Many people believe that better information technology (IT) can help improve the quality of medical care in the U.S. and around the world. For instance, if a doctor prescribes a drug which interacts harmfully with a drug the patient is already taking, a computer program could notify the doctor of this problem. If a patient has a certain disease, a computer program could help to narrow down the physician’s treatment options.
The problem with this top-down, one-size-fits-all doctoring is that every patient is unique. Of course, there are medical standards which should generally be followed, but often these standardized treatments have to be altered slightly or completely depending on patient wishes, the prevalence of multiple diseases, or economic constraints. Further, the physician typically has superior information regarding the patient’s condition than a standardized computer algorithm.
An NBER working paper by Javitt, Rebitzer and Reisman investigates a randomized trial of the implementation of a new IT system at a commercial HMO plan. The program was ‘turned on’ for some patients for each physician in the HMO and ‘turned off’ for other patients. The program would give three care consideration (CC) alerts: stop a drug, do a test, or add a drug. Each of these warnings had 3 severity levels.
The authors compare data on the CC alerts which occurred for the ‘switched on’ patients with the hypothetical CC alerts which would have occurred if the software had been running. The authors found that the IT program lead to 6% lower charges in the turned on group compared to the control. The authors interpret this to be due to lower hospitalization rates and medication complications in the treatment group.
One key aspect of the program is that the CC alerts could be ignored by doctors.
“Physicians often have better information about their patients than does the error detecting software. Actions that look like a misstep to the computer may in fact be the result of informed physician choice, informed patient choice and/or patient non-compliance. For this reason, the HMO and the software company viewed CCs as recommendations that physicians were free to ignore if they disagreed.”
Physicians seemed to heed these CC alerts more than other studies had previously thought they would. Why?
Our results, however, suggest something more: the messages in the CCs seem to have had a bigger effect on physicians than the conventional medical channels used to promote the HOPE trial findings. It seems plausible that the CCs were influential because they linked a general recommendation (“take ACE inhibitors�?) to a specific patient [my italics] and a specific cite to the medical literature.”
To me, this seems to be the most appropriate way to implement medical IT.
- Javitt JC, Rebitzer JB, Reisman L, (2008) “Information Technology and Medical Missteps: Evidence from a Randomized Trial” Journal of Health Economics, 27(3): 585-602.
- Javitt JC, Rebitzer JB, Reisman L, (2007) “Information Technology and Medical Missteps: Evidence from a Randomized Trial” NBER WP #13493.