PRESIDENTIAL ADDRESS
Presidential address: quality of cardiovascular care in the U.S.
George A. Beller, MD, MACCa
a Cardiovascular Division, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
Reprint requests and correspondence: Dr. George A. Beller, Cardiovascular Division, Department of Medicine, P.O. Box 800158, University of Virginia Health System, Charlottesville, Virginia 22908-0158
gbeller{at}virginia.edu
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Abbreviations and Acronyms
| | ACC | = American College of Cardiology | | ACE | = angiotensin-converting enzyme | | AHA | = American Heart Association | | AMI | = acute myocardial infarction | | CAD | = coronary artery disease | | CHAMP | = Cardiovascular Hospitalization Atherosclerosis Management Program (University of California, Los Angeles) | | CHD | = coronary heart disease | | CHF | = congestive heart failure | | CME | = continuing medical education | | GAP | = Guidelines Applied in Practice | | HF | = heart failure | | IOM | = Institute of Medicine | | KDE | = Knowledge Delivery Enterprise | | LDL | = low-density lipoprotein | | LV | = left ventricular | | MI | = myocardial infarction | | NCEP | = National Cholesterol Education Program | | NCQA | = National Committee for Quality Assurance |
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There has been an explosion of new knowledge in our understanding of the biologic mechanisms of cardiovascular disease. Over the past 30 years, the increase in the number of clinical trials has risen exponentially. Today, new therapies and sophisticated technologies are saving countless lives and improving the functional status of millions of patients with chronic heart disease. But, with medical science and technology advancing at such a rapid pace, physicians are overwhelmed with volumes of medical literature and uncertainty about the effectiveness and appropriateness of alternative diagnostic and treatment strategies.
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Lack of time for learning new knowledge
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To quote from the recently released Institute of Medicine (IOM) report, Crossing the Quality Chasm (1), "Health care today is characterized by more to know, more to manage, more to watch, more to do, and more people involved in doing it than at any other time in the nation’s history." Physicians are frustrated by limited time to keep up with, and analyze, this huge amount of new medical knowledge. Increasing patient workloads, caring for a more elderly and sicker patient population, hours wasted writing redundant information in paper charts and engagement in myriad bureaucratic matters limit the time physicians can spend with each of their patients and keep up with the medical literature. They are finding it more difficult to devote the necessary attention to learning and reviewing new and revised evidence-based practice guidelines so that they can effectively apply them to the everyday care of cardiac patients.
Finding the time to stay current with new medical knowledge and practice guidelines and to be trained in new procedural techniques will become more and more difficult in the future. Physicians are caring for an older and sicker patient population with multiple chronic conditions. This requires more physician time for every patient encounter. The number of Americans with chronic diseases is expected to grow to 134 million by 2020 (2). It is estimated that the number of Americans 65 years or older will double to 78.5 million in the next 50 years (3). These increases will contribute to a marked rise in the prevalence of coronary heart disease (CHD) and heart failure (HF). Many of these older patients will have complex, chronic cardiovascular conditions that require careful and frequent surveillance and management with multi-drug therapy and procedural interventions. A good contemporary example is Vice President Cheney’s well-publicized clinical history of four myocardial infarctions (MIs), a coronary bypass operation, a coronary stenting procedure and a balloon angioplasty for in-stent restenosis.
In addition, the epidemic of type 2 diabetes, fueled by another epidemic of obesity and physical inactivity, will lead to a striking increase in the number of young people in the U.S. with CHD (4). For people in their 30s, the incidence of diabetes rose nearly 70% from 1990 to 1998 (5). Diabetes increases the risk of CHD two- to fourfold, and two-thirds of diabetic patients will die of heart or blood vessel disease (4). Thus, both the increase in the elderly population and an increase in the number of young adults with cardiovascular disease will demand that more of cardiovascular specialists’ time be devoted solely to clinical practice duties. There may also be an emerging shortage in trained cardiologists, compounding this demand for more practice activities.
Physicians here and overseas perceive that their ability to provide quality care has declined. In a recent survey (6), 38% to 59% of physicians replied that their ability to provide quality care had diminished in the past five years. Of the U.S. physicians surveyed, 56% felt that way. In this survey, only 10% to 27% of the physicians in the five English-speaking countries surveyed said that their ability to provide quality care had improved. Almost three-quarters of the physicians reported that if they could spend more time with patients, the quality of care would improve (6).
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Antiquated medical information system
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Physicians are working in an environment where information technology is antiquated and the vast majority of clinical information is still stored only on paper. Furthermore, as the IOM report pointed out (1), physician groups, hospitals and other health care organizations operate as individual "silos," with each group rendering care without the benefit of complete information about the patient’s condition, prior medical history, services provided in other settings and medications prescribed by other physicians. Figure 1 depicts four hypothetical "silos" where medical care is often provided to a patient with cardiac disease. It is not unusual for such a patient to have four independent medical records housed in each "silo" of care with poor or no communication among the providers working in these settings. A separate IOM report (7) also indicated that many medical errors, ubiquitous throughout the health care system, could be prevented if clinical data were more easily accessible and readable, and further, that the decentralized and fragmented nature of the health care delivery system "contributes to unsafe conditions for patients, and serves as an impediment to efforts to improve safety. ... Provision of care to patients by a collection of loosely affiliated organizations and providers makes it difficult to implement improved clinical information systems capable of providing timely access to complete patient information."
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Figure 1 Four silos representing locales of care for a hypothetical patient with cardiovascular disease. Presently, there is no common repository of medical information for such a hypothetical patient that can be easily accessed electronically by physicians or other hospital personnel in each of these locales. Such inability to easily share medical information contributes to overall lower quality care and increased chance for medical errors.
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All of these recent developments—information overload, the increase in time pressures on physicians, the increased prevalence of chronic heart disease, the growing complexity of medical care and an increasingly fragmented and antiquated health care delivery system—together present a challenge of colossal proportions. Because of these factors and others, physicians are not providing high-quality cardiovascular care to their patients in a uniform manner.
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Quality of care for patients with acute MI
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The treatment of patients with acute MI (AMI) is a perfect example. Certain quality indicators describe the appropriate process of care for patients with AMI. These indicators include: - aspirin upon admission;
- aspirin at discharge;
- beta-blocker administration early during hospitalization;
- maintenance beta-blocker therapy at discharge;
- angiotensin-converting enzyme (ACE) inhibitors for patients with a low ejection fraction (sometimes, ACE inhibitors for all postinfarction patients);
- assessment of lipid status;
- use of statin therapy during hospitalization and continuing after discharge; and
- dietary, exercise and smoking cessation counseling.
Several years ago, Krumholz et al. (8) reported the rate of beta-blocker use in patients 65 years of age or older who survived hospitalization with AMI. More than 10 years after the American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines confirmed that beta-blockers were highly effective in postinfarction patients, only 50% of patients without contraindications to beta-blockers were given prescriptions for these drugs at discharge. The report noted wide variation by state, from 30% to 77%. After adjustment for potential confounders, those patients on beta-blockers showed a 14% lower mortality one year after discharge. The National Registry of Myocardial Infarction, which collected data on more than 167,000 patients nationwide, analyzed more recent data (9). Figure 2 shows the percentage of patients receiving various discharge medications that have a proven value for enhancing survival after AMI. Only 77% of the patients were discharged with a prescription for aspirin, 65% with a beta-blocker, 42% with an ACE inhibitor and 37% with a statin drug. Only 42% of smokers received smoking cessation counseling. This report surveyed admissions from July 1999 to June 2000 and includes patients with no exclusions for contraindications or intolerance to these drugs.
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Figure 2 Percentage of patients receiving various discharge medications that have a proven value for enhancing survival after acute myocardial infarction (MI). Note that only 65% of patients were discharged with a beta-blocker, despite knowledge for more than 10 years that beta-blocker therapy in post-MI patients reduces subsequent mortality. ACE = angiotensin-converting enzyme. ASA = aspirin.
Data from the National Registry of Myocardial Infarction-3, http://www.med.ucla.edu/champ/NRMI.htm. Reprinted with permission from Gregg C. Fonarow, MD.
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Great variability exists among medical centers in different geographic regions of the U.S. regarding the percentage of patients receiving beta-blockers at discharge for AMI. Data in The Dartmouth Atlas of Cardiovascular Health Care (10) show that compliance with the guideline of prescription of beta-blockers at the time of hospital discharge ranged from 5% of "ideal" patients receiving such prescriptions to 92.5% (Fig. 3). This variability was 10 times greater than rates of compliance with the recommendation for aspirin. If the ACC/AHA guidelines were more effectively and uniformly applied to practice, the compliance rate would exceed 80%. Jencks et al. (11) assessed the quality of medical care delivered to Medicare beneficiaries on both the national and state levels. The median performance was 72% with respect to post-MI patients who were discharged with beta-blockers. The state-by-state breakdown revealed wide variability, with 47% of the patients from Mississippi discharged with beta-blockers after MI, compared with 93% in Massachusetts.
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Figure 3 Percentage of post-myocardial infarction (MI) patients receiving beta-blockers at discharge in various geographic regions (each represented by a solid circle) across the U.S. Note the marked variability in the percentage of "ideal" patients receiving beta-blockers. If practice guidelines were more effectively and uniformly applied to practice, this variability would be far less, and more than 80% of all post-MI patients would be receiving beta-blockers.
Copyright the Trustees of Dartmouth College 1999. Reprinted with permission, from Wennberg DE, Birkmeyer JD. The Dartmouth Atlas of Cardiovascular Health Care. Chicago, IL: The American Hospital Association Press, 1999 (10).
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Approximately 80,000 additional lives would be saved each year in this country if we moved from actual use of proven-effective therapy for patients with AMI to ideal use (12). In this analysis, actual use of antiplatelet agents, beta-blockers, ACE inhibitors and statins was estimated by examining data from recent clinical trials involving patients with MI. Ideal rates of use were derived from known or suspected rates of true drug intolerance and from published drug discontinuation rates in large clinical trials. For ACE inhibitors, moving from a 50% actual-usage rate to 80% as optimal use would save 30,600 lives per year. If beta-blocker usage were increased only 10%, from 75% to the optimal use of 85%, 12,600 lives would be saved. A total of 27,600 lives would be saved if statin usage were increased from 50% to 70%. In a separate study, Phillips et al. (13) calculated the cost-effectiveness of increased beta-blocker use among the 406,000 survivors of AMI in this country. If beta-blocker use were increased over the next 10 years to ideal levels for first-MI survivors, $18 million would be saved, 72,000 fewer deaths would occur, 62,000 MIs would be prevented, and 447,000 life years would be gained.
The quality of care for AMI patients is also dependent on physician specialty and the type of hospital to which a patient is admitted. Figure 4 depicts the usage of aspirin, heparin and beta-blockers in patients with AMI relative to whether patients were cared for by cardiologists, internists or general practice physicians (14). Note that for each indicator, cardiologists performed better than primary care physicians. Nevertheless, beta-blocker usage after AMI was suboptimal for all three types of physicians surveyed. Norcini et al. (15) evaluated the outcome of 30,000 AMI patients relative to whether physicians treating those patients were certified or noncertified by the American Board of Internal Medicine. The outcomes were analyzed relative to whether cardiologists or primary care physicians treated these patients. If board-certified doctors had treated all 30,000 AMI patients, 481 fewer in-hospital deaths would have occurred. If cardiologists had treated all 30,000 patients, 802 fewer deaths would have been expected.
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Figure 4 Usage of aspirin, heparin and beta-blockers in patients with AMI relative to whether patients were cared for by cardiologists, internists or general practice physicians.
Prepared, with acknowledgment of the authors, from data contained in Jollis JG, DeLong ER, Peterson ED, et al. Outcome of acute myocardial infarction according to the specialty of the admitting physician. N Engl J Med 1996;335:1880–7 (14).
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The use of ACE inhibitors and beta-blockers for patients with AMI was analyzed relative to hospital teaching status (16). Patients cared for in major teaching hospitals were significantly more likely to receive ACE inhibitors and beta-blockers compared with patients admitted to nonteaching hospitals.
Insurance status appears to influence quality of cardiovascular care. Patients who are uninsured are less likely to undergo coronary arteriography or a percutaneous coronary intervention after AMI compared with patients who have commercial insurance or who are in the Medicare program (17). Similarly, African Americans are less likely to undergo optimal post-MI care and management of chronic coronary artery disease (CAD) than white patients (18–20). For example, in the study by Laouri et al. (19), 62.5% of African Americans received "necessary revascularization" compared with an 82.2% rate in white patients.
Thus, significant under-use of proven therapies for patients with AMI, and marked geographic variation in adherence to recommended practice guidelines, are prevalent in our health care delivery system. Optimal adherence to evidence-based practice guidelines for AMI is obviously lacking.
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Quality of care for patients with congestive heart failure
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Appropriate medication usage in patients with congestive heart failure (CHF) is also suboptimal, as demonstrated in several recent reports. Quality indicators for HF management include: 1) appropriate use (or non-use) of ACE inhibitors; 2) determination of left ventricular (LV) ejection fraction for new-onset CHF; 3) appropriate use (or non-use) of beta-blockers; and 4) appropriate discharge instructions, such as monitoring of weight, appropriate diet and follow-up appointments. McCullough et al. (21) presented the preliminary data of the Resource Utilization Among Congestive Heart Failure, or REACH, study regarding population-based medication profiling in HF patients at the 2000 Annual Scientific Session of the ACC. Within one year of diagnosis of CHF, only 29% of these patients were receiving treatment with beta-blockers, 49% with ACE inhibitors, 4% with angiotensin-II receptor blockers, 4% with hydralazine, 22% with nitrates, and 52% with one form of vasodilator therapy. In the Medicare population, an average of 69% of CHF patients were discharged with prescriptions for ACE inhibitors (11). Wide variation from state to state was observed.
Although the evaluation of LV function was documented in 82.3% of CHF patients, practice-specific rates in a survey of primary care and cardiology practices in 11 states (22) ranged from 35% to 100%. The use of ACE inhibitors in this study averaged 75.1% but varied between 0% and 100%. Thus, significant performance gaps and appreciable between-practice variation exist in LV function evaluation and ACE inhibitor treatment of HF in the outpatient setting. Another study (23), which surveyed four U.S. health plans at six different geographic sites, revealed lack of documentation of LV ejection fraction in 34% of CHF patients. As with care for AMI patients, cardiologists used ACE inhibitors more than noncardiologists in eligible patients with documented LV dysfunction (24).
Quality of care for patients with CHF varies among types of physicians. Both under-investigation and under-treatment of elderly patients with CHF by family physicians, compared with cardiologists, have been reported (25). When managed by cardiologists, 92% of the patients with CHF had an assessment of LV function when first presenting with HF, compared with 61% for family physicians. Eighty percent of the HF patients were treated with ACE inhibitors by cardiologists, compared with 60% by family physicians (Fig. 5).
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Figure 5 Percentage of patients with congestive heart failure (HF) who had documentation of a measurement of left ventricular function (LVF), and the percentage use of angiotensin-converting enzyme (ACE) inhibitors in HF patients, relative to whether cardiologists or family physicians were responsible for their care. Note that cardiologists assessed LVF and used ACE inhibitors more than noncardiologists in HF patients with depressed LVF.
Prepared, with acknowledgment of the authors, from data contained in Edep ME, Shah NB, Tateo IM, Massie BM. Differences between primary care physicians and cardiologists in management of congestive heart failure: relation to practice guidelines. J Am Coll Cardiol 1997;30:518–26 (25).
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Adherence to lipid management guidelines
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A third area of concern, cholesterol management, also shows gaps in quality care. Adherence to the National Cholesterol Education Program (NCEP) guidelines for cholesterol screening and lowering is suboptimal. Of 603 patients with cardiovascular disease treated at primary care practices and surveyed by McBride et al. (26), 33% were not screened with a lipid panel, 45% received no dietary counseling, only 33% were receiving lipid-lowering medications, and 14% had a low-density lipoprotein (LDL) cholesterol <100 mg/dl. The National Committee for Quality Assurance (NCQA) has been monitoring performance measures related to LDL cholesterol levels in patients discharged after MI, after bypass surgery or after undergoing a percutaneous coronary intervention (27). As shown in Figure 6, an average of only 45.3% of those patients with documented CAD had an LDL cholesterol 
130 mg/dl. Even the 90th percentile of performance yielded only 64.4% of patients achieving this target LDL level. It is likely that far fewer had an LDL cholesterol level <100 mg/dl, which should have been the target goal. Cholesterol control for patients with established CAD varies by region. The NCQA report showed that Seattle fared the best in this benchmark, whereas Dallas performed 20% lower, with only 37.3% of appropriate patients achieving an LDL cholesterol of 130 mg/dl.
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Figure 6 Percentage of coronary artery disease (CAD) patients with either previous myocardial infarction, prior bypass surgery or a percutaneous coronary intervention who had a low-density lipoprotein (LDL) cholesterol level 130 mg/dl. Note that even the 90th percentile of performance in this survey yielded only 64.4% of patients achieving an LDL cholesterol of 130 mg/dl. In actuality, the National Cholesterol Education Program guidelines indicated that such patients with documented CAD need to have their LDL cholesterol levels lowered to <100 mg/dl.
Reprinted with permission from the National Committee for Quality Assurance. The State of Managed Care Quality. 2000:23. ©2000 by NCQA (27).
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Patients with diabetes have a significantly greater morbidity and mortality from CHD than nondiabetics, so it is vitally important to lower abnormally elevated LDL cholesterol levels in diabetic patients. The NCQA data from 2000 (27) indicate that lipid management is markedly suboptimal in diabetics (Fig. 7). An average of only 36.7% of diabetics had an LDL cholesterol 130 mg/dl. Surprisingly, the 90th percentile achieved only a 48.5% lowering of cholesterol to this level. Approximately 30% of diabetic patients did not even have a lipid profile performed (27).
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Figure 7 Percentage of patients with diabetes who had a low-density lipoprotein cholesterol of 130 mg/dl (left) and percentage of patients with diabetes who had a lipid profile documented in their record (right). Surprisingly, the 90th percentile in performance achieved only a 48.5% lowering of cholesterol to this level in the diabetic population. An average of only 69.1% of diabetics had a lipid profile even obtained. These data from the National Committee for Quality Assurance indicate that lipid management is markedly suboptimal in diabetics.
Reprinted with permission from the National Committee for Quality Assurance. The State of Managed Care Quality Report. 2000:24. ©2000 by NCQA (27).
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Patients without health insurance are less likely to undergo cholesterol screening than patients who are insured. Ayanian et al. (28) reported that 40.5% of adults uninsured for one year or longer did not receive cholesterol screening for CAD risk, compared with 18.1% who were insured. In a report by Families USA (29), the question was asked, "Have you ever had your blood cholesterol checked?" Fifty-three percent of the insured answered in the affirmative compared with only 23.2% of those uninsured. That report also found that 43% of uninsured patients with hyperlipidemia were no longer taking their prescribed medications.
Adherence to NCEP guidelines in postmenopausal women with heart disease was poor among the 2,763 women enrolled in the Heart and Estrogen/progestin Replacement Study, or HERS trial (30). While assessing the effectiveness of hormone replacement therapy, this trial determined that only 47% of the women were taking a lipid-lowering medication. Sixty-three percent did not have an LDL cholesterol <130 mg/dl, and 91% did not have an LDL cholesterol <100 mg/dl, which is the target goal for men and women with CHD.
Thus, as seen for post-MI care and evaluation and management of CHF patients, quality of lipid disorders management is suboptimal. Failure to appropriately lower abnormally elevated LDL cholesterol levels in patients with CHD or diabetes will contribute to an increased cardiovascular mortality rate and increased prevalence of CHD.
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Enhancing the implementation of practice guidelines
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Numerous examples of under-treatment of MI and HF patients have been shown. Examples of under-use of lipid screening and under-treatment for elevated LDL cholesterol management have been summarized. Having acknowledged that such gaps in quality care exist, what can be done to ensure that patients receive better care based on the best available scientific knowledge? How can improved adherence and more uniform implementation of the ACC/AHA practice guidelines be achieved? How can the wide variation in cardiovascular care in this country for patients with the same cardiac disease be eliminated? Some progress in finding answers to these questions regarding how quality of cardiovascular care can be improved has already been made. Certain medical groups such as the ACC and the AHA have advocated the use of decision-support tools to improve the implementation of practice guidelines in the inpatient and outpatient settings. Such tools include standard preprinted orders, computer-generated reminders or verbal reminders from nurses, pocket guidelines, clinical pathways or algorithms of care, standardized patient discharge forms and feedback on physician performance relative to predetermined quality indicators. Often, opinion leaders are called upon to educate physicians regarding appropriate care based on evidence-based practice guidelines. The increasing tendency of patients to educate themselves is also an important element in improving quality of care. Informed patients work with their physicians to develop optimal treatment plans for their specific medical conditions.
Use of such tools has yielded some recent improvement in the care of patients with AMI. Figure 8 shows an increase in beta-blocker treatment rates from 1996 to 1999 in NCQA-accredited health plans, where quality indicators are made public and health systems have an incentive to improve (27). The rate of post-MI beta-blocker use increased from 62.2% to 85% over this four-year period. Table 1 shows the quality improvement for post-MI care achieved by the UCLA Cardiovascular Hospitalization Atherosclerosis Management Program (CHAMP) (31). Using a variety of tools, CHAMP was able to achieve a substantial increase in the utilization of aspirin, beta-blockers, ACE inhibitors and statin drugs for post-MI patients. Usage of ACE inhibitors increased from 4% to 56%, and statin usage increased from 6% to 86%. Similar improvement in the management of CHF has been achieved, primarily by employing a multidisciplinary approach. Tools for HF care include patient education, close monitoring of patients in the outpatient and home settings, preprinted physician order sets, chart audits with feedback of results, reminder systems and use of local opinion leaders.
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Figure 8 Improvement in treatment rates for beta-blocker therapy and post-myocardial infarction (MI) patients from 1996 to 1999 in National Committee for Quality Assurance-accredited health plans, where quality indicators are made public and health systems have an incentive to improve. Note that the rate of post-MI beta-blocker use increased from 62.2% to 85% over this four-year period.
Reprinted with permission from the National Committee for Quality Assurance. The State of Managed Care Quality Report. 2000:30. ©2000 by NCQA (27).
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Another example of quality improvement is New York State’s program of collecting standardized clinical data for coronary bypass patients and releasing to the public the risk-adjusted mortality rates for this procedure for hospitals and individual surgeons (32,33). This program achieved a lowering of the statewide mortality rate for bypass operations.
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The ACC and quality of cardiovascular care
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The ACC has given priority to improving the quality of cardiovascular care and encouraging better compliance with clinical practice guidelines (34,35). The ACC launched a major quality improvement initiative, the Guidelines Applied in Practice (GAP) Project (36). The goal of this project was to see whether it is possible to improve adherence to guidelines for treating AMI patients. Ten hospitals in the greater Detroit area participated, with Dr. Kim Eagle of the University of Michigan serving as the principal investigator. The GAP team used a toolkit that included pocket guides, standing orders, chart stickers, information for patients, grand rounds presentations by opinion leaders and reporting of hospital performance data. Results of the GAP Project were presented at the College’s 2001 Annual Scientific Session. Some of the quality indicators measured were beta-blocker usage within 24 h, beta-blockers at discharge, ACE inhibitors at discharge, aspirin at discharge, smoking cessation counseling and cholesterol measurement and treatment. A significant improvement in many of these quality indicators was observed, particularly in the Medicare population (e.g., early beta-blocker usage increased from 62% to 73%). Other GAP Projects are being planned, including one for improving quality of care for patients with CHF.
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Internet-based on-line learning
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More than decision-making tools are required to improve the quality of cardiovascular care. Internet technology that will allow physicians to access specific medical information in any setting, at any time, using their computers or handheld, wireless devices and sophisticated search engines that extract this information from a rich database is being developed. The ACC and the AHA are establishing an Internet website that will enable physicians to do just that. It is presently known as "KDE," or the Knowledge Delivery Enterprise. Based on advance Internet technology, KDE holds a key to increased guideline use. It will permit physicians to obtain information at the point of care to help guide them with their decision-making for specific patient problems.
The dissemination of computer technology into physician offices with greater use of desktop computers and more Internet access to medical information websites has facilitated more rapid delivery of new scientific information and medical knowledge as well as providing self-learning programs for which continuing medical education (CME) credit is given. The KDE system will be robust in this regard.
Didactic teaching in the form of lectures is not that effective in changing physician performance (37). Interactive CME sessions that require active participation of the learner are more effective in changing outcomes. Such interactive learning models are presently available from many Internet websites. The electronic delivery of CME in the form of case-based learning using multimedia technology should prove a more effective way of disseminating the application of practice guidelines. We hope that this type of on-line education will translate into greater quality and less variation in cardiovascular care.
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Advanced information technology and the electronic medical record
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Once greater and easier access to more medical knowledge through advanced computer technology is attained, new technology for sharing patient information among caregivers must also be developed. To do this, a cultural shift in the everyday use of information technology in physicians’ offices and hospitals must occur. Far too much patient information is stored only on paper. The space industry has integrated its technology systems to send a space ship to an asteroid 117 million miles from Earth (38), but the medical profession is still documenting its patient information in numerous charts stored in different health care settings with no technological linkages among them. We must move to electronic medical records. Automating clinical data will improve coordination of care across the various venues where health care is delivered. We should no longer hear, "We can’t find the old chart," and we should no longer treat patients without the full knowledge of their previous and concurrent treatment by other health care providers.
In their outpatient practices and the hospitals where they work, cardiologists must advocate the use of new technology to integrate the care their patients receive across the various settings, or "silos," where patients are seen (Fig. 1). There should be a single electronic repository of medical data for each patient that can be accessed by all that patient’s physicians, wherever they may be.
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Conclusion: the need for an electronic revolution in health care
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The ACC is committed to closing the gap between average care and best care for cardiologic conditions in the U.S. for all Americans. The College is applying the talents of its members and its staff to making scientific medical knowledge more accessible and useful to clinicians and patients. Web-based decision-support tools, like KDE, will assist doctors and patients in approving the quality of cardiac care. No matter how successful we might be in obtaining state-of-the-art knowledge where we need it from a system like KDE, cardiac care will never be optimal until we also transform, via new technology, our health care delivery system. The members of the College are encouraged to work in their own communities to implement the information technology needed to better use scientific knowledge in an efficient and coordinated manner across all settings of care. We need an electronic revolution in medicine to meet the challenges of the future.
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Acknowledgments
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I am grateful to Ms. Kathy Boyd of the American College of Cardiology, Dr. Gregg C. Fonarow of the University of California, Los Angeles, and Dr. David E. Wennberg of the Maine Medical Center for providing me with information used in this presentation. I also thank Mr. Jerry Curtis for his editorial assistance in preparing this manuscript.
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References
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