Do physicians need a "shopping cart" for health care services?

ELECTRONIC MEDICAL RECORDS ARE BEING IMPLEmented throughout the US health care system. Incentives for implementation are being partially paid for by the US taxpayer. To receive implementation incentives, clinicians must demonstrate meaningful use—that is, the electronic medical record must be used to improve quality and must satisfy certain indicators. What is missing from the definition of meaningful use is any direct measure of either value or cost. It is likely that introducing electronic medical records will improve quality on such dimensions as whether a vaccine is administered, measurement of blood pressure is taken, diabetes is better controlled, and admissions for poorly controlled diabetes are reduced. However, in most systems there are no measures built into electronic medical records to help physicians control cost or even to know the cost of the care that they are providing. Other organizations use computers to improve the purchasing experience, cost, and value of consumer products. Anyone who has shopped online has been presented with multiple ways to judge the quality of the product being purchased. There are ways to compare a given product with other similar products along specific dimensions, and to see what individuals who purchased the product thought about it. The assumption is that this information can help a consumer decide whether the product is worth the cost. However, the consumer’s experience does not end with the description of the product’s quality or efforts to encourage purchase of a better-quality product. Invariably the site has an electronic “shopping cart” that not only lists all the products that the consumer has put in the cart but also shows the cost of each one, as well as the total cost of everything in the shopping cart. The cart’s total automatically updates whenever the cart’s content is changed. In essence, on Internet sites, meaningful use means giving information to the consumer about the quality and the cost of a product in real time. In the United States, the primary purchaser of medical care is the individual clinician, whether that is a physician or a nurse practitioner. Practitioners can access many sources to determine the quality of a test or procedure, but real-time cost data are not available anywhere. In this context, cost means what a typical patient who is insured by a typical company or by the government would be expected to pay for a given service. Cost includes both what the company or government paid and what the patient paid out of pocket. For example, if the insurance company paid the pharmacy $80 and the patient paid $8, the cost of this service is $88. What if every time a practitioner used an electronic medical record system to order a procedure or test for a patient, an electronic shopping cart appeared, indicating how much that “purchase” would cost? What if at the end of the day the practitioner received a statement indicating precisely how much money he or she had ordered to be spent on behalf of patients? What would happen? Would anybody care? Some evidence suggests that providing this type of information to physicians may be helpful. For instance, in a study at one hospital, following the initiation of a weekly announcement informing the surgical house staff and attending physicians of the actual dollar amount charged to non– intensive care patients for laboratory services (ie, daily phlebotomy) ordered during the previous week, there were reductions in daily per-patient charges for laboratory services, with estimated cost savings of more than $50 000 over the course of the 11-week intervention. Perhaps the designers of computerized medical record systems should be advised that the records will be considered incomplete unless they contain information about the cost of the procedures, tests, or services that physicians are purchasing using the systems. How rapidly could the systems currently in use be modified to include such information? Perhaps it is time to begin making physicians and patients aware of what is being spent on a real-time basis, in a form with which they are comfortable. Retail clinics, which provide care for a limited number of acute and preventive conditions, post prices for their services. Patients can see what it will cost them to get a flu vaccination or to be evaluated for a urinary tract infection. But clinicians must do better than retail clinics, or at least as well. It should be possible to keep a running total of the costs for everything that a physician orders. For instance, every time a physician admits a patient to the hospital and orders the nurses to obtain vital signs every hour, or to collect intake