The old adage “prevention is better than cure” could not be more relevant than in current times. The marvels of modern medicine have definitely prolonged the longevity of people, but have made them dependent on frequent hospitalization without any plan for preventive care. As a result patient wait times for critical procedures have increased tremendously and the strain on the healthcare system is showing. Costs have spiraled across all patient segments. Healthcare Medicare costs in the US have been growing by almost 3.5% annually. In some states like Miami which has a huge population of senior citizens the costs have been growing by more than 5%. (Source: Fisher et al, NEJM 360; 9 2009). Most of these rising costs are attributed to Hospital and Physician charges. The scenario is not very different in other parts of the world. The Global Scenario The United States has recently witnessed the passing of many regulations including the federal mandated healthcare reforms. When fully implemented in 2014 this will see a surge in the number of Americans with health insurance and almost 30 million Americans will become dependent on the already stretched public healthcare system. As it is not possible to compromise on the quality of education and churn out physicians to meet that demand, there is bound to be a big gap in demand for quality healthcare and supply (availability of adequate healthcare providers). The use of technology such as Electronic Health Records and Computerized Physician Order Entry is only marginally expected to improve the skewed demand-supply scenario. Europe is in a relatively in a better position with eHealth roll out in advanced stages, particularly in the UK through the National Health Services program, the public health authority. Also they have adopted standards like ICD 10, which is the international standard diagnostic classification for all general epidemiological grouping of conditions for health management purposes and clinical use, according to the World Health Organization s website. Most of the clinical procedures use SNOMED (Systemized Nomenclature of Medicine Clinical Terms). But even here the healthcare costs are very high, mostly borne by the Government and as people continue to retire and birth rates decline, soon Europe too will have to deal with a demand-supply gap. Australia and New Zealand have robust healthcare systems, thought the waiting time for procedures like transplants is anywhere between 6 months to 2 years. Indian Scenario India is relatively new to the concept of using standards for health care management with information technology (IT) adoption in healthcare in nascent stages. Major private hospitals do have Hospital Information Systems (HIS) in place but are not built to handle large volumes. The wait times in hospitals can be anywhere between 2- 5 hours. The scenario is far worse in the rural areas. In such times, there is need for a health care model that can lower costs and ensure minimum reliance on public health care system. Preventive care works on this model and is fast gaining traction. Preventive Care: The silent revolution Preventive care as a concept is relatively new in the post penicillin world and but is slowly gaining ground especially in the United States, with states like Virginia and Arizona trying out pilot implementations. The philosophy behind preventive care is that patients suffering from chronic illnesses can be monitored regularly by physicians and be in much better health than those receiving episodic or symptom based care at hospitals. This also reduces the strain on the public health system and results in lower costs for the patients. Take the example of a patient with a predisposition to having a heart attack. The cost of monitoring such a patient regularly at his home or by routine visits (typically once in three months) to his family physician s clinic would amount to about Rs 500 per visit. The physician would check for vital statistics such as blood pressure, cholesterol, weight, heart rate and ECG, essentially trying to prevent the occurrence of a heart attack. Compare this to a scenario where the patient suffers a heart attack and is admitted to a hospital. Treatment costs may vary between a few Lakh Rupees for minor procedures to up to Rs 10 lakh for complicated surgery. Plus there is no guarantee if the patient might survive and if he does, how vulnerable and medicine-dependent his health has become A good example is the National Health Service (NHS) in the UK. The NHS is the largest Health network in the world. It caters to all British citizens and the cost of the healthcare services are borne by the UK government. All Hospitals, physicians, Paramedical staff and trusts associated with the NHS are paid by the government. In 2008 the NHS administrators decided to embrace the preventive care methodology and decided that the payments to be received by the constituents will depend on the medical outcomes. So if a trust or a practice managed to control the Cholesterol levels of its patients and reduced their number of hospital visits then they would be receiving more payment from the government as compared to another practice that was unable to do so. In order to improve outcomes, many trusts took preventive measures like installing NHA Comparators, an online data analytics tool to monitor patients with Chronic Obstructive Pulmonary Disease (COPD) which is one of the largest causes of death in the UK. (Source: http://www.ic.nhs.uk) Another step taken towards preventing COPD attacks in patients was the collaboration between the Meteorological office and the NHS. The precursors to COPD are extreme temperatures, virus strains and humidity. Therefore, warning text messages were sent to all Patients with a history of COPD whenever such conditions occurred in the weather. The messages contained basic preventive measures and advice on how to tackle the initial symptoms. When an evaluation was done in 2009 on the results of these measures at a particular trust, it was found that hospital admissions attributed to COPD were down 51%, from the time the preventive measures were instituted. Other measures included Patient Portals, Online doctor consultation and Keeping special clinics open in the weekend and in the evenings. IT plays a large role in the preventive care model, which is primarily centered on the Electronic Medical Records (EMR) and can be used to increase efficiency and in identifying and closely tracking patients with chronic conditions. Using IT would also reduce medical errors. The long term objective of the preventive care model is to incentivize physicians for overall value of care rather than the number of procedures they performed per month. Also IT supported initiatives like remote patient monitoring with integration between the health care providers and medical devices companies would help render this model very effective. Additionally, one can enable consultation over email and telephone and standardize clinical performance measurement. Physicians have traditionally opposed IT adoption and that is not going to change immediately. But this demand supply gap in providing care is a valid concern and has to be addressed both by the governmental agencies and care administrators. Also it is cheaper to train doctors on IT than to churn out new doctors. The success or failure of the preventive care model would depend on collaboration between all stake holders i.e. physicians, patients, hospitals, medical device manufacturers, health insurance firms and the government. Currently the Patient Centered Primary Care Collaborative (PCPCC), a US based coalition of major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals and clinicians, is taking the lead in getting all these stake holders together. According to the PCPCC website (www.pcpcc.net) almost 36 pilots have been undertaken, the largest one being in Michigan involving 8000 plus physicians. The healthcare stimulus package of almost $27 Billion dedicated for EMR adoption through meaningful use is going to further serve as a catalyst. Organizations like United Healthcare, US based health insurance firm, have started a pilot on lines of the preventive care model and the Blue Cross Blue Shield of Arizona is planning to start similar pilots (Source: United Healthcare s Medical Home Concept to Cut Costs- The Arizona Republic, Ken Alltucker, Aug 22 2010) A study conducted on similar lines, involving around 25 physicians, found that the preventive care model had reduced patient walk-ins to Emergency in public hospitals by 4.5 per cent in areas of critical care and upto 22.5 per cent in cases of non-critical emergency care. This clearly indicates the viability of the preventive care model and its effectiveness particularly when implemented in developing nations. Preventive care in India: Small scale private practices should take the lead India definitely would need such a model to keep its healthcare costs low. Individual small scale private practices can take the lead in providing preventive medical care. With basic HIS physicians can schedule regular appointments for their patients battling chronic illnesses. For e.g. a diabetic should get his blood sugar checked every three months, so the physician could set up an alert on his information system that alerts him as to when his patient is due for his blood test. He can then inform the patient either through email, SMS or phone. India today has more than 40 Million diabetics and this would go a long way in preventing high hospitalization costs for them. During my seven year tenure as a practicing dentist, I had developed a basic HIS system which had the feature to alert patients when their next appointment was due. In cases where regular monitoring of patients was required, such as gingivitis related to pregnancy or Periodontal care for diabetics, this system proved valuable and reduced chances of major treatment for patients. Incidentally orthodontics treatment for children (putting braces for better development of teeth) which can cost upto Rs 30,000 today, can be avoided with regular half yearly check-ups costing Rs 500-700 to monitor growth and take corrective action. This was way back in 2002. With the advances in technology today, a more complex system can be designed and customized to individual physicians. Indian patients still prefer being treated by their family physicians over visiting large hospitals and it is in the physician s best interest to monitor and help their patients avoid major procedures.
(Also published in India Software Brief 24th March 2011)
Often providers including small physician practices end up with tonnes of medical data. Often this data is not mined for information and analysis done to generate reports. In the recent times there has been increased emphasis on the utilization of this data to generate information that would help physician make better decisions.
An example can be the propensity of a certain infection or condition to manifest itself at certain times in the year. In New Delhi for example the period after the onset of winter till the first winter rains is often associated with dry cough. Most of the OTC Pharmaceutical companies increase their inventory of the cough syrup for the same reason.
Though it is a simple example still it indicates a need to dig deep into clinical records to establish patterns say between climatic conditions and the prevalence of diseases.
How analytics can help and the challenges that they face is something we shall take up in the next post.
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