An Evening with Dr. Blumenthal

I just got home from a fascinating 3 hour talk with Dr. David Blumenthal. You can read more about him here, but he is basically one of the leaders in the quality field of health care and recently spent 2 years working in the Obama administration as the head of Health Information Technology (HIT). He came to speak to our US health policy class at the Harvard Kennedy School of Government and a smaller group of us had dinner with him afterwards. I wanted to share a couple things he spoke about that I found compelling.

Cost
Dr. Blumenthal answered one question about cost containment, which has been a hot topic in the national debate of late and something I've been reading quite a lot about. His answer was not novel nor complicated but brought my attention back to the reality of our health care system. 5% of the patients account for 50% of the costs. Atul Gawande wrote about this in his The Hotspotters article in January and countless others have shed light on this as well. Blumenthal's answer was simple: "Go where the money is." He spoke about better coordinating care, keeping these patients with multiple chronic diseases out of the ER and hospital, and actively pursuing them to better manage their care. Call them at home everyday, visit them in person, lay out their 15 or 20 medications for them, and fill in every gap where their care is dropped.

My reflection is this: If we are serious about reducing health care costs, and there is no doubt that we now are, we must work tirelessly to first find these patients in our health care system, even if they are not our own. We must proactively engage them in the medical system so that we are not caught reactively responding in extremely inefficient ways. We must think system-wide about the ways in which we currently fail to fill the gaps and bring all of the sometimes dozen providers for these patients into the discussion. And we must find innovative ways to engage the patients and their communities to embrace healthier attitudes and behaviors the are community driven.

Health Information Technology
We couldn't spend three hours with Dr. Blumenthal without talking about health IT, something he spent the last two years of his life on in Washington. Here are some of his reflections:

-Health IT is rapidly expanding across the country and has doubled in the last 2 years
-Competition and decentralization of HIT is good because it is driving innovation in the field. There are now over 1300 different private companies providing HIT and the innovation they are creating will have enormous positive impacts decades into the future. Quelling that force now in favor of a more unified system is the wrong thing to do.
-That being said, cross-talk is an important part of the future of our electronic medical records (EMR). Patients need to be able to take their records with them when changing locations and health systems. The government has put in place standards that are being adopted by the private HIT enterprise. Providers will also have to achieve some standard of meaningful use in the coming years to earn the substantial savings available through the stimulus bill that passed in early 2009. It is up to providers to put pressure on the health IT companies they work with to comply with these standards
-Privacy isn't nearly as big an issue as people say it is. Technology has been developed. Barriers to the sharing of information is primarily systems and politically generated.
-He doesn't have much sympathy for small practice physicians who are complaining about the cost of switching to EMR. The previously mentioned stimulus bill has provisions that will more than pay for their implementation, provisions that amount to $100 of tax revenue per American citizen to make this happen. He says this indicates that the public prioritizes it and it is high time providers do too.
-He is very optimistic that HIT will continue to grow, and it is necessary, but not sufficient, to attending to many of the problems in our health care system.

Quality
Dr. Blumenthal is a national leader in the quality movement in health care. He spoke at length about this during our structured lecture with him. Quality essentially was put on the map in the late 1990's after the Institute of Medicine's report in 1999 called "To Err is Human." This was followed in 2001 by another report from the IOM that Blumenthal described as a seminal document called "Crossing the Quality Chasm." Prior to these reports, quality was not on the policy map as much of an issue.

Quality is something that I admit I don't think about much. I tend to be of the mindset that our health care system is pretty darn good, but I often compare it to other places I've been in the world that have far worse health systems but also shoddy electricity. This fails to ask the important question, "How can we do better?" If I truly reflect on my medical training, I'm appalled at much of what goes on in the hospital and even in the outpatient setting. Care is so fragmented that providers are often very under-informed about the stage of care delivery a given patient is in or a recent change in treatment plan proposed by a different physician or service. The bottom line is that lots of bad things happen all the time with even more near-misses to make even the most inexperienced clinician worried.

This is what Dr. Blumenthal has been trying to remedy. So while I often push quality issues to the back of my mind, they are an area we can drastically improve on. We will save money if we keep people's blood pressures and hemoglobin a1c's under better control and don't order unnecessary costly imaging studies. We will save lives if we prevent infections in the hospital by washing our hands. And we will make much better clinical decisions if we have electronic records that remind us when we are doing something outside best practices. I think we can do a lot better to improve quality and I am excited that through better care coordination and the smart use of HIT we can work to accomplish so much more than simply containing costs. After all, our primary goal is helping patients get and stay healthy.

JK-R