Blaming the wrong culprit

December 03, 1993|By Arthur Caplan

WHO dunnit? Who is responsible for the high cost of health care in the United States? The usual suspects are being hauled into lineups in newspapers, on television and in Congress.

Some policy wonks think the evidence points to greedy doctors, drug companies and for-profit hospitals.

Inspector Hillary has fingered private health insurance companies. Other health-policy detectives say lawyers and malpractice insurance are driving costs through the roof.

But lots of the health-policy police think these culprits are just small fry. They say the Mr. Big of health-care cost is technology. U.S. health care is overflowing with technology. Transplants, bypass operations, CAT scans, laser surgery and hip replacements -- these are the real villains responsible for the red ink spilling out of the federal budget.

These cost-control cops argue that unless we get tough on technology, unless we lock up the researchers and engineers who are busy right now inventing the next generation of medical innovations, we will be in hock up to our eyeballs.

Phooey! This line of blarney has found too many receptive ears. Technology, contrary to what so many experts and pundits say, is not public enemy No. 1 when it comes to the high cost of U.S. medicine.

Technology can be expensive, but it can also save money. The need for more technology is especially pressing with respect to the use of computers in medicine.

In 1863 Florence Nightingale complained in her classic book, "Notes on a Hospital," that "I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purposes of comparison. If they could be obtained . . . they would show how money was being spent, what amount of good was really being done with it, or whether the money was doing mischief rather than good . . . "

If the good nurse were to suddenly be transported into the typical U.S. hospital, clinic or group practice in 1993, she would be amazed to find that her 130-year-old lament still rings true. Medical record-keeping is still in the dark ages in the United States.

A group of Dutch physicians reports that 38 percent of Dutch general practitioners are using computer-based patient records. Of these, 70 percent no longer use any written records or charts in treating their patients.

In the United States, fewer than 1 percent of general practitioners use computer-based patient records. The average U.S. hospital is still using handwritten paper copies of information that are kept on file in huge record rooms.

Most U.S. doctors cannot instantaneously call up your medical record on the office computer, but must wait for someone to find your chart in the record room.

In this country it is still possible to die or be injured as a result of bad penmanship. In the current antiquated handling of information, tests are repeated, errors are made, unnecessary tests done and laboratory results misplaced because no one can find your chart.

In Annals of Internal Medicine, a magazine for health professionals, three doctors in the Laboratory of Computer Science at Harvard Medical School offer what is truly a horrifying diagnosis of record-keeping and information storage in U.S. medicine. They complain of fragmented patient medical records and say, "The primary emphasis has not been on the clinical record but functions such as billing . . . "

What the doctors are saying is that our current health-care system is great at using computers to track you down and make sure you pay your bill, but it has no idea how to use them to keep track of the state of your health.

Florence Nightingale was right. A key strategy for controlling health-care costs is to use information efficiently and effectively. We are not going to get a handle on the cost of health care until President Clinton's health security card contains a computer chip on which your medical history is encoded (and there is a computer at your doctor's office that can read it).

Spending money on this kind of technology not only will save money; it might even save your life.

Arthur Caplan is director of the Center for Biomedical Ethics at the University of Minnesota Medical School.

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