Do e-patients drive up medical costs?

A recent article on NPR looks at the concern of “how the modern patient drives up health costs.” The issues described – patients coming to physicians with interest in products seen in advertising, or looked up on the Internet – have validity, and describe some of the consequences of increasingly-available information (including health information) flooding in through modern technology. Is this a necessary down-side of the trend towards “e-patients” and what has been described as Participatory Medicine?

The concern raised in the NPR article describes the effect of information dissemination without context or interpretation – it happens anyway, with direct-to-consumer advertising in all forms of media, and it happens even faster with the Internet. And when patients, armed with these “facts” and the questions they raise, come to their physicians – the physician is often hard-pressed to put things into perspective. The result? Often, very-low-yield tests (or even unnecessary tests that raise the risk of harm through adverse events) and unnecessarily expensive treatments are agreed-to, simply because it’s the path of least resistance.

What are some of the factors that result in this pattern? Traditional compensation methods (fee-for-service) reward volume of service, which results in crowded schedules and minimal time allotted for discussion of these kinds of questions. This is especially true for Primary Care Physicians, who only generate income based on office visits (rather than higher-dollar-amount procedures) – typically 10 or 15 minutes is the maximum time available for an encounter. Lengthy discussions about why the out-of-context treatment or testing is inappropriate, and what the true indications actually are, is something there simply isn’t time for. Over and over again, over the course of a day, a physician gets worn down. Additionally, many physicians claim that acceding to patient-initiated requests is simply “defensive medicine” driven by fear of malpractice litigation.

Such effects on healthcare costs are more the result of a chaotic delivery system, rather than the result of Internet connectivity (“it’s not the tool that’s the problem; it’s how it’s used”). The Internet, and the deluge of information from all media, simply accelerate the problems inherent in how we deliver healthcare in this country.

People are moving to the Internet for health information in increasing numbers, and when the information is without perspective and context, then problems of inappropriate care arise. Where might solutions be found?

A systemic fix that moves away from fee-for-service care (especially for PCPs) is needed in order to break the hamster-wheel workday of 10-15 minute clinical encounters – the Patient Centered Medical Home is one way of moving in this direction, and the federal government has indicated a desire to begin funding the Medical Home model. Many physicians also are convinced that tort reform around malpractice law is needed in order to reduce the tendency to practice “defensive medicine.”

Research on “comparative effectiveness” is also moving forward, with hopes of building upon the already-robust collection of Evidence-Based treatment recommendations. However, simply “knowing what the best treatment pathway is for condition x” is not sufficient to result in a change in the social behavior of physicians – presentation of these guidelines at the point of care is also needed. That is where Electronic Health Records (EHRs) come in. Clinical Decision Support tools, which present the physician with the recommendations most appropriate for the clinical situation ad-hand, is a goal of EHR development. The industry is at best hit-and-miss in this regard, but such build-out is an important direction for EHR builders – Practice Fusion is growing in this direction, and delivery of powerful tools that can rapidly and universally be deployed is part of the roadmap. An example of such a tool, rapidly developed and deployed across the landscape, is the H1N1 candidate identification tool recently announced by Practice Fusion.

However, simply physician-facing Decision Support tools are not enough. They do not result in enabling Participatory Medicine. What is also needed is a similar set of Decision Support tools, from trusted and evidence-based sources, that are available to patients/consumers as well. There needs to be a trusted source where a patient can go to find out more about a question that might have come up due to seeing an ad for a product or service, or hearing comments from friends – some place that describes “comparative effectiveness” research data that fills Decision Support written in ways that are accessible to a lay-person audience. That, too, is part of the Practice Fusion vision, as the Personal Health Record (connected to the physician’s EHR) is rolled out in the ensuing months.

Empowerment of Participatory Medicine – not simply flooding healthcare consumers with out-of-context “information” – is what the next level of technology promises. The hope is that – given that patients are using the Internet more actively as time goes on and becoming “e-patients” – these new technologies (coupled with structural changes in the health delivery model that encourages physicians and consumers to use these resources) will result in improvement of healthcare outcomes and cost run-ups, rather than simply the “more, faster chaos” that is lamented by some.


Robert Rowley, MD – Chief Medical Officer, Practice Fusion, Inc.