Prevention via digitalization

The Baltimore Sun

Nearly everyone agrees that America's health care system is badly broken. Most people focus on out-of-control costs and lack of coverage: Every year, we spend almost $2 trillion on health care, 16 percent of our gross domestic product. One in six Americans has no health insurance.

These are major problems. But another urgent issue gets far less attention. Despite the astronomical costs, our system doesn't provide the right kind of care - even to people lucky enough to have insurance.

In short, we're not getting enough for our trillions. One key way to measure the shortfall: Life expectancy here is significantly lower than in dozens of other countries that spend far less on health.

The problem is not with doctors but with the system. Most American health care relies on "fee for service." Doctors provide a service - an office visit, a test, a surgical procedure - and in exchange receive fees from a patient or insurance company. This encourages doctors to focus on patients' immediate problems.

"Our current system is mostly focused on treating late-stage illness," says professor Jonathan Weiner, an expert on health information technology at the Johns Hopkins Bloomberg School of Public Health.

This is a crucial gap. Often, preventive measures - reducing blood pressure in people with heart disease, for example - are inexpensive and relatively simple. Used widely, these strategies could save or lengthen millions of lives.

Amazingly, less than 5 percent of U.S. medical spending goes toward prevention; the rest goes to treatment. To remedy this imbalance, the U.S. must help doctors change how they practice. A good place to start is by encouraging the use of electronic health records (EHRs), software that stores and analyzes patients' medical information.

Doctors tend to ignore prevention largely because they're overworked and busy. The EHR can help doctors stay on top of this excess of incoming data, allowing them to track exactly who needs what preventive measures. When Mr. Smith is due for a blood pressure check or Ms. Ramirez needs a reminder to stay on top of her blood sugar level, the software can send a prompt to the doctor's computer.

"Computers are a lot better about remembering these things," says Mr. Weiner. "There's good evidence this can really work."

But getting doctors to adopt EHRs will require encouragement. Switching from paper records to EHRs costs a doctor a lot - $40,000 to $60,000. Savings from going digital mostly end up not with the doctor but with insurance companies. So most doctors are understandably reluctant to change. The result: 90 percent of U.S. doctors and more than two-thirds of U.S. hospitals still use paper for patient records.

Incentives will help speed this switch, and some interesting experiments are under way. New York City has helped 200 doctors - who together take care of 200,000 patients - to set up a state-of-the-art EHR system. The city subsidizes the cost, and offers free training, maintenance and support. By the end of the year, the program, already the largest community-based EHR network in the country, will add another 800 doctors and 800,000 patients.

Howard County has started a similar, if smaller, effort as part of its new low-cost insurance program. A team of six "health coaches" will teach patients - eventually there will be more than 2,000 - a range of prevention strategies. The coaches will keep track of patients via EHRs and will link digitally with the 250 doctors who have agreed to see the enrollees.

But these experiments represent a tiny percentage of America's 700,000 doctors and 300 million patients. Over the next five years, the federal government must develop an EHR "Marshall Plan" so that every doctor, clinic and hospital in the country adopts prevention-oriented technology.

The election of Barack Obama and his choice of Tom Daschle as health czar bode well. Mr. Obama seems serious about changing health care, and Mr. Daschle is a tech-savvy health wonk who has praised EHRs as a key reform strategy.

The price of such an initiative would not be trivial. But by replacing expensive treatment with low-cost prevention, EHRs eventually would save billions. Even more important, a nationwide EHR system can help trigger a health revolution, leading to better care, and better health, for millions of Americans.

David Kohn, a reporter for The Baltimore Sun, spent last year as a Nieman/Gates fellow studying global health. His e-mail is

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