A decade ago, doctors Tom Frieden and Farzad Mostashari wrote a commentary for a leading medical journal entitled, “Health Care as If Health Mattered.” The essay, published in JAMA (sorry—it’s behind a paywall), had a simple, if obvious, premise: “Health care must be restructured to make maximizing health the organizing principle.”
As simple and obvious as that might seem, however, that’s not how health care today is structured. Our system is a try-to-fix-it-if-broken one, not a try-to-keep-bodies-healthy model.
Dr. Frieden and Dr. Mostashari, at the time of their commentary, were then the New York City Health Commissioner and Assistant Commissioner, respectively—where they had led pioneering efforts to reduce smoking and rid the city’s restaurants of artificial trans fats, among other initiatives. One can argue, of course, whether or not such peremptory municipal injunctions are appropriate, but the idea behind them was the try-to-keep-bodies-healthy approach. Get people to quit smoking and you reduce the risk of them developing cancer, heart disease, cerebrovascular disease, COPD, and those wet, hacking coughs on the subway. Push restaurants and other food suppliers to stop serving junk laced with industrial-strength trans unsaturated fatty acids—“solid fats produced artificially by heating liquid vegetable oils in the presence of metal catalysts and hydrogen”—and you might actually reduce the incidence of coronary heart disease and diabetes in a wide swath of citizens.
In their JAMA commentary, the duo suggested three “synergistic changes” to transform the health paradigm: (1) change the payment structure overall to offer “substantial rewards for disease prevention and effective management of chronic disease”; (2) develop an “information system oriented toward prevention”; and (3) change care management so that it supports the above.
Importantly, all these things have to be done together, they argued, for such a new model to work. (“Pay-for-performance initiatives have been hampered by lack of reliable information on quality of care and outcomes,” for instance.)
Back in 2008, Frieden, who would later go on to run the CDC during the Obama administration, and Mostashari, who would become National Coordinator for Health IT, had high hopes for information systems, such as electronic health records. “EHRs have the potential to enable valid clinical quality measurement, high-quality preventive care, and better management of chronic conditions such as hypertension and hypercholesterolemia,” they wrote.
I think it’s fair to say they haven’t lived up to that potential. But who knows, maybe if we can truly reorient the entire U.S. health system toward a prevention, preemption, and maintenance model, EHRs will find their right mission and achieve it.
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