E-Health – It All Depends on How It’s Used

Technology isn’t a quick fix. Just ask General Motors. In the 1980s, the auto giant spent $50 billion to automate and computerize its plants in an effort to compete with Toyota. Today, GM is emerging from bankruptcy while Toyota still leads in producing high quality, fuel-efficient vehicles.

What happened? “The Japanese have a great way of describing the error that General Motors made,” said Thomas Kochan, co-director of the Institute for Work and Employment Research at the Massachusetts Institute of Technology Sloan School of Management. “It’s workers who give wisdom to these machines.”

Will the Obama administration’s $20 billion push to flood the nation’s physician offices and hospitals with electronic medical records (EMRs) suffer a similar fate? The July/August cover story in the Washington Monthly by Phillip Longman pointed to one possible stumbling block on the road to widespread diffusion of EMRs – self-interested software firms pushing proprietary systems that can’t talk to each other.

But there may be an even greater danger. The people who actually deliver care will fail to achieve the potential health benefits of having every patient’s EMR at their fingertips.

That was the reality facing Kaiser Permanente’s Colorado medical group in Denver five years ago.  The health maintenance organization, touted as an exemplar of quality care, was an early adapter of EMRs. And what those records told local managers when it came to controlling blood pressure — a major goal — was troubling. Despite annual free checkups and prescribing lots of blood pressure pills, only 59 percent of patients had achieved control in follow-up visits. “Putting a blue sticker on a piece of paper that says you have high blood pressure wasn’t working,” said Sean Riley, the medical director of the group.

Since Kaiser is a unified health system with salaried physicians, it had a direct stake in raising compliance. Greater blood pressure control would almost immediately translate into fewer heart attacks, fewer hospitalizations and lower costs. But how could office-based medical groups reach into patients’ homes and lives to get them to change behavior?

Kaiser’s top managers took a page from Toyota’s production system: organize the office staff throughout its system into unit-based teams and throw the problem to them. They relied on what they believed was every health care worker’s inherent desire to deliver high quality care. “When we started, nobody wanted to buy in,” said Dominique Spain, a medical assistant in the Denver group. “But when they realized it wasn’t about just taking on one more task, it became doable.” The EMRs became a benchmark for a team motivated to get its numbers up.

The Denver unit-based team adopted a holistic approach to treating patients with hypertension. Nurses would hand out literature and give a short talk outlining the long-term health effects of uncontrolled hypertension. Medical assistants began making follow-up phone calls to non-compliant patients. They scheduled additional office visits for patients simply to see a nurse to get their blood pressure checked. Some patients were given kits for taking their blood pressure at home.

Less than three years after starting the program, blood pressure control is up to 70 percent of patients. Kaiser officials estimate that translates into 350 people leading healthier lives, which will prevent 12 deaths and $500,000 in additional medical costs by preventing heart attacks and strokes.

“Technology doesn’t change lives,” Riley said. “It’s the process around the technology that brings results.”

Kaiser’s team-based approach for using EMRs to improve patient care for its 8.6 million beneficiaries was facilitated by a union-management partnership that’s been in place since 1997. About 104,000 of Kaiser’s 165,000 employees are unionized.

“The evidence is very clear that improving patient care requires the coordination of nurses, service employees, doctors and technicians working together in a coordinated fashion,” said MIT’s Kochan, who studies union-management partnerships around the country. “You cannot get sustained teamwork in an adversarial relationship.”

It’s a lesson reform advocates in Washington ought to keep in mind as they craft legislation. Getting health improvements and lower costs from EMRs is not a given. It will require creating workplace environments that know how to make the best use of those records.

“To demonstrate higher quality and become more affordable, we had to take a systemic approach that required a hundred percent engagement strategy,” said Barbara Grimm, a senior vice president at Kaiser Permanente. “Health care needs to be a continuously evolving process.”

The Japanese called their strategy kaizen or continuous improvement. EMRs, like statistical process controls in a manufacturing setting, are only a tool for generating information. It takes people changing the way they work to actually improve quality and lower costs.

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Merrill Goozner has been writing about economics and health care for many years. The former chief economics correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect and The Washington Post. His most recent book, “The $800 Million Dollar Pill – The Truth Behind the Cost of New Drugs ” (University of California Press, 2004) has won acclaim from critics for its treatment of the issues facing the health care system and the pharmaceutical industry in particular. You can read more pieces by Merrill at  GoozNews, where this post first appeared.

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