When a widely respected group of obstetricians said it had found an easy way to prevent infants from dying, the advice went largely ignored by dubious doctors.
Intermountain Health Care, located in Utah and Idaho, was one of the few health care providers to heed the American College of Gynecologists and Obstetricians' suggestion not to induce births before 39 weeks. After putting the claim to the test, Intermountain analyzed its electronic records and proved the obstetricians were right, eventually instituting the new policy. According to hospital estimates, that's kept between 400 and 500 babies out of the ICU.
"It's our belief that most of the problems that happen in health care are not because the right thing isn't known, but because the right thing isn't done consistently," said Greg Poulsen, senior vice president of Intermountain.
Administrators at these hospitals preach "evidence-based medicine," where the best practices are analyzed, identified and then made the norm. Standardizing care, they say, can reduce mistakes that keep patients in the hospital longer than needed. "Last I heard, no pilot intentionally landed with the wheels up, but that used to happen all the time before they had checklists and automated routines," Poulsen said. "What we've discovered is the thing that was most likely to keep people alive was being very routine in care."
To that end, the current health care bills encourage health IT systems, and some would set up councils and committees to identify the most effective practices. All of the bills circulating in Congress instruct the Health and Human Services secretary to set up standards for electronic records systems that health plans would have to follow under the threat of a financial penalty or decreased funding.
That would help other health providers catch up with the model hospitals, all of which use some form of electronic record system. These systems do a lot more than store data -- the most effective ones also make recommendations. Doctors at Intermountain, for example, realized that many complications after heart episodes were a result of patients leaving without their medicine. The easiest way to fix that problem, Paulsen said, was to go to the computers.
"We got all the docs together, and they pricked their fingers and swore they wouldn't let their patients go without medicine, but nothing really changed," Poulsen said. "It didn't work until we changed the system and it became part of the discharge requirement."
Administrators at these hospitals all warned that legislation can be designed to encourage electronic records, but the system has to be one doctors will actually use. David Blumenthal, national coordinator for health IT at the Department of Health and Human Services, is being tasked with overseeing the switch to electronic records and certifying new records systems. Blumenthal said that one basic capability he was looking for was computerized order entry, a system to centralize doctor recommendations for the next step in care, from a drug prescription to referrals to a specialist.
"Basically, if you want to do anything to a patient, you have to find that patient's record on the computer and launch a program that prompts you to type in the order," Blumenthal explained. The computer could then alert you to a generic drug option, any negative drug interactions, allergies or other complications. He also said the better systems would have pre-formed sets of recommendations to eliminate oversights.
Blumenthal said he expected health IT systems will soon be the standard in hospitals, despite the fact that only 13 percent of doctors currently use even a basic electronic system, according to a survey in the New England Journal of Medicine. (Four percent report having a full e-records system.) Doctors' slow adoption is largely a factor of cost concerns and a lack of financial incentives. The health care bills would offer bonuses to providers using an electronic system and even some penalties for not using one.
Aside from legislation, HHS has been increasing grants for hospitals to use electronic systems. Delos "Toby" Cosgrove, CEO and president of the Cleveland Clinic, said that the financial push was necessary to get hospitals on board. "There will eventually be cost savings when you get better care, but it's certainly expensive up front to put it in place," Cosgrove said. "You can keep track of your numbers with an abacus or a cash register, and one's definitely more expensive, but you'll get more accurate numbers and better results with the cash register."
Another concern was that the system had to be uniform across the country so that data could be shared with hospitals across city or state lines. Blumenthal said he was enlisting states in that regard and that his team was working on the Nationwide Health Information Network, which would be a secure "network of networks" for sharing health information across the country.
However, evidence-based medicine can be implemented in an analogue world as well. The Mayo Clinic has doctors apply for a 90-day Quality Academy, where they study ways to increase efficiencies and reduce complaints. Douglas Wood, the chair of the Mayo's division of health care policy and research, said the academy has done wonders for increasing efficiencies in everything from procedures to patient wait times.
In Pennsylvania's Geisinger Health System, the ProvenCare program allows patients to pay an up-front fee for a variety of procedures, which will cover their care for 90 days, including post-acute care and any complications that might happen. Howard Grant, executive vice president and chief medical officer, explained that the only way the system could work is with a standardized system of care that all doctors agreed on and eventually put in the computer system.
"You get your physicians together in a room with performance-improvement teams, and you scour the literature to identify what the best practices are before, during and after the treatment," Grant said. "Then you do your best to make sure that 100 percent of the time a patient with that diagnosis gets those steps. If you do the right thing every time with every patient, you increase the quality of care."
Geisinger's first attempt with the system was for a standard cardiac surgery. Within months, Grant said, the doctors were meeting the 40 recommended measures all of the time. Complication rates went down by more than 20 percent, readmissions were reduced by 44 percent and for 15 months there were no deaths related to the procedure.
"We always think we can do better," Grant said. "If you apply the best practices consistently, you can achieve even better-than-expected performances."
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