A Healthy Revolution Awaits

Question: What could this revolution in information technology do to the American health care system as a whole?

George Halvorson: Well, I think we need a database for the entire country that helps us track how well we're doing in the major areas where we're not performing well. But I think we need to do it sort of step by step and condition by condition. So take asthma: asthma is the fastest-growing condition among kids. It's the number one killer. It's the number one expense item. It's a horrible condition when kids have asthma attacks. One of my sons had multiple asthma attacks years ago, and you know, when they're almost dying because they're going through the misery they're going through, that's very, very traumatic to everybody. And sometimes they do die; I mean, it's all bad. And when you look at the country, how well we're doing in asthma care, the most recent RAND study showed that we're getting it right 47 percent of the time. So, fastest-growing condition, horrible condition, and we're only getting it right 47 percent of the time. We should fix that. If we covered every kid in America -- which is why we need universal coverage -- if we covered every kid in America, that's a start, because then they can get the inhaler and then they can get the medication.

But in addition to that -- covering them is not enough -- in addition to that we need to have information about every kid with asthma. We need to know who they are, and then we need something tracking whether or not those kids are getting the appropriate care, whether or not they're refilling a prescription, like I talked about earlier with the heart patient. We need to know if those inhalers are being refilled, and if they're not, we need to intervene. And what we really need to know is if the kid has a crisis, if they have an asthma attack and they're in the emergency room, we need to know that that crisis happened, and then that needs to trigger an intervention so that somebody can do something meaningful to make it better. And in the current unconnected system, nobody knows. No one has a clue. So the person has the asthma attack, and the hospital has that information, but the hospital has no one to give it to, and they have no mechanism to give it through, and so what you end up with the kid having another attack, another attack, another attack. Some die, and some crippled and debilitated, and certainly demoralized. I mean, it's a bad condition. We could easily say as a country, we're going to focus on that; we're going to fix that; we're going to make that better; and we're going to use universal coverage and the new database to do that.

So that's what we need to do as a country, and if we fix a few things -- if we fix congestive heart failure -- you know, we can cut the congestive heart failure admissions for Americans in half by having absolute consistent follow-up care. But we're not going to do that until everybody has coverage and until there's a care coordination process embedded in the coverage. But there's no reason not to do that, and we will save a lot of money for the country, and we'll save a lot of misery and agony and terror for the people involved if we do that.

Question: Will current health care proposals advance the vision you have laid out?

George Halvorson: It can be. It can be. There are some things in the bills that are directionally correct. They really do want to have database connectivity. There's kind of a pointer in that direction. The details of how to do that are not fleshed out, so the ability to figure out how do we actually create connectivity isn't there, and there's enough resistance to connectivity that I can imagine a scenario where five years from now we've spent an awful lot of money on IT and haven't connected anybody. And I can also imagine a scenario where five years from now we've spent a lot of money on IT and we've connected everybody. I mean, you can get to either out come from here, and part of it's going the be the steerage; part of it's going to be Secretary Sebelius, who in these bills is given all kinds of accountability for doing pieces of this work, which I think is a good thing to do rather than trying to design all the pieces of it; point it in a direction and assign someone. And if she has the kind of years that I really hope she has, care could be a lot better in America.

On the other hand, there are enough people resisting change and happy enough with the status quo that we could also run up against roadblocks and end up not making the progress. So we need to cover everyone. We really do need to cover everyone. Every other country in the world -- every other industrialized country -- covers all of their citizens. We're the only outlier, and we really need to cover everyone because there are some really serious health conditions that we cannot fix until everybody has coverage. I mean, asthma's one of them. All the kids need coverage so we've got continuity of care. And then they need to be in a database so we can track the care and we can follow up on the care. And if you have that kind of a vision for where we're going, you can get there. The bills would allow for that, but it's going to take execution on the back end.

Question: Why isn’t technology front and center in the health care debate?

George Halvorson: Because nobody knows what to do with the technology. People don’t have a sense of how to use it. I just talked about how to use it for asthma care. But when people talk about technology, what they generally say in this very generic way -- almost magical thinking -- let's put all the data on a computer, and then care will get better. Well, that doesn't work. Care doesn't get better when you put it on a computer. Then you have to do something with the data, and somebody has to be accountable for doing that. And so you have to create a data infrastructure, but then you have to create an accountability, and then you have to create the mechanisms. And if all you do is put it on the computer, that's not enough. And then people know that, but what people talk about up front is, let's get all the data on a computer.

So if an individual doctor says, I'm getting a lot of pressure to computerize my office, and they go down that path and they invest all the money to computerize their office, and then when they're done, instead of having a paper file with information about you as a patient they have an electronic file with information about you as a patient, but it's the same information. It hasn't expanded, it hasn't gotten better, it hasn't gotten interactive; it's just electronic. And electronic doesn't cure anything. What cures things is if that database is then connected with another database and every other doctor you have is in the database, and then there's team care that can come out of that and also more informed care. But the agendas up to now for American health care, because the doctors are all in solo practice, hasn't connected the data. It's just computerized it, and that doesn't -- that's not enough.

So people need to have a vision for what you can actually do with it. There are some people who are kind of zealots and saying, let's get all the data on the computer, and that's a good first step as long as it's a first step. But if it's a final step, it's a completely inadequate and incredibly expensive final step. And the other thing is, typically when a doctor has worked with the same piece of paper for 30 years, they know that piece of paper really well. Now, they can put a little note here, little note here. If they're going to a computer screen, now they have to learn a whole different interaction, and they have to -- you know, just think about when you change from, you know, Blackberry to an iPhone or whatever. I mean, you have to go through all this learning curve. If you go through the learning curve to go from paper to electronic, and you get nothing out of it except it slowed you down, well, of course you're not going to do it. I mean, when you -- one of the things I talk about in the book is, all of the information for all of the patients all the time is really important.

But the second thing is, make the right thing easy to do. And that's really important. You've got to make the right thing easy to do. And whoever is writing in, if you make the right thing easy to do as a result of the computerization, doctors will go there and the care system will go there. And if you don't make the right thing easy to do, then the barriers to moving in that direction will be insurmountable.

Question: What’s the biggest technology breakthrough on the horizon in health care?

George Halvorson: I think a couple of things are exciting. I think the ability to take a DNA database and figure out on cholesterol-reduction drugs -- we know that the drugs work really well on a portion of the population, and we know they don't work so well on another portion of the population. But we don’t know why they work in some, and we don't know why they don't work in others. If we could do a DNA analysis and figure out which patients benefit from Zocor, and make sure those patients get Zocor, then we've got a very different, much more effective, care delivery world. So I think the ability to personalize care around the patient based on DNA is really exciting, and I think the research that will follow from that is really exciting.

And I think the connectivity issue, the ability to deliver care remotely, to have -- there's a shortage of primary care on the one hand, and there's logistical issues relative to specialty care on the other hand, and if you can resolve the logistical issues by doing many of the things virtually, and if you can solve the primary care issues by reaching out into a broader continuum and then having the care delivery up front delivered in some cases by nurse practitioners who have a close ally who is a primary care physician, who is completely supported by an infrastructure of specialists, the combination of that sort of a tiered system is going to be a more effective, more efficient, better use of energy and more patient-responsive sort of care delivery system than much of what we have now. So I think there's some opportunities to re-engineer care delivery as well as to personalize care and get care right.

Recorded on November 18, 2009




George Halvorson believes in the power of information technology to transform the American health care system. So why isn’t it front and center in the current debate?

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