family and Preventive Medicine at the University of Utah School of Medicine in Salt Lake City. David Classen, MD, VP, First Consulting Group, Salt Lake City. "To Err Is Human: Building a Safer Health System," Institute of Medicine, Nov. 1999. Lazarou J, Pomeranz BH, Corey PN, "Incidence of adverse drug reactions in hospitalized patients. A meta-analysis of prospective studies," IIThe Journal of the American Medical Association, 1998, 279: 1200-5.
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