Symposium on Health Information Technology - July 2006
By Ken Ortolon
When his three-doctor family medicine practice adopted an electronic medical record (EMR) system more than four years ago, Plano physician Christopher Crow, MD, barely knew how to turn on a computer, let alone use one.
But now he says computerized recordkeeping makes him a better physician.
If you polled most physicians, especially physicians over 40, they're going to tell you that they probably do everything 100-percent right, when all the data shows we're lucky to get it right 50 percent of the time," Dr. Crow said. "I found out that I wasn't doing a very good job with blood pressure, but I was doing a great job with cholesterol."
While Dr. Crow says tracking that type of data can be "humbling to a physician," experts agree that health information technology (HIT) can be a powerful tool to reduce medical errors, improve quality and efficiency in health care delivery, and control costs. And, two years ago, President George W. Bush made widespread adoption of HIT a key plank in his health care agenda.
But major hurdles stand in the way of achieving that goal. First, some physicians and hospitals have been reluctant to make the substantial investment to get into the electronic age. David Brailer, MD, PhD, who headed the federal Office of the National Coordinator for Health Information Technology (ONCHIT) until his resignation in April, estimates that only between 15 percent and 20 percent of physicians and 20 percent to 25 percent of hospitals have adopted EMRs. (See " Embracing EMRs.")
Another major challenge is to make sure EMRs and other HIT products and software are compatible, so that hospitals, physicians, clinics, and other health care providers and payers can easily share data.
Toward that end, the federal government, working with the HIT industry and other stakeholders, has launched an effort to put the infrastructure in place to support the president's goal. And, experts say, physicians better get on board.
Unless you have your head in the sand, you understand that information technology is going to be a significant driver of future quality and safety measures, and it should be," said American Medical Association Past President J. Edward Hill, MD.
Setting the Agenda
In his 2004 State of the Union address, President Bush challenged the nation to create an EMR system and provide EMRs for a majority of Americans within 10 years. The president created ONCHIT to oversee that effort, and appointed Dr. Brailer, a Santa Barbara, Calif., family physician who had led a local effort to create a regional health information network, as national coordinator for HIT.
In the past two years, Congress has dragged its feet on HIT. Last fall, the Senate approved the Wired for Health Care Quality Act to give ONCHIT statutory authority and authorize regular appropriations. The bill, sponsored by Senate Majority Leader Bill Frist, MD, (R-Tenn.) and Sens. Hillary Clinton (D-NY), Edward M. Kennedy (D-Mass.), and others, also outlines privacy standards and provides roughly $700 million in grant funding for HIT adoption between 2006 and 2010.
The measure currently is pending in the House, where a competing bill has been filed by Reps. Nathan Deal (R-Ga.) and Nancy Johnson (R-Conn.). The Deal-Johnson bill also would codify ONCHIT and create a framework for a national health information network. But AMA officials say it does not include funding for HIT adoption. They predict some amalgamation of the two bills might emerge from Congress this year.
If Congress has been slow to act, the federal bureaucracy and private industry have not. Since President Bush issued his challenge, a plethora of federal agencies, ranging from the Department of Health and Human Services (HHS) to the Centers for Medicare & Medicare Services (CMS) to the Veterans Administration to the Department of Agriculture, have jumped on the HIT bandwagon. And ONCHIT developed collaborative relationships with numerous private organizations that are rapidly pushing HIT development forward.
In addition, HHS Secretary Michael Leavitt created a public-private collaboration called the American Health Information Community to give HHS recommendations on how to make health records digital and interoperable, and assure that the privacy and security of those records are protected in a smooth, market-led way.
The 17-member panel, chaired by Secretary Leavitt, includes leaders of other federal health agencies, such as CMS and the Centers for Disease Control and Prevention (CDC), as well as physicians and other provider representatives. It also includes representatives of patients, employers, health plans, and the HIT industry.
Dr. Brailer says developing a national health information network is about a year ahead of where he thought it would be at this time.
We're at what I would call the end of the beginning," Dr. Brailer said. The "beginning," he says, was to create the infrastructure to support the HIT network envisioned by President Bush.
We looked around and said, 'We do not have any of the institutions, tools, policies, or mechanisms in place to do this,'" Dr. Brailer said. "If we decide we're going to put a lot of money into [HIT] adoption incentives, we have nothing to guide or shape it."
Getting Down to Business
So the first order of business was to create those policies, mechanisms, and tools.
First, government and industry officials believed physicians and other health care professionals needed tools to help them determine which EMR systems to buy. While a broad range of health care payers, from government to the private sector, were prepared to offer financial incentives for HIT adoption, physicians were reluctant to invest in such systems because of uncertainty over data portability and product suitability, interoperability, and quality.
Cost is a significant factor holding back many physicians. About 60 percent of America's physicians are still in essentially small practices, Dr. Hill says. "If you hit them with $30,000 to $50,000 per doctor for a system, they can't afford it."
In July 2004, three HIT industry associations created the Certification Commission for Health Information Technology (CCHIT) as a voluntary, private-sector initiative to certify HIT products. CCHIT's mission is to accelerate the adoption of robust, interoperable HIT throughout the U.S. health care system by creating an efficient, credible, and sustainable mechanism for certifying HIT products.
Last October, HHS awarded CCHIT a $2.7 million contract to develop criteria and evaluation processes for certifying EMR systems and the infrastructure or network components through which they interoperate. Among criteria for certification are the capabilities of EMR systems to protect health information and standards by which the systems can share health information and clinical features that improve patient outcomes.
CCHIT was expected to begin certifying EMR systems in March, but pushed back the date for the first certifications until June.
The second step was to set privacy standards. "We knew the American public would not support this if we didn't have new and state-of-the art privacy safeguards," Dr. Brailer said.
A multidisciplinary team of experts and the National Governors Association partnered to create the Health Information Security and Privacy Collaborative to define what state and federal privacy policies ought to look like. Last fall, that group received an $11.5 million contract from HHS to work with approximately 40 states or territorial governments to assess and develop plans to address variations in organization-level business policies and state laws that affect privacy and security practices that may pose challenges to interoperable health information exchange.
Finally, Dr. Brailer says the technical infrastructure was needed to pull the whole network together. "If we want to start sharing data back and forth routinely among doctors, between doctors and ERs, labs and doctors, doctors and pharmacies, and with patients, we have to have the electronic infrastructure to do that," he said. "And that's something that goes far beyond the electronic health record."
In November, HHS awarded contracts totaling $18.6 million to four technology groups to design prototype architecture for a Nationwide Health Information Network.
"The Nationwide Health Information Network contracts will bring together technology developers with doctors and hospitals to create innovative, state-of-the-art ideas for how health information can be securely shared," Secretary Leavitt said. "This effort will help design an information network that will transform our health care system, resulting in higher quality, lower costs, less hassle, and better care for American consumers."
The four consortia are led by Accenture, Computer Science Corp., International Business Machines, and Northrup Grumman. Each is a partnership between technology developers and health care providers in three local health care markets. Each group will develop a prototype network for secure information-sharing among hospitals, laboratories, pharmacies, and physicians in those markets.
The projects will be carried out in markets in Kentucky, Tennessee, West Virginia, Massachusetts, California, New York, North Carolina, and Ohio.
"These prototypes are the key to information portability for American consumers and are a major step in our national effort to modernize health care delivery," Dr. Brailer said. "This is a critical piece of moving HIT from hope to reality."
With contracts in place for developing the business, policy, and technical mechanisms necessary for a national health information system, Dr. Brailer says his office is turning its attention to a second phase, focusing on four initiatives he hopes will lead to tangible components of a health information network. Those initiatives, or "breakthroughs" as he calls them, include the creation of online medication histories for every American, an electronic database to speed health plan enrollment and eligibility determinations, secure messaging capabilities between physicians and patients, and a network to communicate key bioterror and pandemic information to state public health departments.
Dr. Brailer says the online medication history is the first step toward creating personal health records for everyone, which AMA supports. And, the electronic databases containing enrollment, eligibility, demographic, and other data will allow physician offices and hospitals to make coverage determinations instantly with fewer mistakes, Dr. Brailer says.
"These breakthroughs have just been convened in the past six weeks and they've got a one-year clock," Dr. Brailer said in February. "So by Feb. 1, 2007, they need to deliver something where hundreds of thousands of Americans or tens of thousands of doctors are actually using them and then the numbers keep scaling up."
Eventually, 30 to 40 such breakthroughs will go into creating the national health information network, he says.
In addition to infrastructure and other initiatives, the federal government currently is sponsoring nearly 80 different HIT initiatives involving more than a dozen agencies, including the Department of Homeland Security, the Department of Defense, the Department of Commerce, CMS, CDC, and others.
The Agency for Healthcare Research and Quality alone has issued $139 million in contracts and grants, including $96 million for projects in 38 states to help communities, hospitals, health care professionals, and health care systems plan, implement, and demonstrate the value of HIT. Those projects include two Texas initiatives that will receive $2.98 million over the next three years.
The first Texas project is a rural hospital collaborative for excellence using HIT. Palo Pinto General Hospital in Mineral Wells is the principle investigator, but some 30 other rural Texas hospitals will be part of the project, which also involves Texas A&M University System Health Science Center, Baylor Health Care System, and TMF Health Quality Institute. It will implement advanced information technology in rural and small community hospitals, including Web-based business tools, Internet connectivity, and standardized national measures of patient safety and quality. Texas A&M will provide educational support to train hospital medical, administrative, nursing, and other staff to develop and implement quality and patient safety standards using the Web-based tools.
The second project is being conducted at The University of Texas Health Science Center at Houston. UTHSC Houston researchers will examine an "electronic intensive care unit" set up by the Memorial Hermann Health Care System that uses telemedicine technology to remotely monitor patients in ICUs at hospitals throughout the Memorial Hermann system.
Eric J. Thomas, MD, associate professor of medicine at UTHSC Houston and lead researcher, says physicians and nurses at the e-ICU use computer workstations to get real-time vital signs for patients, talk with patients, talk with physicians and nurses onsite at the remote ICUs, and review physician or nurse notes in patient charts.
The researchers will compare patient records from before and after the e-ICU was launched to determine the impact on mortality, complications, and length of stay. They also will survey physicians and nurses about their attitudes about remote monitoring and conduct a cost analysis of the system, Dr. Thomas says.
Building the Grassroots
Not all of the action is at the federal level. In 2005, Texas lawmakers created a Health Information Technology Advisory Committee to develop a long-range plan for HIT in Texas. That committee was appointed in December by the Texas Statewide Health Coordinating Council, and it held its first meeting in January.
Dr. Crow, the Plano family physician, sits on the advisory committee and says it will help state officials understand the role HIT can play in improving health care delivery efficiency, lowering costs, and improving quality.
He says it is important for physicians and local and state leaders to play a major role in HIT development because the building blocks for a national system have to start at the grassroots level.
A vast majority of people feel like it's not going to happen from the top down," he said. "Top federal peoople and even state officials can be catalysts for change and facilitators for change, but the actual change is going to happen, the actual interconnectivity of communities is going to be more of a grassroots, bottom-up type situation."
The basic building blocks for a national health information network will be regional health information organizations (RHIOs) that can get all of the stakeholders in their communities working together, Dr. Crow says.
If you have all the physicians in the Dallas area on 20 different EMRs and each hospital on a different EMR and they don't talk to each other, you can be efficient but you're still in a silo," he said. "That was like banking in the 1970s, when you could only cash a check at your bank. Now you can go all over the world and use your ATM card, whether you bank at Bank of America or a small local bank, and transfer funds and get cash.
The idea is to let local municipalities or regions set up their network, then connect the state, and then connect all the states in the country over a 10- to 20-year period."
Already RHIOs are being developed in Dallas, Houston, Tyler, and elsewhere across the state, he says.
Getting on Board
With less than 20 percent of physician offices and 25 percent of hospitals already on board the HIT train, there is much work remaining to build a truly national network. Dr. Brailer says he knows cost is a stumbling block that is keeping many small physician practices from adopting HIT.
He's confident that young physicians will buy in. Already the Association of American Medical Colleges has reported that use of EMRs ranks among the top three factors new doctors consider when determining which practice to join.
Many older physicians nearing retirement may never adopt HIT, Dr. Brailer says. That leaves the physicians in the middle.
The game's over in the long term," Dr. Brailer said. "Doctors will not allow their practices in the long term to not have these tools if they're using them for every other part of their lives, and the same thing with their patients. How do we make that a positive change rather than something that literally crushes 50-year-old doctors in the vice grips of having to make this change but not really wanting to because they're not going to be in practice for 30 years to build on it?"
The way to do that, he says, is to lower the cost, reduce the risk of choosing the wrong product, and increase the value for most physicians. Certification and standards for interoperability of HIT products will help. Also, HIT developers need to be encouraged to design products for small practices, not just large physician groups. Lastly, health plans must be encouraged to support investment in these systems.
The federal Office of Personnel Management last year informed health insurers that how well they support HIT would be an important factor it evaluates in choosing insurance options to offer federal employees, Dr. Brailer says.
With so much attention and federal money being focused on HIT, some might question its true potential for improving quality, efficiency, and cost. But Dr. Brailer is convinced the potential is big in terms of eliminating routine medical errors caused by poor handwriting or faulty communications, encouraging more rigorous adherence to proven preventive health practices, and getting consumers to play a bigger role in managing their own health.
I'm pretty bullish," Dr. Brailer said. "If it were something that just gave us some theoretical benefit 10 years from now, I'd say it's not worth it, it just needs to percolate its way through. But this is something that the year we put it in, we get results back. It literally means a doctor uses an electronic medical record and suddenly an error gets averted. That's real, and that's the kind of thing that, once it starts to catch fire, is going to have a real impact and people are going to say this really changes the standard of medicine."
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at Ken Ortolon.
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