EMR : Right Answer, Wrong Question

The administration is moving at warp speed to improve our health care system by pursuing new EMR initiatives-one key component of the administration’s health care reform bil. The objective, reinforced by President Obama: computerize all medical records within five years. Proposed benefits include reducing waste, eliminating red tape, reducing the need to repeat expensive medical tests and helping reduce costly medical errors. So if these are the benefits, and these are the right answers to the how can EMR help, why is there ‘pushback’ on EMR and reluctance to aggressively pursue new EMR initiatives.

Maybe these are the right answers but maybe we have the wrong question here. Fixing the system makes sense when you look at today’s health care system problems. Many studies exist- I find the University of Maine study (2001) reviewing OECD and WHO data particularly insightful. Look at some of the statistics; 42 million uninsured in the U.S.; we spend about $4,178 per capita for health care in the U.S., more than two times the median cost of $1,783 in OECD countries and much more than Switzerland which is next on the list at $2,794; we spend 13.6 percent of our GDP on health care vs. the next highest at 10.6 and 10.4 percent in Germany and Switzerland.

So with these investments you may assume our health care system should be world class. Unfortunately the same study, and many others, tell a different story. Overall health care system satisfaction among the population ranks reasonably high in many OECD countries; Denmark, Finland, and the United Kingdom are at 91, 81 and 60 percent respectively. Canada, notwithstanding any commercials we have seen, shows a 46 percent satisfaction rate. Most countries are over 50 percent some are over 60. Compare these to the United States where only 40 percent of the population is satisfied with our health care system- small comfort that we exceed only Italy where only 20 percent are satisfied with their system. Some may argue this is perception and studies are subject to error in design or methodology. What is more difficult to challenge, and I find particularly insightful, are ‘hard’ statistics such as infant mortality rates where the U.S. ranked 26^th among all industrialized countries with 7.2 deaths per 1000 live births. Compare this to Japan, Norway, Finland and Sweden which are all under 4, and the United Kingdom, Canada and Germany at 5.9, 5.2 and 4.9 respectively.

Now related to EMR, one statistic I find most insightful is U.S. hospitals, by all measures the most expensive in the world, spend about 19.3 to 24.1 percent of their total budget on administrative costs. For private, ‘for profit’ hospitals this increases to about 34 percent vs. 19.3 percent for public hospitals. I do not see these statistics mentioned. What this means is about one-third of all private hospital expenses look like what you may expect in a hotel business – costs for check-in, room service, reservations, meals, cleaning and check out. Given this model, which I believe fits well based on my experience, we need a new operational paradigm to shift the focus from the benefits of reducing paper to changing business processes. Virtually all other industry sectors learned years ago in the e-commerce revolution that replacing paper is not the cost saver. Business re-engineering of processes is how firms drive bottom line improvements to achieve improved performance. You spend more to create efficient operations structures then you save by reducing operating costs.

So given the above and going back to EMR, I suggest we reframe the EMR question – the additional cost to implement EMR is an issue but should not be. The real EMR question should be what are the primary and secondary business processes that will be enabled by EMR and what are the investment and process improvement metrics?. That should be the key question, not implementation cost of over $100,000 per physician office or other cost metrics. Other sectors migrating to a paperless environment all show cost increases which are often dramatically offset by process improvement savings. When today’s average private hospital is spending about 34 percent of total budget on administrative costs, we can clearly see the opportunity to achieve dramatic efficiency improvements.

As one example, consider hospital operating rooms which many do no know are a profit center within hospitals. Studies suggest these facilities today operate at less than 60 percent efficiency. Why? Changes or delays in patient admittance means facilities become available but this information is useless unless it can be managed, disseminated and acted upon to reschedule surgeries, identify the location of hospital assets and maximize use of resources. Imagine a hotel where a cancellation occurs and it takes hours to reschedule other customers to use the room. These problems occur in every sector today and are solved by robust, agile information systems and solutions driven by well proven business process re-engineering techniques. That is the real opportunity I foresee today in the U.S. health care sector. We are now well positioned to make substantive changes in our health care sector driven by national leadership and vision, new technologies and the opportunity to dramatically reshape health care sector business processes.

Paul B. Silverman

November 1, 2009