In a pair of op-ed columns published online by The New England Journal of Medicine on May 24, Howard Brody, M.D., Ph.D, in “From an Ethics of Rationing to an Ethics of Waste Avoidance,” and M. Gregg Bloche, M.D., J.D., in “Beyond the ‘R Word’? Medicine’s New Frugality,” both address issues around rationing in healthcare very carefully and very thoughtfully. Both of these widely recognized medical ethics experts anchor their “Perspectives” columns around the well-publicized statistic that 30 percent of annual U.S. healthcare spending, or $800 billion, is spent on ineffective, and therefore wasteful, patient care.
As both Drs. Brody and Bloche point out, below the level of mainstream media headlines around the politics of rationing, healthcare experts and leaders are generally in consensus that something must be done to use evidence-based comparative effectiveness strategies to bring down that estimated $800 billion of non-useful healthcare spending taking place every year.
Both writers plunge into the thicket of ethical and political issues cross-hatching this controversial area. But let me focus on the pragmatics of this. As Brody notes in his column, with regard to the clinical literature, “Here, I believe, we must consider the limitations of evidence. Data from Randomized clinical trials represent population averages that may apply poorly to any individual patient.”
One of the drill-down complexities here is the question of how more useful information—both evidence-based and practice-/consensus-based—can be pre-loaded into clinical decision support tools within EHRs, as well as provided through empirically based clinical performance reporting. And in that area, of course, CIOs, CMIOs, and other clinical and non-clinical informaticists will need to be front-and-center in participating in, and often leading, the discussion.
In fact, it’s impossible to imagine the years-long discussion that needs to take place in this arena taking place without very solid leadership from healthcare IT leaders, particularly those with clinical backgrounds. Looking now at the vendors providing evidence-based order set solutions, it’s clear that the current iterations of these very useful, indeed critical, solutions, are still in their relative infancy with regard to their ultimate evolution.
So here’s an immense challenge carrying inside it a tremendous opportunity. On the one hand, it will require enormous efforts across the healthcare system in order to seriously and thoughtfully look at the issue of the expending of non-useful clinical resources on patient care, particularly in an inevitably politics-tinged operating environment. On the other hand, there is the genuine potential here for clinical informaticists, other informaticists, and clinicians to be involved at the ground-floor level in building the information and knowledge systems that will be essential to addressing resource allocation in healthcare going forward.
And wouldn’t it be far better if those closest to patient care processes had such input, as opposed to faraway bureaucrats and politicians? This touches on the essence of what has been called “internal healthcare reform”—efforts generated within the healthcare system itself to make needed system changes. The bottom line here? The day when clinicians will be pressed into service to join the discussion on resource utilization will be with us sooner than anyone might wish. And when that day comes, it will take all the expertise, ingenuity, and compassion in the healthcare system to do it right.
