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Linda P. Fried Headshot

To Build a Bridge

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Invest in infrastructure! This has become an appropriate centerpiece of President Obama's plan for the nation and for proposals to improve the healthcare system, and is certainly critical. In this plan, there are healthcare counterparts to roads, bridges, or buildings: one example is the electronic health record (EHR). But technology is only as good as the system it supports, and infrastructure funding that expands technology without addressing the limitations of the system itself will ultimately come up short.

Such is the longing for the efficiencies that could be achieved with the creation of seamless, high quality electronic health records that companies like Google have versions to promote. There is much that the EHR might accomplish. These records permit unified, easy-to-access records of a person's health problems and needs and the care they receive over time. This would be a tremendous advance, supporting prevention and effective care of chronic health problems; transitions from one healthcare provider or setting to another, prevention of medical errors and possible dangerous drug interactions; and the links to services and community resources. It could improve the rate at which we translate new knowledge about health promotion and disease prevention into healthcare practices. As we all live longer and the likelihood of having multiple health problems increases with age, this system will be a critical investment in nation's health.

But if an electronic health record is like a bridge or tunnel or road, it matters not simply that it is there and in good condition, but what it connects. Infrastructure improvements must not simply make what we already do better; they must support a new type of health system: one that integrates hospital and clinic with community-based and home care services and ties in local health departments and other public health approaches essential to keeping our whole population healthy.

A comprehensive information system designed for the future would not simply link patients with physicians more efficiently, it would bridge the multiple domains in which intervention is possible. For example, an effective information system for the identification and care of children with asthma would share information across school-based clinics, primary care providers, hospital emergency rooms, pharmacies, and home visits by community health workers. In this way, we could improve use of medications and decrease environmental factors that worsen asthma. Such an information system could help local health departments implement more effective prevention policies and practices, and work with public health scientists to develop new knowledge for needed prevention strategies.

At the other end of the age spectrum, such an information system could also be designed to support the care and well-being of frail older adults, similarly linking home-based care by physicians, nurses and other health professionals with clinic-based doctors, emergency rooms and hospitals, and with community services such as visiting nurses, exercise programs, or pharmacists.

For all ages, addressing our country's epidemics of obesity and diabetes will require team-based healthcare linked to an array of workplace, school, and community-based health promotion supports to help people change diet, increase their physical activity and manage health.

As a major step towards designing a new approach to link medical care and population health, the New York City Department of Health and Mental Hygiene (DOHMH) has been an innovator on the use of information technology: considering a successful health system as much more than the doctor-patient encounter, clinical providers now use a variety of DOHMH information systems, including immunization and lead registries, communicable disease reporting, syndromic surveillance, and school health forms. The DOHMH's ambitious new EHR program seeks to provide clinical partners with tools such as prompts to schedule routine tests and vaccinations and advice on appropriate treatment.

Other cities have been innovators, as well, regarding the use of information technology to protect health, including community-based IT systems addressing prevention practices that provide an effective platform on which to build more complicated EHR systems. For example, the Baltimore City Commission on Aging has utilized IT systems to identify frail older adults at risk in severe heat waves or in other emergency situations.

We need to build a "bridge" that links a patient with all of their doctors and clinical providers, but does much more. We need to create the infrastructure for a new kind of health system: one that brings clinic and community together, integrates medical care and public health approaches, and makes the connections critical for good health.