VANCOUVER - The adoption of information technology will be critical for keeping healthcare costs under control, and physicians must play an important role in driving that change, according to Dr. Leo Black, retired CEO of the Mayo Clinic Jacksonville (MCJ) in Florida.
"I would present that one of the things that physicians can do (to help tamp down rising costs) is to move more rapidly towards information technology and automation in practice," said Black, who spoke at today's opening session of the Society for Computer Applications in Radiology (SCAR) meeting.
MCJ decided in 1992 to move aggressively towards an electronic medical record, certain that a new world of medicine was evolving, and that the institution would need to cut its expense base significantly while improving quality, Black said. In addition, they believed reimbursement would progressively decrease.
At the time, MCJ also believed that the public in the future was going to want better, easier and more convenient access to the institution. They would also want reduced cost and increased value, more health and disease education, and more involvement in their care, Black said.
"Now, 12 years later, these (factors) are just as true today as they were then," he said.
The institution made a crucial decision in 1992 to focus its energies on getting clinical information into an electronic format. The administrators drafted a long-range plan for the institution's electronic network to envelop the medical record, ordering, scheduling, billing, data mining, patient education, and home care functions.
Today the cost of care is a major problem facing U.S. providers, with rising costs transforming the system in ways that are perhaps not best for patients, Black said. There are over 40 million uninsured patients in the U.S., he said, and insured patients are facing reduced benefits and increased deductibles and premiums. Some smaller companies are no longer offering healthcare insurance for their employees, while big firms are placing caps on their healthcare expenditures and reducing or eliminating coverage for retirees.
"This is a huge problem, and the end-result is that each individual that does have insurance will have to pay more and more themselves," he said.
And the cost situation will only worsen, thanks to new technology and the burden of treating an aging population. Black said that many people and groups are responsible for this cost problem, including lawyers, pharmaceutical companies, insurance companies, doctors, hospitals, and government regulators.
Improving quality, cutting costs
At the same time, the quality of care needs to improve, and achieving these quality gains is becoming more data-driven, he said. The solution is to move to an EMR system that includes an emphasis on cost reduction; this system also needs to provide a cost-efficient infrastructure necessary to improve quality, Black said.
"It's important to remember that cost reduction and improved quality are not necessarily mutually exclusive," he said.
After introducing the EMR in MJC's outpatient setting, management calculated the internal rate of return for the technology at 19%-32%, depending on what variables were included in the calculation.
MCJ also undertook a cost reduction program over four months, involving physicians as well as allied health professionals. In addition to driving cost reductions, this process also helped convince the institution's body politic of the seriousness of its cost-cutting goals, Black said.
Most of the cost savings were related to personnel who handle paper, with FTE reductions for support staff and increased efficiency of desk personnel, he said. In the first year after implementing the EMR, 165 FTE positions of 470 involved with handling paper were eliminated. Desk attendant efficiency increased from 100% to 200%.
"We had saved money and become more efficient," he said.
MCJ implemented electronic radiology and digital image distribution, a process that began in 1994 and was completed by mid-1999. The internal rate of return was pegged at 11% to 16%, he said.
Again, FTE reductions produced much of the savings. The technology also yielded non-economic benefits such as improved scheduling and reduced waiting time for patients, improved telephone response to patients, and faster lab and radiology reports, Black said.
For example, secretary access times for up a patient chart used to take between 45 and 240 minutes, and is now accomplished in less than three seconds. Charges are also now billed automatically in 80% of cases, compared with 0% previously.
Slow adoption rate
Still, the adoption of information systems has been maddeningly slow overall, due to a number of reasons. First among them is that adopting practice automation represents a major behavioral change. And because information systems are viewed as expensive, and the task for adoption is often assigned to the institution's information systems department, he said.
"It's my belief that (if the electronic medical record is to be widely implemented), doctors and nurses have to lead," Black said. "It's not fair to delegate this to IS and expect them to get this done quickly."
A lack of standards has also been a significant problem, and there has been a lack of medical leadership in the matter.
"Medical leaders in this area have not been very good change agents," he said. "They haven't spoken out to get their colleagues to understand they have to move in this direction."
The challenge in implementing an electronic system is behavior modification these days, not technological, Black said. As such, a clear vision for the future of the institution and how the electronic system fits into that vision must be communicated to the physicians and other healthcare providers.
Key people, i.e. the risk-takers, must be recruited to lead the effort to implement an electronic environment, and a business plan must be developed to justify the large, up-front capital costs, Black noted.
"In Jacksonville, we calculated the number of FTEs we probably no longer would need if we moved to an electronic environment, and the final number didn't come that far off from what we projected," he said.
Processes must be evaluated, and many of them will need to be changed with the help of electronics to obtain maximum benefits. And the conversion to the electronic environment needs to be continuously encouraged to retain momentum.
Even if universal health insurance is eventually implemented in the U.S., it will not solve the cost problem, Black said. Physicians need to understand the cost of care to the patient, and teach medical students and residents about cost.
"The physicians of the future must be self-contained," Black said. "We can't afford all of the assistance we've had in the past."
They will, for example, need to ways of performing tasks electronically that assistants used to do on paper, he said. Information systems technology can be deployed to reduce cost through reduced errors and duplication of tests.
Medical leaders must sell changes to their colleagues and to patients, and many of these changes involve information technology, he said.
"Changes are coming, and the cost of care will drive the changes," Black said. "Laws, rules, regulations, and capital constraint will produce the changes."
By Erik L. RidleyAuntMinnie.com staff writer
May 20, 2004
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