Thursday, May 26, 2011

The Cost Cutting EHR

Healthcare Information Technology (HIT) and Electronic Health Records (EHR) are at the heart of health care transformation. Everything we want to change and improve upon, hinges on the availability of EHRs in every hospital and every physician practice. We all know that EHRs can improve quality of care by providing evidence-based, patient-centered clinical decision support at the point of care, while measuring outcomes and customer satisfaction, so we can monitor and reward providers for their efforts. But this is not nearly enough. After all, our current health care crisis is not due to hundreds of thousands of citizens succumbing en masse to shoddy medical practices as much as it is due to having to squander 17% of GDP on pampering Americans with unnecessary, excessive and way too technologically advanced diagnostics and therapies. We must cut health care costs or perish. There could be an EHR for that. The following is a blueprint for transforming any EHR into a cost-cutting machine guaranteed to chop health care costs in half in less than one year of use.

Cost Awareness - There’s been much discussion lately revolving around small studies showing that when physicians are made aware of costs, they order fewer tests and save the system money, and it was suggested that EHRs can help place costs of everything in front of ordering providers. Absolutely. There is a tiny problem with obtaining true costs, as opposed to arbitrary prices, but in this era of Data Liberacion, surely we can summon the liberation of all insurance negotiated fee schedules. The innovative computer geeks can take it from there, and if we are missing some numbers here and there, we can make them up just as well as hospitals do. Armed with these data, the CPOE module will display the cost for every test about to be ordered, in a very patient-centered way, since we know what insurance the patient has. This in itself should also reduce disparities since Medicaid pays so much less for everything that we can easily order twice as many tests for Medicaid patients, for the same cost to society. Just so patients don’t feel disempowered, patient portals should clearly display tests and procedures costs as well. We could show the costs to their insurer, but a more deterring shock value would come from displaying the hospital list price, so patients can be better prepared in case the insurer decides to deny payments.

Subliminal Messaging – Well, yes this is illegal for advertising, but it should be acceptable for the public good. For providers, we should have two types of subliminal messaging in the EHR. Prospective messaging would flash inducements to order generic drugs for example. A more sophisticated and patient-centered strategy would be to tailor the message to the individual patient. So if, say, the EHR knows that the patient is there to discuss his PSA test results, and the EHR knows what the results are, it could flash “wait and see” all through the visit. Careful programming is required here to ensure that messaging occurs only on provider screens. Retrospective messaging could be used to create feelings of guilt and regret if providers order an MRI. It is likely that they would want to avoid these feelings in the future. We could integrate subliminal messaging into patient portals to help reduce utilization. For example, in the scheduling module, we could flash the word “NP” for consumers attempting to make an appointment, so they are guided to less extravagantly priced resources. Although this particular feature must be written from scratch, the potential for code reuse is obviously enormous. I’m sure pharmaceutical and device companies can come up with great ideas as well, but please remember that for marketing purposes, this is illegal, and no, this is not an infringement on commercial free speech.

Spending Counter – In the olden days when EHRs were mainly good for billing, some used to have funny little counters that showed physicians (there were no providers in those days) how much they made so far today based on selected E&M and CPT codes. Those widgets were not very accurate, and not widely used. Well, here’s a chance to reuse that old code or write new one if we must. As providers go through their daily work, the counters will add up how much health care money each particular provider has spent, in real time, and display the cumulative amount on every EHR screen (much like those page visit counters on the web).  As we gain more experience with value based benchmarking, the spending counters can become interactive. Each day spending limits could be preset per provider, adjusted to reflect schedule complexity, and the counter will run down all through the day as patients are seen and orders are placed. As the counter approaches zero, we could implement popup alerts to notify providers that the end is near. When the spending counter hits rock-bottom, the CPOE module is disabled and no further orders can be placed without administrative override. We can reduce spending limits by a few dollars every week and like Milo of Croton, providers won’t even notice the gradual cost efficiency achieved over time. To foster healthy competition, we could display other providers’ spending status too. The larger the group practice, the more competition we can foster.

Patient Centered Spending Counter – Upscale EHR vendors who are marketing their products to Accountable Care Organizations (ACO) may want to personalize the above counters for each patient. These widgets should display on the summary page for every chart and on each screen where the patient is in context and be represented by an hourglass graphic image. Since the ACO will be receiving claims data from other providers, we could easily calculate how much was spend on each patient during the current fiscal year and compare to what the ACO projects that should be spent to maximize shared savings. To assist providers at the point of care, an info button should be added that will provide clinical decision support when the hourglass gets low on sand. For example if the patient already had six office visits this year, the software may suggest sticking to e-visits and secure messaging for the rest of the year. It is very important to display this counter in patient portals as soon as the consumers log in, so they can judiciously manage their personal flow of sand. The ACO may wish to offer small, Sand Savings rewards to consumers who end the fiscal year with a surplus of sand in their hourglass.

Break the Plastic – Many EHRs, particularly those designed for inpatient care, have a “break the glass” feature which, in an emergency, allows physicians to access medical records of people who are not their patients. Physicians are given explicit warning that such access will be logged and audited and often these events are indeed audited by administration. The EHR code used to implement this functionality can be easily modified to support adherence to evidence based medicine and assist providers in keeping unreasonable consumer demands at bay. For example, if a provider caves in and attempts to prescribe an antibiotic for a documented diagnosis of common cold, the EHR will pop up a dialog screen with a red stop sign icon saying that this action cannot be completed. The provider may then show this screen to the consumer and hopefully he/she will just go away. If the consumer insists and the provider is talked into changing the diagnosis and trying to prescribe the antibiotic again, the EHR will pop up a different alert stating that the documented positives do not match the new diagnosis, but if the provider wishes to proceed and “break the plastic”, the event will be logged and audited by the committee to discover the reason for changing a diagnosis after trying to prescribe. Hopefully the consumer will take pity on the provider by now and go spend his own money on a Theraflu generic at Walgreens.

Consumer Digital Signature – Most EHRs today have nifty little checkboxes that allow physicians to acknowledge that they provided counseling to patients on a variety of issues. Since we know that a lot of money can be saved by providing consumers with counseling on smoking cessation and weight management, for example, we need to be certain that such counseling was indeed provided in earnest. Who better than the consumer to attest that sufficient counseling took place? All we need to do here is implement existing code for digital signature, usually written for the provider e-prescribing module, and add it to the progress note page. If satisfied, consumers will enter their special credentials, a simple PIN should suffice, at the end of the encounter. Other than saving money by improving lifestyle behaviors, the EHR can keep count of counseling sessions and automatically deliver a small punishment to consumers who show no positive changes in behavior. For example, a smoker who digitally signs 3 cessation counseling sessions, but is still documented as a smoker on his fourth visit, may see his Sand Savings reward disappear. Small rewards and punishments have been shown to consistently improve wellness and save money.

As outlandish as these features may seem, they really are quite easy to implement in a robust EHR. The only complex development consists of the various real time interfaces with insurers to bring claim data into the EHR, which is really nothing more than reversing the current interfaces that send claim data out to payers. As health information exchange matures in the next couple of years, and more and more data is liberated, many different cost cutting, personalized features could be added. Unlike the first generation of EHRs, widespread adoption should not be a major problem since most providers will be employees of large systems and accustomed to following policies and procedures. Judging by the growing spirit of innovation in Health IT, it may also be easy to find young entrepreneurial companies to quickly build this type of widgets and integrate them into existing EHRs for a fraction of the cost of proprietary development. These are exciting times.


  1. Not all cost-cutting is negative... sometimes it's really just cutting the exess fat.

  2. "We all know that EHRs can improve quality of care by providing evidence-based, patient-centered clinical decision support at the point of care, while measuring outcomes and customer satisfaction, so we can monitor and reward providers for their efforts. But this is not nearly enough"
    We do? Evidence shows this is anything but a settled matter.

  3. "There is a large gap between the postulated and empirically demonstrated benefits of eHealth technologies. In addition, there is a lack of robust research on the risks of implementing these technologies and their cost-effectiveness has yet to be demonstrated, despite being frequently promoted by policymakers and "techno-enthusiasts" as if this was a given. In the light of the paucity of evidence in relation to improvements in patient outcomes, as well as the lack of evidence on their cost-effectiveness, it is vital that future eHealth technologies are evaluated against a comprehensive set of measures, ideally throughout all stages of the technology's life cycle. Such evaluation should be characterised by careful attention to socio-technical factors to maximise the likelihood of successful implementation and adoption."

  4. tooearly, I did read the article you cite and did refer to it in an earlier post
    along with similar literature surveys that reach the same conclusion, and as I wrote there, I believe we are approaching the issues in the a "cart before the horses" fashion. Not surprised it doesn't work very well.

    Anonymous, this was a tongue-in-cheek type of remark. Of course we don't know that, and the research is largely inconclusive.