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Do Physicians Need a “Shopping Cart” for Health Care Services?

Do Physicians Need a “Shopping Cart” for Health Care Services? Electronic medical records are being implemented throughout the US health care system. Incentives for implementation are being partially paid for by the US taxpayer. To receive implementation incentives, clinicians must demonstrate meaningful use—that is, the electronic medical record must be used to improve quality and must satisfy certain indicators.1 What is missing from the definition of meaningful use is any direct measure of either value or cost. It is likely that introducing electronic medical records will improve quality on such dimensions as whether a vaccine is administered, measurement of blood pressure is taken, diabetes is better controlled, and admissions for poorly controlled diabetes are reduced.2 However, in most systems there are no measures built into electronic medical records to help physicians control cost or even to know the cost of the care that they are providing. Other organizations use computers to improve the purchasing experience, cost, and value of consumer products. Anyone who has shopped online has been presented with multiple ways to judge the quality of the product being purchased. There are ways to compare a given product with other similar products along specific dimensions, and to see what individuals who purchased the product thought about it. The assumption is that this information can help a consumer decide whether the product is worth the cost. However, the consumer's experience does not end with the description of the product's quality or efforts to encourage purchase of a better-quality product. Invariably the site has an electronic “shopping cart” that not only lists all the products that the consumer has put in the cart but also shows the cost of each one, as well as the total cost of everything in the shopping cart. The cart's total automatically updates whenever the cart's content is changed. In essence, on Internet sites, meaningful use means giving information to the consumer about the quality and the cost of a product in real time. In the United States, the primary purchaser of medical care is the individual clinician, whether that is a physician or a nurse practitioner. Practitioners can access many sources to determine the quality of a test or procedure, but real-time cost data are not available anywhere. In this context, cost means what a typical patient who is insured by a typical company or by the government would be expected to pay for a given service. Cost includes both what the company or government paid and what the patient paid out of pocket. For example, if the insurance company paid the pharmacy $80 and the patient paid $8, the cost of this service is $88. What if every time a practitioner used an electronic medical record system to order a procedure or test for a patient, an electronic shopping cart appeared, indicating how much that “purchase” would cost? What if at the end of the day the practitioner received a statement indicating precisely how much money he or she had ordered to be spent on behalf of patients? What would happen? Would anybody care? Some evidence suggests that providing this type of information to physicians may be helpful. For instance, in a study at one hospital, following the initiation of a weekly announcement informing the surgical house staff and attending physicians of the actual dollar amount charged to non–intensive care patients for laboratory services (ie, daily phlebotomy) ordered during the previous week, there were reductions in daily per-patient charges for laboratory services, with estimated cost savings of more than $50 000 over the course of the 11-week intervention.3 Perhaps the designers of computerized medical record systems should be advised that the records will be considered incomplete unless they contain information about the cost of the procedures, tests, or services that physicians are purchasing using the systems. How rapidly could the systems currently in use be modified to include such information? Perhaps it is time to begin making physicians and patients aware of what is being spent on a real-time basis, in a form with which they are comfortable. Retail clinics,4 which provide care for a limited number of acute and preventive conditions, post prices for their services. Patients can see what it will cost them to get a flu vaccination or to be evaluated for a urinary tract infection. But clinicians must do better than retail clinics, or at least as well. It should be possible to keep a running total of the costs for everything that a physician orders. For instance, every time a physician admits a patient to the hospital and orders the nurses to obtain vital signs every hour, or to collect intake and output, or to get the patient out of bed and walk the patient for an hour, a cost could be put into the record and into the shopping cart. Any time a physician ordered a laboratory test or procedure, the total in the shopping cart would be updated. Once awareness about the cost of care on a real-time basis becomes part of the culture of medicine, perhaps the information could be used to increase the value of care and to control costs. At the very least, the presence of such information would be a wake-up call to physicians and nurse practitioners, helping them to understand just how much money is being spent on behalf of patients. The content and total cost of the shopping carts could be shared with patients so that they saw not only the list of tests and procedures and their results, but also the costs of those services in real time. Once the cost data are collected from these shopping carts, there are many ways to present and analyze them. For example, it might be useful to compare physicians on the same clinic schedule, inpatient rotation, or in similar office practice settings. Such a comparison need not adjust for every difference in patient mix. Rather the purpose would be to develop a general picture of cost trends and spending patterns. Presenting the information in this way could produce a learning environment in which data could be used efficiently and effectively, potentially changing the production of value-based medicine. On commercial websites, consumers are given incentives to purchase other products. For example, “Customers who bought this product also bought . . . ” Or “Free shipping for purchases over $50.” Such an approach might be adapted for the medical shopping cart. Analytical tools could be developed that assess the content of the shopping cart and suggest a different mix of services that would save X numbers of dollars or advise the physician “consumer” that 30 minutes of nursing time could be saved on an inpatient ward if care orders were modified in the following way. Such tools might indicate that efforts to reduce the total cost of a laboratory package should focus on a subset of 10 tests because they make up 90% of the cost as opposed to the other 80 tests that only make up 10% of the cost. Consumers making Internet purchases are given multiple opportunities to consider whether they want to purchase a given product for a specified amount. The orders that physicians write cause patients and insurance companies to spend money, but physicians have no information about how much they have spent, how they might change the amount of money spent, or how they might provide a more cost-effective mix of services. The current system effectively shields physicians from cost information and hence prevents them from asking these kinds of questions. Maybe physicians should need to click twice instead of just once before placing an order just to increase the likelihood that the patient needs that service or test. Can health care learn from commercial Internet sites and translate the lessons into meaningful use criteria for medical records? Any airline's site allows potential customers to search not just by schedule but by cost and schedule, and to narrow the schedule choices based on what the customer is willing or able to pay for a ticket. Changing the context to health care, does making a diagnosis in 3 weeks cost 3 times as much money as making the diagnosis in 4 weeks? If physicians and patients knew that it did, would they choose to change the time schedule for making the diagnosis in order to reduce costs? Providing physicians with cost data in real time automatically as a part of the electronic medical record could make them better purchasers for their patients and provide better value. Given that patients in the future are likely to spend even more money out of their own pockets for premiums and the care they receive, increased attention to value may also increase patient satisfaction and enhance the likelihood that they will purchase only care that will improve their health. Back to top Article Information Corresponding Author: Robert H. Brook, MD, ScD, RAND Corporation, 1776 Main St, Santa Monica, CA 90401 (brook@rand.org). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. References 1. Centers for Medicare & Medicaid Services. CMS HER Meaningful use overview. https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp. Accessed January 12, 2011 2. Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff (Millwood). 2005;24(5):1103-111716162551PubMedGoogle ScholarCrossref 3. Stuebing EA, Miner TJ. Surgical vampires and rising health care expenditure: reducing the cost of daily phlebotomy. Arch Surg. 2011;146(5):524-52721576605PubMedGoogle ScholarCrossref 4. Mehrotra A, Wang MC, Lave JR, Adams JL, McGlynn EA. Retail clinics, primary care physicians, and emergency departments: a comparison of patients' visits. Health Aff (Millwood). 2008;27(5):1272-128218780911PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Do Physicians Need a “Shopping Cart” for Health Care Services?

JAMA , Volume 307 (8) – Feb 22, 2012

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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.2012.204
Publisher site
See Article on Publisher Site

Abstract

Electronic medical records are being implemented throughout the US health care system. Incentives for implementation are being partially paid for by the US taxpayer. To receive implementation incentives, clinicians must demonstrate meaningful use—that is, the electronic medical record must be used to improve quality and must satisfy certain indicators.1 What is missing from the definition of meaningful use is any direct measure of either value or cost. It is likely that introducing electronic medical records will improve quality on such dimensions as whether a vaccine is administered, measurement of blood pressure is taken, diabetes is better controlled, and admissions for poorly controlled diabetes are reduced.2 However, in most systems there are no measures built into electronic medical records to help physicians control cost or even to know the cost of the care that they are providing. Other organizations use computers to improve the purchasing experience, cost, and value of consumer products. Anyone who has shopped online has been presented with multiple ways to judge the quality of the product being purchased. There are ways to compare a given product with other similar products along specific dimensions, and to see what individuals who purchased the product thought about it. The assumption is that this information can help a consumer decide whether the product is worth the cost. However, the consumer's experience does not end with the description of the product's quality or efforts to encourage purchase of a better-quality product. Invariably the site has an electronic “shopping cart” that not only lists all the products that the consumer has put in the cart but also shows the cost of each one, as well as the total cost of everything in the shopping cart. The cart's total automatically updates whenever the cart's content is changed. In essence, on Internet sites, meaningful use means giving information to the consumer about the quality and the cost of a product in real time. In the United States, the primary purchaser of medical care is the individual clinician, whether that is a physician or a nurse practitioner. Practitioners can access many sources to determine the quality of a test or procedure, but real-time cost data are not available anywhere. In this context, cost means what a typical patient who is insured by a typical company or by the government would be expected to pay for a given service. Cost includes both what the company or government paid and what the patient paid out of pocket. For example, if the insurance company paid the pharmacy $80 and the patient paid $8, the cost of this service is $88. What if every time a practitioner used an electronic medical record system to order a procedure or test for a patient, an electronic shopping cart appeared, indicating how much that “purchase” would cost? What if at the end of the day the practitioner received a statement indicating precisely how much money he or she had ordered to be spent on behalf of patients? What would happen? Would anybody care? Some evidence suggests that providing this type of information to physicians may be helpful. For instance, in a study at one hospital, following the initiation of a weekly announcement informing the surgical house staff and attending physicians of the actual dollar amount charged to non–intensive care patients for laboratory services (ie, daily phlebotomy) ordered during the previous week, there were reductions in daily per-patient charges for laboratory services, with estimated cost savings of more than $50 000 over the course of the 11-week intervention.3 Perhaps the designers of computerized medical record systems should be advised that the records will be considered incomplete unless they contain information about the cost of the procedures, tests, or services that physicians are purchasing using the systems. How rapidly could the systems currently in use be modified to include such information? Perhaps it is time to begin making physicians and patients aware of what is being spent on a real-time basis, in a form with which they are comfortable. Retail clinics,4 which provide care for a limited number of acute and preventive conditions, post prices for their services. Patients can see what it will cost them to get a flu vaccination or to be evaluated for a urinary tract infection. But clinicians must do better than retail clinics, or at least as well. It should be possible to keep a running total of the costs for everything that a physician orders. For instance, every time a physician admits a patient to the hospital and orders the nurses to obtain vital signs every hour, or to collect intake and output, or to get the patient out of bed and walk the patient for an hour, a cost could be put into the record and into the shopping cart. Any time a physician ordered a laboratory test or procedure, the total in the shopping cart would be updated. Once awareness about the cost of care on a real-time basis becomes part of the culture of medicine, perhaps the information could be used to increase the value of care and to control costs. At the very least, the presence of such information would be a wake-up call to physicians and nurse practitioners, helping them to understand just how much money is being spent on behalf of patients. The content and total cost of the shopping carts could be shared with patients so that they saw not only the list of tests and procedures and their results, but also the costs of those services in real time. Once the cost data are collected from these shopping carts, there are many ways to present and analyze them. For example, it might be useful to compare physicians on the same clinic schedule, inpatient rotation, or in similar office practice settings. Such a comparison need not adjust for every difference in patient mix. Rather the purpose would be to develop a general picture of cost trends and spending patterns. Presenting the information in this way could produce a learning environment in which data could be used efficiently and effectively, potentially changing the production of value-based medicine. On commercial websites, consumers are given incentives to purchase other products. For example, “Customers who bought this product also bought . . . ” Or “Free shipping for purchases over $50.” Such an approach might be adapted for the medical shopping cart. Analytical tools could be developed that assess the content of the shopping cart and suggest a different mix of services that would save X numbers of dollars or advise the physician “consumer” that 30 minutes of nursing time could be saved on an inpatient ward if care orders were modified in the following way. Such tools might indicate that efforts to reduce the total cost of a laboratory package should focus on a subset of 10 tests because they make up 90% of the cost as opposed to the other 80 tests that only make up 10% of the cost. Consumers making Internet purchases are given multiple opportunities to consider whether they want to purchase a given product for a specified amount. The orders that physicians write cause patients and insurance companies to spend money, but physicians have no information about how much they have spent, how they might change the amount of money spent, or how they might provide a more cost-effective mix of services. The current system effectively shields physicians from cost information and hence prevents them from asking these kinds of questions. Maybe physicians should need to click twice instead of just once before placing an order just to increase the likelihood that the patient needs that service or test. Can health care learn from commercial Internet sites and translate the lessons into meaningful use criteria for medical records? Any airline's site allows potential customers to search not just by schedule but by cost and schedule, and to narrow the schedule choices based on what the customer is willing or able to pay for a ticket. Changing the context to health care, does making a diagnosis in 3 weeks cost 3 times as much money as making the diagnosis in 4 weeks? If physicians and patients knew that it did, would they choose to change the time schedule for making the diagnosis in order to reduce costs? Providing physicians with cost data in real time automatically as a part of the electronic medical record could make them better purchasers for their patients and provide better value. Given that patients in the future are likely to spend even more money out of their own pockets for premiums and the care they receive, increased attention to value may also increase patient satisfaction and enhance the likelihood that they will purchase only care that will improve their health. Back to top Article Information Corresponding Author: Robert H. Brook, MD, ScD, RAND Corporation, 1776 Main St, Santa Monica, CA 90401 (brook@rand.org). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. References 1. Centers for Medicare & Medicaid Services. CMS HER Meaningful use overview. https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp. Accessed January 12, 2011 2. Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff (Millwood). 2005;24(5):1103-111716162551PubMedGoogle ScholarCrossref 3. Stuebing EA, Miner TJ. Surgical vampires and rising health care expenditure: reducing the cost of daily phlebotomy. Arch Surg. 2011;146(5):524-52721576605PubMedGoogle ScholarCrossref 4. Mehrotra A, Wang MC, Lave JR, Adams JL, McGlynn EA. Retail clinics, primary care physicians, and emergency departments: a comparison of patients' visits. Health Aff (Millwood). 2008;27(5):1272-128218780911PubMedGoogle ScholarCrossref

Journal

JAMAAmerican Medical Association

Published: Feb 22, 2012

Keywords: health services,shopping cart

References