Smart Care Via a Mouse, but What Will It Cost?

By STEVE LOHR Published: August 20, 2006

THE electronic medical record seems an example of pure progress, a technology that yields only winners. So it has been cast as a geeky hero in health care policy circles. Michael O. Leavitt, the secretary of health and human services, recently said the rollout of electronic health records was ''the most important thing happening in health care.'' Major technology corporations like I.B.M., General Electric and Microsoft, as well as a crowd of specialist companies, including Cerner, Epic Systems and Eclipsys, are all chasing what they see as a fastgrowing, multibillion-dollar opportunity to sell health information technology to hospitals, clinics and doctors. Congress is joining the bandwagon. Last month, the House of Representatives passed a bill to promote the adoption of the computer hardware and software necessary to generate and share digital patient records. The House bill and a previously passed Senate version are scheduled to go to a conference committee next month. Politicians across the spectrum of the health policy debate, from Senator Hillary Rodham Clinton, Democrat of New York, to Bill Frist of Tennessee, the Senate Republican leader, are united on this issue. The technology itself is simply a software storehouse of a person's medical history, including chronic conditions, medical tests, drug prescriptions, diagnoses and doctors' comments. Yet bringing pen-and-ink patient records and prescriptions into the computer age is seen as a vital step toward modernizing the nation's inefficient, paper-clogged health system. Various studies say that it should reduce medical errors and costs, saving lives and saving dollars -- about $80 billion a year, according to the RAND Corporation. Yet even the technological optimists expect turmoil from the information revolution they see coming in health care. Electronic patient records woven into a national digital network will help identify cost-saving opportunities, they say, but when combined with the emerging field of genomics, the records will also open the door to personalized medicine, new treatments -- and, ultimately, more care. While that is by no means a bad thing, it is also not the hoped-for fix for the nation's rising health care bill. ''All the new information tools have enormous promise,'' said Dr. Brian L. Strom, a professor at the University of Pennsylvania School of Medicine, ''but they will not necessarily drive down the overall cost of health care.'' The full effect of health-information technology is years away, because only about 20 percent of physicians now use electronic medical records. But the policy and corporate push is under way and accelerating.

Digital files are a building block in the creation of far more efficient markets in health care, medical experts say. That is what the enthusiasm is really about: not computers and software, but health information that can be easily shared, searched, measured and analyzed to determine what treatments and drugs are most effective, and at what cost. But efficient markets can be ruthless and unpredictable, threatening incumbent powers and producing losers as well as winners. An information revolution in health promises to be powerfully disruptive for some lucrative businesses in the industry, according to medical experts and economists, and could lead to more spending on health care instead of less. ''Information is a dual-edged sword, especially in health care,'' said David M. Cutler, a health economist at Harvard. ''Better information might blow apart some of the blockbuster markets in the pharmaceutical industry, for example. But it might also increase demand for other drugs in smaller, more focused markets. ''And if better information really helps us understand what is happening in health care,'' Mr. Cutler added, ''it could well lead to more care for more people and higher costs for the system as a whole.'' The technology backbone for more efficient health care markets is being called the ''national health information network.'' Such a network -- with patient records stripped of their personal identifiers -- is intended to someday allow doctors, nurses, researchers and ordinary people to track the outcome of various therapies, drugs and devices. The idea is that they could tap into a public Web site to sift through health databases that are based on millions of records, updated regularly. Clever software would help them to understand what works and what doesn't -- and to seek answers about side effects, recovery times and vitamin regimens. A result, health experts say, is that fewer decisions about how to treat patients would be based on studies by drug companies and medical device makers, as they often are now. ''The technology is just an enabler so we have shareable, useable information,'' said Dr. David J. Brailer, the architect of the Bush administration's health information technology policy. A GLIMPSE of the potential impact of a national health information network is found in smaller-scale networks already operating around the country. These are mainly at so-called integrated health systems that combine hospitals, clinics, laboratories, doctors and nurses, and serve a metropolitan area or region. Some, like the Veterans Affairs health system and Kaiser Permanente, the health maintenance organization, are also insurers and well as health care providers.

The integrated health systems have been leaders in adopting electronic records. They have the data, systems and incentives to measure the therapeutic effectiveness and cost-benefit tradeoffs in health care. Modern computer technology, to be sure, is hardly foolproof. It can magnify privacy problems, and the recent loss of computer files of personal data, including medical records, at the V.A. underline that nettlesome issue. And electronic records will not cure other problems: Kaiser recently suffered a black eye when it paid a $2 million fine for administrative foul-ups and long waits at a kidney transplant center in San Francisco, which it closed in May. Still, the potential for market-disrupting cost savings is illustrated by what Kaiser and the V.A. have done in their drug management programs with statins, cholesterol-lowering drugs. Statins are the largest prescription drug category in the United States, with sales of $16 billion last year, according to IMS Health, a research group; Lipitor ($8.4 billion), from Pfizer, and Zocor ($4.4 billion), from Merck, took 80 percent of the market. In recent years, Kaiser and the V.A. have been using generic lovastatin for many of their patients taking statins, saving millions of dollars. At Kaiser, for example, its research pharmacists and cardiologists had been looking at closely at using the generic even before Merck's Mevacor, the brand name for lovastatin, lost its patent protection in 2001. Kaiser's research on safety and effectiveness concluded that lovastatin could generally be used as an alternative. Lovastatin is less potent than Zocor or Lipitor, so Kaiser doctors prescribe higher doses of lovastatin for equivalent potency. Patients have regular blood tests to monitor their cholesterol levels, which become part of their electronic medical records. Alerts are sent to patients and doctors if tests are missed or cholesterol levels rise. Doctors are still free to prescribe Lipitor and Zocor, and they do for patients who need the strongest statins. But nearly 90 percent of patients, according to Kaiser's research, can reach their cholesterollowering goals with lovastatin. (Zocor lost its patent protection in June, further opening the statin market to lower-priced generics.) The V.A. also makes extensive use of lovastatin. These kinds of programs can be carried out confidently only at places with the resources to conduct research, monitor individual patients and track outcomes across patient populations using electronic medical records. ''This has to be driven by the clinical data, not merely cost savings,'' said Joseph J. Canzolino, associate chief consultant for pharmacy benefits management at the V.A. Ideally, electronic patient records and a national health information network would someday give doctors everywhere the information to make similar prescribing decisions and to track their patients closely, if they

chose. ''Can you imagine the savings if what we do here were done across the country?'' said Dr. Ambrose Carrejo, a drug use manager at Kaiser. ''We're talking billions of dollars in savings.'' Imagine, too, the potential impact on blockbuster products like Lipitor, the world's largest-selling prescription drug. ''The whole blockbuster model relies on prescribing a drug for a whole lot of people who don't really need it,'' said J. Mark Gibson, deputy director of the Center for Evidence-Based Policy at the Oregon Health and Science University, which conducts independent reviews of the effectiveness of drugs and medical treatments. ''So much of the information doctors get now comes from studies paid for by the companies that are looking for positive outcomes,'' Mr. Gibson said. ''The more independent information you can generate, analyze and distribute, the more the blockbuster model is in doubt.'' Lipitor, according to Dr. Gregg Larson, vice president of cardiovascular medical at Pfizer, is a blockbuster by merit. Hundreds of clinical trials, Dr. Larson said, have found the benefits of Lipitor as a particularly potent cholesterol-lowering drug that reduces the risk of cardiovascular disease and strokes. ''The evidence demonstrates that not all statins are the same,'' he said. Whether more data threatens blockbuster drugs or not, there are likely to be cases in which more information is likely to generate more prescriptions, more care and more health care spending. A wave of genetic research, for example, is under way, and someday a person's genomics information will be included on his or her electronic health record. Genomics holds the promise of personalizing treatments to make them more effective and to reduce unwanted side effects. CONSIDER the anti-clotting drug warfarin, sold by Bristol-Myers Squibb under the brand name Coumadin. The drug is extremely useful in treating patients with heart and circulatory problems. But it can also be tricky to get the dose right so that a patient gets the blood-thinning benefits without dangerous side effects, like internal bleeding or strokes. Personal-injury lawyers closely watch the use of warfarin, and many doctors are leery of prescribing the drug. Medical researchers at a number of clinics and universities have identified gene types that appear to determine how an individual metabolizes warfarin. If the early research is confirmed in broader studies, it will be possible to tailor dosages by gene types to minimize the toxic side effects. ''We could make warfarin a lot safer with genetic testing,'' said Dr. Michael Caldwell, a researcher at the Marshfield Clinic, an integrated health system in northern Wisconsin, which has a genetic research program. But improved safety would also likely mean a lot more prescriptions for warfarin, since studies have concluded that only about half the people who might benefit from the drug are taking it. Yet those

prescriptions, in an era of personalized medicine, might well be individually tailored doses. If the old blockbuster business model is endangered, so is the standard pill, in 10-, 20- or 100-milligram doses. The electronic medical record, for all its promise, is no silver bullet for the nation's health system. Placing too much faith in technology, skeptics warn, could be counterproductive. Dr. David Himmelstein, a physician and associate professor at the Harvard Medical School, said: ''It encourages the belief that we don't need real reform, all we need is computers.'' Photos: David M. Cutler, a health economist at Harvard, says that having more information could lead to more care and higher spending. (Photo by Rick Friedman for The New York Times); David J. Brailer, a doctor and economist, calls technology a path to more efficient markets. (Photo by Jerry W. Hoefer for The New York Times)(pg. 4) Drawing (Drawing by Matt Collins)(pg. 1) Chart: ''An Argument for Electronic Records'' Here is an estimate of how much money could be saved annually by widespread adoption of electronic medical records. Many analysts agree that such a change could cut costs, but some say those savings could be offset by an increase in overall demand for medical care. TOTAL, in billions Estimated average yearly savings from widespread use of electronic medical records: $41.8 Inpatient Length of stay: $19.3 Nursing time: $7.1 Drug use: $2.0 Lab tests: $1.6 Medical records: $1.3 Outpatient Drug use: $6.2 Radiology: $1.7 Lab tests: $1.1 Transcription: $0.9 Chart pulls: $0.8 (Source by RAND)(pg. 4)