When Medical Informatics Clashes With Medical Culture
What's the sense of having IT systems in place that can help cut medical costs if physicians ignore the price tag of the care they provide?
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Ever ask your family doctor how much the test she just ordered will cost? Chances are she doesn't know. Physicians have been trained to provide the best possible care and to order whatever procedures they deem necessary to diagnose and treatment disease, regardless of the cost.
That philosophy is consistent with the Hippocratic oath, but as the nation tries to cope with its runaway medical tab, that philosophy requires close scrutiny. And it's especially important given all the IT systems in place that can help contain medical costs.
Tools are available that can help reduce the number of duplicative or otherwise unnecessary diagnostic tests doctors order. And although their main function is not cost containment, these systems can have a profound effect on the bottom line. EHRs, for example, when properly implemented, can keep clinicians informed of recent lab tests and imaging studies--through the magic of HL7.
HL7, which stands for Health Level Seven, is the set of standards that lets a healthcare provider format electronic information so that it can be exchanged between two or more databases that speak different languages. Data in a hospital's radiology information system, for instance, can be shared with the laboratory information system. And both systems can share test results with a hospital's EHR, keeping clinicians informed of tests that others have ordered.
Health information exchanges, both private and public, take this sharing capability even further by making caregivers aware of procedures performed at other hospitals and medical practices.
Even the Direct Project, the national protocol for secure clinical messaging, can help physicians stay current about test results and treatment regimens from other caregivers. Direct Project is push technology that lets physicians, hospitals, labs, pharmacies, and other entities exchange results, reports, and other clinical data over a secure network. Providers can view Direct Project messages on a website or use their EHRs to send and receive messages if those EHRs have Direct capability.
These tools are valuable, but they run up against a deeply rooted medical culture that doesn't pay all that much attention to costs. This culture begins to take hold during medical school. As soon as medical students begin their clinical training, they're encouraged to consider all the diagnostic possibilities when caring for patients, say Lisa Rosenbaum, MD, and Daniela Lamas, MD, editorial fellows at the New England Journal of Medicine.
So what is most likely a case of community-acquired pneumonia, during medical rounds soon morphs into a possible pulmonary blood clot or heart failure, "necessitating" a chest CT, ultrasound, and sophisticated cardiac procedures that push the patient's bill into the stratosphere.
Many physicians would argue that ignoring these more remote diagnoses means putting costs ahead of patients' welfare, and that's simply unethical. But Rosenbaum and Lamas point out in their recent NEJM editorial, Cents and Sensitivity--Teaching Physicians to Think about Costs, "Considering cost serves not only the equitable distribution of finite services but also the real interests of individual patients. Medical bills, after all, are among the leading causes of personal bankruptcy."
Among the worst offenders: screening EKGs, chest X-rays before outpatient surgery, and CT scans or MRIs after a patient faints. Unnecessary tests have become so prevalent that nine major medical organizations have launched "Choosing Wisely" campaigns to educate clinicians and the public about wasteful testing.
Of course, there is another side to this story: Many malpractice lawsuits have been filed against physicians for failing to diagnose life-threatening diseases, and one way docs cope with the lawsuit threat is to over-order diagnostic procedures to catch even the most unlikely disorders.
Still, the mandate to "do no harm" requires clinicians to not just worry about their patients' physical well-being but their financial limitations. And that means taking full advantage of EHRs, HIEs, direct messaging, and related IT tools. As Rosenbaum and Lamas put it, "Helping a patient become well enough to climb the stairs to his apartment is meaningless if our care leaves him unable to afford that apartment."
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