Joseph Calderaro, 67, is one of health care’s quiet success stories. Over the last four years, he has carefully managed his diabetes by lowering his blood sugar, blood pressure and cholesterol with diet, exercise and medication.
To keep on track, Mr. Calderaro visits his doctor, attends meetings for diabetes patients and gets frequent calls from a health counselor. It is a team effort, orchestrated by the Marshfield Clinic here. And it is animated by technology, starting with Mr. Calderaro’s computerized patient record — a continuously updated document that includes his health history, medications, lab tests, treatment guidelines and doctors’ and nurses’ notes.
To visit the Marshfield Clinic, a longtime innovator in health information technology, is to glimpse medicine’s digital future. Across the national spectrum of health care politics there is broad agreement that moving patient records into the computer age, the way Marshfield and some other health systems have already done, is essential to improving care and curbing costs.
A paper record is a passive, historical document. An electronic health record can be a vibrant tool that reminds and advises doctors. It can hold information on a patient’s visits, treatments and conditions, going back years, even decades. It can be summoned with a mouse click, not hidden in a file drawer in a remote location and thus useless in medical emergencies.
Modern computerized systems have links to online information on best practices, treatment recommendations and harmful drug interactions. The potential benefits include fewer unnecessary tests, reduced medical errors and better care so patients are less likely to require costly treatment in hospitals.
The widespread adoption of electronic health records might also greatly increase evidence-based medicine. Each patient’s records add to a real-time, ever-growing database of evidence showing what works and what does not. The goal is to harness health information from individuals and populations, share it across networks, sift it and analyze it to make the practice of medicine more of a science and less an art.
The Bush administration has left it mainly to advocacy and the private sector to introduce digital medicine. But President-elect Barack Obama apparently plans to make a sizable government commitment. During the campaign, Mr. Obama vowed to spend $50 billion over five years to spur the adoption of electronic health records and said recently that a program to accelerate their use would be part of his stimulus package.
The Marshfield Clinic, a large doctors’ group in Wisconsin, shows that computerized records can indeed improve the quality and efficiency of medicine. Yet the Marshfield experience suggests that the digital record becomes truly useful only when patient information is mined to find patterns and answer questions: What treatments work best for particular categories of patients? What practices or procedures yield the best outcome?
The Marshfield Clinic “understands that it’s a system of improvement that technology makes possible that really matters, and the electronic health record itself is no silver bullet,” said Dr. Carolyn M. Clancy, director of the federal Agency for Healthcare Research and Quality.
For the Obama presidency and the administrations that follow it, the challenge will be to somehow link electronic medical islands into a network that begins to approach on a national scale what organizations like Marshfield have achieved regionally. Ideally, a lone physician in a rural community could tap into the national health information network and be as well informed on treatments and research for patients with certain conditions as a specialist at Marshfield.
Some experts caution that such a broad capacity for record-sharing could take decades to achieve — if it is even possible in the decentralized American marketplace of medical competitors.
Marshfield Clinic, a nonprofit organization founded in 1916, has a long history of using information technology to further research and improve care. In the 1960s, the clinic bought the digital breakthrough of its day — a mainframe computer — and used punched cards to feed it information on diagnoses and procedures. In 1985, the clinic introduced its first basic electronic health records, kept refining them and by 1994 mandated that its doctors all use them. In 2003, it introduced wireless tablet computers, whose screen can written on like digital paper or flipped up, exposing a keyboard, and used as a conventional laptop PC.
Today, Marshfield’s 790 doctors and their support staff at 43 locations in Wisconsin all use the tablet PCs. At the end of last year, the group eliminated paper charts for the more than 365,000 patients its doctors see each year, freeing up storage space the size of a football field at the main clinic in Marshfield. At each step toward a fully digital system, physicians were consulted and involved in the design process.
“It’s been a fabulous journey from physicians being reluctant to now being unable to live without this technology,” observed Dr. Karl J. Ulrich, the clinic’s chief executive. Marshfield is one of a few dozen medical groups across the country that are aggressively embracing information technology. The organizations tend to be big — ranging from providers with thousands of physicians like Kaiser Permanente and the Department of Veterans Affairs to ones with hundreds like Marshfield and Geisinger Health Systems in central Pennsylvania. They are typically responsible for most or all aspects of a patient’s care. They are often insurers, as well.
Those groups, in other words, have the scale and economic incentives to invest in information technology to capture the gains from improved quality and efficiency. In that regard, they lie outside the mainstream of America’s health care economy, a fee-for-service system in which providers are typically paid for doing more, not necessarily doing better. It is a system that encourages more doctor visits, more tests, more surgical procedures, more pills.
For most doctors, who work in small practices, an investment in electronic health records looks simply like a cost for which they will not be reimbursed. That is why policy experts say any government financial incentives to use electronic records — matching grants or other subsidies — should be focused on practices with 10 or fewer doctors, which still account for three-fourths of all doctors in this country. Only about 17 percent of the nation’s physicians are using computerized patient records, according to a government-sponsored survey published in The New England Journal of Medicine.
Even for the large doctor groups, there is no crisp, conclusive cost-benefit arithmetic. Marshfield can point to various measurable savings, but has scant proof they outweigh the millions spent in the past and the $50 million-a-year technology budget.
“People ask about return on investment, but that’s the wrong question,” said Dr. John W. Melski, the medical director of clinical informatics at Marshfield. “This requires the usual leap of faith that knowledge will yield good things — better care, doing things smarter and, yes, saving money in the long run.”
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