| 摘要 | At a Department of Veterans Affairs Medical Center just a few miles from my office in the U.S. Capitol, you can glimpse a piece of American medicine’s future. Sitting at an ordinary desktop computer, Dr. Ned Evans hits a few keys on the keyboard and clicks his mouse a few times. Sample patient data spill out: X-ray images, lab notes, and blood pressure numbers. “Everything I might want, everything I need, I can see right here,” he says. “It’s a seamless part of life. It lets me do just about everything better.”
And when the New England Journal of Medicine used 11 measures to compare VA patients with Medicare patients treated on a fee-for-service basis, the VA’s patients were in better health and received more of the treatments professionals believe they should. According to the VA’s own medical professionals, a computer system called Vista is the key to their success. “I’m proud of what we do here, but it isn’t that we have more resources,” explains Sanford Garfunkel, the director of the Washington VA Medical Center. “The difference is information.”
While it’s a glimpse into the future, the VA’s computer system isn’t a breakthrough. Everything the VA’s system does has been possible for some time. I used electronic medical records myself 15 years ago to track the complex regimens of pills and procedures I used to treat my heart transplant patients. I published papers based on the data I collected, and feel I did at least a little to advance the science of transplantation as a result. Given how much data it requires, it seems likely that transplant medicine would have developed much more slowly without computers. But the use of information technology in medicine simply hasn’t lived up to its early promise. Even today in transplant medicine, there’s no common standard for sharing or keeping data.
Many of our doctors and hospitals remain stuck in a medical stone age. While people speak of a medical “system,” American medicine is in fact very unsystematic: It lacks the standards, measures, and ability to exchange information that constitute a true system. Even where the VA and other organizations like Kaiser-Permanente and Utah’s Intermountain Health Care have built systems, the systems can’t communicate with each other or exchange records. While the VA has invested a lot in its computer system, most hospitals haven’t invested enough. Among America’s important economic sectors, health care spends the smallest percentage of its revenue on information technology—only about 3 percent. Industries such as banking spend 10 percent or more.
Doctors have embraced every kind of clinical technology from digital thermometers to MRIs and CT scanning machines. But the information side of medical practice remains a generation behind the rest of our economy. I still write prescriptions and keep records much the same way my father did 70 years ago. Most of my fellow physicians had very little computer training in medical school, and many still see the computer as a distracting intermediary between them and their patients.
The medical profession’s failure to embrace information technology have had catastrophic consequences. Primitive recordkeeping drives up costs, makes it nearly impossible to measure quality, and undermines the control that patients want over their own health care. For the overwhelming majority of Americans, these are the three biggest problems with health care. Moving medicine into the information age can begin to solve all of them.
Cost
A revolution in information management has lately remade numerous sectors of the American economy, while passing by health care. Take one example: by making better use of information technology, the nation improved shipping so much that the percentage of America’s GDP spent on logistics fell from over 14 percent to less than 10 percent, while new procedures like overnight shipping and just-in-time delivery became an integral part of daily life. Telephone companies, airlines, retailers, and banks also charge less for services that are better than they were in the past, to a considerable degree because of advanced computerization.
Health care, however, has moved in just the opposite direction. Fifteen years ago, Americans spent less than one dollar in ten for health care. By the end of this decade, nearly 20 percent of our national income could go for health care. Some of the increase was probably inevitable because our population is getting both older and more affluent, and because new medical advances require more resources. But much of the medical cost explosion is linked to waste—in particular, misdirection of resources due to a persistent underinvestment in health information technology.
Researchers at Dartmouth College have found that America wastes as much as a third of the $1.8 trillion we spend on medical care. Without up-to-date clinical data, doctors often need to reorder tests that others have already done. Without good aggregate information about which procedures produce good results, doctors sometimes perform unneeded surgeries or prescribe drugs that do little to prolong or improve patients’ lives. Much of this ineffective, squandered, and duplicative effort could be eliminated if we just had better records and sharing of information.
Quality
Even worse, American health care leaves us with almost no way to tell the difference between doctors and hospitals that provide superior care and those that need improvement. Some doctors who provide substandard care may get paid well for it; some who provide superior care may be underpaid. Right now, financial incentives are, at best, loosely linked to the quality of medical care a doctor or hospital dispenses. This lack of quality control explains many of the weaknesses in our health care system.
Sometimes our failure to use technology has deadly consequences. Doctors write about 2 billion prescriptions each year, but because of unclear handwriting, some get filled incorrectly: about 7,000 people die annually as a result. Under the Medicare bill the President signed in 2003, however, we’ve begun the process of rolling out a national electronic prescription system that should eventually eliminate many of these problems. But even properly filled prescriptions can sometimes be dangerous: Without a way of accessing a patient’s drug records, doctors have no way of knowing what medications he is already taking when he shows up at an emergency room.
I have personal experience with the difficulty this lack of information can cause. As a cardiothoracic surgeon working on the cutting edge of medicine, I would send transplant patients home with as many as 15 different prescriptions. Their doctors, mostly family physicians working in rural Tennessee, had little hands-on experience with the just-evolving field of transplant medicine. Sometimes, they would prescribe drugs that would interact poorly with one of the prescriptions I had written. Often, these treatments would make patients worse and result in emergency room visits. Simply because good, transferable records weren’t available, patients ended up needing thousands of dollars worth of additional care.
Control
Right now, American health care often takes doctors and patients out of the loop and replaces them with bureaucrats from insurance companies or the government. While managed care, for instance, may save money, it also stops many people from choosing their own doctors. Pressed for time and the need to do endless paperwork, doctors and nurses can’t devote as much attention as they would like to their patients.
Other forces also interfere with the doctor-patient relationship that should lie at the heart of medicine. Some predatory trial lawyers have created a litigation lottery that drives up costs for every doctor in the country, while often failing to compensate people who experience real problems. Arbitrary litigation leads to the practice of “defensive medicine” on an enormous scale: Rather than risk getting sued, many doctors order unnecessary tests or avoid doing risky but potentially lifesaving procedures. As a result, everyone suffers and the quality of medical care declines. Better medical records could be invaluable in separating inferior physicians from better ones. They would provide a clear paper trail to track doctors’ decisions and medical actions. And they would give patients more control over their own information and course of treatment. Today’s lack of information leaves many people feeling less secure: If a traveler gets into a car accident a thousand miles from home, the emergency room he arrives at should have a system that can bring up his full medical history, allergies, and information about the medications he takes. Right now, it’s very unlikely the doctors treating this patient will know anything about him.
The case for action
The problems with America’s health care system did not develop overnight, and we cannot deal with them instantly. Moving the entire medical system into the information age will take time. Fixing things will require commitment from the government and private insurers, from the medical community, and from Americans who use health care.
Medicine has remained behind the times in large part because we have no uniform standards for keeping medical records. The government needs to take the lead in creating such standards. Right now, every hospital, doctor, and residency program uses slightly different terminology to describe and code an individual’s problems. One group might refer to pain in the “thoracic cavity” while another might refer to “the chest.”
Private efforts to standardize medical records and share them electronically have failed repeatedly because they never provided any real benefits to the medical profession: For the vast majority of doctors, it remains easier and probably better to keep records by hand than to use most existing computer software. After finishing a heart transplant at 5:00 a.m., I didn’t want to spend another two hours entering every bit of data about the procedure into a computer, particularly since I knew that I wouldn’t be able to share it. I did it anyway. But I could understand why many of my colleagues didn’t. Today’s lack of a uniform set of recordkeeping standards puts sharp limits even on good systems like the one at the Department of Veterans Affairs hospitals: Doctors can electronically search patients’ records all they want, but without a standard vocabulary, they may not always find what they look for.
The Senate has passed legislation I developed along with Senators Hillary Clinton, Edward Kennedy, and Mike Enzi, which will begin the process of moving America toward a national system of electronic medical records. The House plans to consider the bill in June and I hope that the President will sign legislation before the end of 2006. Making such a system work everywhere will take additional computers and software and fiber optic cable. But much more, for the system to work, government will have to set standards for everyone to follow. The private sector has tried to do this for over 20 years, and still hasn’t managed.
Our measure allows doctors, nurses, medical technicians, patients, and medical administrators—the people who know health care best—to design the format for electronic medical records. Once the standards exist, the government will need to lead by example. As our single largest health insurer—the government pays slightly more than half of all medical bills in this country—federal officials need to make sure Medicare, Medicaid, the State Children’s Health Insurance Program, and the Indian Health Service take the lead in using the records for all of their beneficiaries.
The government can’t create the system entirely on its own. The medical profession needs to play an active role. First, doctors will need to overcome their reluctance to use electronic medical records and work to create a standard they can accept and use. Second, state medical boards and medical associations need to make sure that every doctor gets training in how to use electronic medical records. Use of information technology needs to become a part of continuing medical education for every physician in the country. Doctors will also have to accept increased scrutiny; publicly available measures of treatment, patient outcomes, and quality will bring much more transparency to the work of doctors. The bill I helped write will begin some preliminary experiments at rewarding doctors who provide better-than-average care.
Equipped with better information, consumers will also need to take more responsibility for their own health. Individuals will own their electronic medical records, and a combination of legal and technological safeguards will make sure that, except in life or death emergencies, nobody else can access them without permission. This, in turn, will require patients to play a more active role in medical care: All of the information in the world about medical quality will do little good if people don’t pay attention to it and act upon it. Giving doctors better information won’t fix all our problems unless patients have a better idea of how to work with their physicians.
For far too long, America made the mistake of investing little in health-related information technology. It’s long past time to move the entire nation towards health care that’s truly systematic and working in sync with our information-age economy. If we create a privacy-protected electronic medical record for every citizen who wants one, we’ll not only save money, we’ll save lives.
Bill Frist is a heart and lung surgeon, and U.S. Senate majority leader. |
