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Emergency roomIn February 2003 I had an accident. I won’t bore you with the details — a freak fall that resulted in a concussion. It was quite an ordeal — but nothing compared to the associated paperwork. After arriving at the hospital via ambulance, the first encounter with the medical system was a person approaching my bed with a ThinkPad on a cart. I I was glad to see that it was a ThinkPad but a bit surprised at the priorities. I was bleading and suffering a concusion but the most important thing was to get my vital data (insurance data, not medical data) into electronic form. You would think that this near real-time capture of data would assure speedy processing of the charges and settlement by my HMO. I spent four hours in the emergency room but after more than nine months, the financial aspects of the incident are still not settled.

Before continuing with the saga of the data and the implications, it is important to put the incident in perspective. Surely, the biggest tragedy of healthcare is that tens of millions of people in America have no healthcare insurance and outside of America there is a staggering number with no access to healthcare, with or without insurance. To be inconvenienced or even outraged in some way in America is a relative inconvenience, and those of us with good healthcare should feel very fortunate. However, the inequity in world healthcare is no reason that any of us should be satisfied with a system that relies on antiquated paper-based approaches to record keeping. In fact, part of the reason that more people don’t have healthcare in America is because of how expensive it is. Part of the reason that it is so expensive is that there is so much paper and related delays in processing of information. There are also errors and the errors lead to legal actions which in turn add even more to the total cost of healthcare. And then there is the liability insurance necessary because of the lawsuit caused by the errors. It is an endless and out of control spiral. I saw parts of the problem with the accident behind this story.

There were four providers involved in my emergency care: the ambulance company, the hospital emergency physician, the radiology department (CAT scan) at the hospital, and the hospital emergency room. Each of the four are separate business entities. None of the first three could be paid by the HMO unless the hospital was paid because it is the hospital that in effect validates the case. The hospital billed my HMO. The HMO said the billing code was wrong. The HMO said they couldn’t talk to the hospital about it because the hospital was not affiliated with the HMO. I called the hospital and they said the code was right but that I wasn’t covered since I was “out of network”. This is true — I was in a different state than where I live when the accident happened. Then the HMO said the system threw out the charge because there had not been a prior approval by the “primary care physician” where I live to authorize the need for the “outpatient” care. You would think that laying in a bed in an emergency room with a concussion and bleeding would be adequate validation that some medical care was required.

After a dozen phone calls and escalations the issue is almost resolved — ten months after the incident occurred. I say “almost” because yesterday I got a call from a collection agency who says that I owe them $200+ for the emergency room physician. I explained that the bill for $310 for the physician’s time was reduced to approximately $100 through some negotiated fee structure. The collection agency asked me if I had a piece of paper with the numbers on it and could I fax it to them? I suggested they get the information from the HMO. They said they can’t talk to the HMO because they are not a healthcare provider, they are a collection agency. I said I would fax it if they would give me the name of who would call me back to confirm that they received it so I will know the issue is close. They put me on hold for awhile and then said that they could not commit to call me back. They made it clear that it is my responsibility to do any follow-ups. All of the issues were the result of a lack of information transfer. Nothing fancy. Not complicated. Simple, basic information for which there are no standards and few systems.

Healthcare paperwork is a nightmare. My mother is 84 and she gets a constant stream of paperwork from healthcare providers and payers, almost all of which is unintelligible. The paperwork causes stress in people. Elderly people do not like getting notices from collection agencies, especially when they know (or thought) that they had coverage. The simplest of procedures results in delay after delay. All of this adds up to cost. Time is money. Multiple, redundant copies of forms and paperwork mean money. I saw a story recently about a group of doctors who decided to charge cash at the door (a low affordable fee) to anyone needing care. No paperwork. No insurance. They were able to reduce their office staff from a half dozen to one or two and cut their fees from $100 to $35. The doctors are happy and so are the patients.

Why can’t something be done? Is it a technical problem? No. It is an attitude and leadership problem. The Fall/Winter 2003 issue of CIO Magazine ran a story called The Cure for What Ails Us, by Newt Gingrich. His premise is that “the health-care industry has failed to utilize IT systems that could dramatically improve the safety of health care while lowering overall costs”. He makes the point that consumers have become accustomed to real-time transaction systems such as using a credit card to activate a gas pump and then transfer personal financial information from the gas pump to a credit card billing system. He then contrasts that with a healthcare system in which sick patients are required to fill out multiple forms with the same information that they have been asked to fill out numerous times before. He also points that the Institute of Medicine reports that we lose between 44,000 and 96,000 Americans every year due to medical errors. Not lose as in lost but lose as in deaths. Newt says that there are 18 people in the health-care system for every doctor. Instead of paying the doctor to provide us with health care, “we are paying the health insurance company to pay the doctor to pay the clerical people to determine what kind of health care the insurance company believes we are eligible to receive”.

Many doctors and hospitals say that they can’t afford the IT investment to streamline things. They want to see the business case. It is a fair question but yet the benefits seem so obvious, and once a small prototype is started, the implementations would surely snowball — if properly managed — and the benefits would flow. Reduction of errors and improved healthcare would happen to. If Google can find virtually anything in less than a second, couldn’t a system verify the services you are eligible to receive while you are still in the doctor’s office? . If we can find a rare book and buy it in one click, wouldn’t it be possible to file claims instantly while sending your prescription electronically to the pharmacist? If we can go to quicken.com and print out a complete financial analysis of a portfolio, couldn’t the doctor’s office print out your “Explanation of Benefits” from your insurer, listing what you were charged for, how much you were charged, how much the insurance paid, and how much you owe?

Newt says that more than 150 million prescriptions require the pharmacist to call the doctor because either the pharmacist cannot read the writing, the drug is not compatible with another drug the patient is taking, or the pharmacist wants approval to substitute a drug so that the patient’s insurance will cover it. Roughly 15% of office-based physicians are using electronic prescribing tools, but it is a drop in the bucket of the billions of prescriptions that are written every year. Ever more tragic than the ancient approach of “writing” a prescription is that more than 7,000 people die every year because of prescription errors. I am generally not supportive of regulation but this is an area where our political leaders should lead. Electronic administration of prescriptions should be mandated. The private sector can implement it. The drug companies should be required to agree on “vocabulary” to describe all medications. It needs to be part of the infrastructure. This isn’t the only issue in healthcare — there are many but this is a good place to start and it could lead the way to automating many other aspects.

The healthcare paperwork mess is not something we need to live with. There are alternatives. There are digital environments in doctors’ offices and hospitals, like the systems at the Mayo Clinic in Jacksonville, Florida, or the Indiana Heart Hospital, and others. Systems such as these can allow doctors to access your complete health history (with proper authorization by the patient), including your allergies and medications. In South Korea they have a HealthOne card. The chip on the card contains personal identification, emergency health data, prescription data, a payment mechanism (both debit and credit), and mass transit access. The smartcard can connect over the Internet at a smartcard reader to the public key infrastructure which was established by the government of South Korea to allow for authentication and authorization of services. More than 90% of healthcare claims are paid automatically based on this system.

Now is the time for leadership and to move forward aggressively. Using IT more effectively in healthcare should not be optional. Airline pilots have to communicate clearly with airport towers worldwide. They don’t get to make up their words. They is a specific terminology and it is very precise. Imagine the consequences otherwise. Lawyers have to be precise. Each word in a legal document has meaning and it matters precisely how those words are written down. In the case of doctors, prescriptions are written in a way that millions of them are not readable. In the past we have justified this on the basis that doctors are incredibly busy (which they are) and therefore it was ok for them to scribble something on a pad, tear it off, and let someone else worry about figuring out what it says. That should no longer be acceptable. I agree with Newt when he says, “With all of the information technology available today, we can no longer accept suffering and death because of prescription errors or any other preventable errors”.