The current relationship between cost, quality, and access in healthcare can be summarized by adapting a familiar software development adage: Cost, quality, and access: pick any two. In the book Healthcare USA: Understanding Its Organization and Delivery, Harry Sultz and Kristina Young state, “It is obvious that these goals are contradictory and that attainment of any two leaves the third uncontrolled.”

Quality refers to the relationship between interventions and outcomes, and the degree to which interventions achieve the desired effect (return to well state, reduction in symptoms, prolonged life, or comfort at end of life, among others). Cost refers to the financial burden of care to all interested parties: patients, providers, government, employers, and insurers. Access refers to the availability of care to those who need it.

Attempts to address each of these aspects of healthcare since then 1960s have not resulted in a balance between the three. Medicare and Medicaid were created to provide healthcare for all, but costs escalated as a result. Cost containment then became the priority. With the advent of managed care, costs should have been maintained in theory, but so far this has not been the case. According to Sultz and Young, with “the primary goal of the market [being] contain[ment of] costs,” access suffers.

Managed care was also designed to ensure quality by monitoring patterns of treatment and outcomes “to identify deviations from quality and efficiency standards.” Quality metrics involve number and kinds of tests ordered and procedures conducted, outcomes from these interventions, and number of errors that occur in medical care. The current healthcare philosophy in the United States values “heroic medicine” over preventive care. This was brought on by an insurance system that rewards such practices. Providers react to this by conducting more tests and performing more procedures than those in other countries because they are rewarded financially. However, costs continue to rise while quality does not.

If technology used to increase the number and kinds of tests and procedures that are administered doesn’t result in quality improvement, and access to these interventions is not equitable, perhaps then technology could be more effectively used to improve preventive care and involve patients in their treatment. Preventive care is “far less costly” and “results in measurable economic and human benefits.”

 Examples of technology used for preventive care range from health information delivered via the Internet to wearable medical devices designed to alert caregivers of potential problems with elderly patients before they arise. To use the example of prenatal care from the text, technology could be used to provide remote access to classes about prenatal care to patients who don’t have transportation or time to attend a class in person, with supplemental information delivered via email, SMS, or social media.

Changing the prevailing attitude of patients that they are not solely responsible for being sick, and that they are also not responsible for getting themselves well is a radical cultural shift that technology alone cannot achieve. However, technology can break down some of the barriers to access and provide relatively low-cost preventive care. In addition, changing the current philosophy of healthcare to value these kinds of approaches means a cultural shift, which will not occur until financial rewards exist for these types of interventions. 

Lee Farabaugh
Director of User Experience

Patient portals, with access to information about patients’ medical conditions, secure email communication, and appointment scheduling, educational materials, and other valuable components, are being developed by providers, hospitals, retailers, and other interested parties across the nation. These portals will be a valuable tool for patient education, increased ease of communication, anticipated time savings, and competitive advantage. There are a number of challenges, however, that must be addressed in anticipation of a patient portal development effort.

The decision to provide patient education is a wise one. Patients have a myriad of health information resources at their fingertips today, and it is sometimes difficult to determine the accurate, scientific, and reliable information from that which is not. An organization that develops a patient portal will be perceived as a credible source for health information, but with that assumption comes the responsibility to make sure the information is up-to-date and accurate. The organization should vet and ensure a physician expert in the area of practice writes each piece of content, and determine a review process and schedule so that information is always current, or make provisions with a content vendor of choice to ensure this is done.

Adequate planning is necessary for this effort. Organizations should understand the capital and technological investments needed to make the portal a reality, and how it will allow a reduction in costs, improvement in service, and enhancement of the quality of care before the first line of code is written. Strategic planning will determine where the project going, while operational planning will tell how to get there. Evaluation of the portal, both before it is put in front of users and after it is operational, will tell you if you’ve arrived.

There will likely be concern over how much the system will cost to deploy, operate, and maintain, and how much it will improve care and reduce costs, as well as how well it can be integrated with legacy systems.  The organization should also be cognizant of interoperability amongst all of the facilities in the enterprise, especially in terms of patient scheduling. You may also want to consider future integrations with consumer health platforms such as Microsoft HealthVault and Google Health.

An organization may decide that a vendor system is the best route, rather than building the portal in-house. In this case, adequate review of vendor systems is necessary to ensure that the one chosen has the desired features, and has been adequately designed and tested to ensure patient safety and privacy. A detailed systems acquisition process, including defining objectives, screening the marketplace, determining requirements, developing an RFP and evaluating proposals, and conducting a cost-benefit analysis to make a decision is necessary when going this route.

Patient confidentiality is another area of importance, especially in connection with messaging. Protection of sensitive patient information from breaches of confidentiality and from corruption is a chief concern with consumer health applications accessed via the internet. A secure messaging system, instead of direct physician-to-patient email, will help to provide confidentiality. Rather than showing a message containing personal health information in the body of an email message, which might be the property of a patient’s employer if it is viewed on the employer’s workstation, a secure message requires that the patient log in to a secure web site to view the message. This method allows us to further warn patients about confidentiality, and provides an additional level of security, through encryption. The organization also needs to consider and document appropriate uses for email communication between patients and physicians, for example warning patients that email is not appropriate for emergency situations.

The organization should investigate current workflow and how the patient portal will affect daily operations. The Committee for Enhancing the Internet for Health Applications states that “internet applications tend to demand new (or modified) organizational policies and procedures” and that “internet applications have been shown to alter work patterns within organizations in unanticipated ways.” Adequate user research, involving both staff members and patients, coupled with appropriate training and follow-up will lead to greater success in user acceptance. The organization should also consider some of the more philosophical issues, such as how the Internet will alter the traditional relationships among patients and their physicians.

Finally, the organization needs to evaluate the portal after launch to determine how its benefits compared to its costs. It is sometimes difficult to do this once a system is implemented, because the organization believes it has already invested significant capital in the system. However, patient satisfaction feedback, usability testing, and measurement of patient outcome improvement can be valuable tools for further development and modifications that will increase adoption and improve care.

Lee Farabaugh
Director of User Experience