Cover Story - May 2007
By Ken Ortolon
Most people agree on two things about health information technology: It will significantly impact the future of medicine, and it's going to happen whether or not physicians embrace it.
Proponents tout health information technology (HIT) as the solution for improving efficiency, patient safety, and quality while reining in costs. And policymakers across the country, from President George W. Bush to California Gov. Arnold Schwarzenegger, are trying to fast-track HIT development and implementation, especially adoption of electronic medical record (EMR) systems that will enable physicians, hospitals, and others to share clinical data on patients, while giving patients and payers of health care more information on cost and quality.
Now, Texas policymakers appear to be jumping on the bandwagon, and the Texas Medical Association believes physicians should prepare to move into the electronic age. Earlier this year, Gov. Rick Perry appointed a committee to look at proposals to jump-start development of health information exchanges here. And, even though that panel didn't formally recommend proposals put before it by the governor's staff, several lawmakers are moving forward with legislation to put those and other HIT initiatives into effect.
"I am very excited about this opportunity to centralize our efforts on electronic health information technology," said. Sen. Jane Nelson (R-Lewisville), chair of the Senate Health and Human Services Committee and author of one of the bills designed to speed implementation of HIT. "Health information technology allows us the opportunity to streamline the health care delivery system, contain our costs, and improve efficiency on virtually every level."
But while enthusiasm for HIT and EMRs is growing, physicians warn that several nagging issues must be addressed. Foremost among these, they say, are who will bear the cost of creating an EMR system and who will control the data?
Abilene otolaryngologist Austin I. King, MD, chair of TMA's Council on Legislation, says financial incentives must be built into the system to encourage physicians to invest in HIT. Otherwise, many physicians simply may not be willing or able to invest tens of thousands of dollars in expensive information technology.
"The financial burden needs to be shared by all the different entities involved - the insurance companies, the physicians, the hospitals, the government," Dr. King said.
So far, none of the proposed legislation addresses the funding issue.
Building a Partnership
Governor Perry and the leaders of House and Senate health committees are committed to pushing adoption of EMRs forward in Texas, although they do not appear to agree on how that should be accomplished or funded.
Rep. Diane White Delisi (R-Temple), chair of the House Public Health Committee, has filed House Bill 1066 to create a Texas Health Service Authority Corp. to promote a statewide network for communicating electronic health information. The authority also would foster a coordinated public-private initiative for developing and operating the health information infrastructure in the state.
The authority not only would help develop a statewide health information network, but also would set performance standards for the network; conduct pilot projects to encourage HIT adoption; provide grants and loans to create local, regional, or statewide health information networks; and adopt standards for interoperability among such networks.
The idea for the authority came out of Governor Perry's office and was one of several proposals on HIT, transparency on pricing and quality in health care, and bolstering the small-employer health insurance market presented to the governor's Texas Health Care Integrity Partnership this year.
The partnership, created by an executive order signed by Governor Perry in October, met three times in January and February. In a March 1 report, the partnership stopped short of recommending that the authority be created. Instead, it concluded that a public-private partnership in the form of a state-chartered corporation to promote exchange of clinical data by providers and facilities could add value to the health care system, but questioned whether such a corporation is needed or whether it can be self-sustaining.
"The partnership felt that it's best that the effort be limited to development of a portal for heath information exchange and technical support to promote the establishment of operations of regional health information exchange initiatives already going on throughout the state," said Sugar Land internist Spencer Berthelsen, MD, who was a member of the Texas Health Care Integrity Partnership. He said members, especially physicians, were concerned about funding, "that the funding be adequate and not fall on the shoulders of physicians as an unfunded mandate from the state."
James Cooley, administrative assistant to Representative Delisi, says she filed HB 1066 even though the governor's partnership did not recommend creating the authority, because she feels there's a need to "just move" HIT forward.
"There seems to be a need to get coordination and get interoperability and get the stakeholders to work with each other on something that works together," he said.
Mr. Cooley says the concept for the authority is similar to what is being done in some other states, including Vermont.
In addition to HB 1066, Representative Delisi has filed three other bills to promote EMRs.
One, HB 3472, allows the state to leverage its purchasing power to promote HIT by requiring health insurance plans with which the state does business to provide incentives for their network physicians to adopt EMR systems. HB 3471 creates a pilot program to help physicians who treat Medicaid patients implement EMR systems in their practices. Finally, HB 2610 encourages electronic communication in Medicaid for eligibility, enrollment, verification, prior authorizations, and electronic prescribing.
Coordinating the Effort
On the Senate side, Senator Nelson also filed legislation to promote HIT adoption. Her Senate Bill 40 would create an Electronic Health Information Coordinating Committee within the Texas Department of State Health Services that would consult with practicing physicians about financial incentives to increase their use of EMR systems.
The coordinating committee was proposed by the Health Information Technology Advisory Committee, created under legislation passed in 2005 and which carried out a much more extensive review of HIT issues during the legislative interim than did the governor's partnership.
The coordinating committee also would serve as a liaison with federal agencies concerning electronic health information exchange, make recommendations about the design and implementation of the electronic health information exchange framework for regional stakeholders, and create regional or statewide centers of excellence to facilitate the sharing of information among patients, providers, vendors, and health benefit plans. A center of excellence would be an organization designed to offer expertise to users to implement best practices, for example, or to provide value-added benefit on a specific issue such as HIT.
Senator Nelson says she envisions the committee as "the central point of contact as we progress in the transition to electronic health information." She also says the financial incentives called for in her bill would make it as convenient as possible for physicians to transition into the electronic world. "Most of them have already done so or are in the process of doing so, but I know that physicians fight so many administrative battles in their offices already," she said. "We want to ease the transition if there are any hardships."
The coordinating committee is similar in approach to a cabinet-level work group of public and private sector representatives that Governor Schwarzenegger recently created in California. Under an executive order signed March 14, that work group will seek to develop strategies to improve quality, transparency, and accountability of health care through expanded use of HIT.
Where's the Money?
While TMA supports adoption of EMRs, the business case for a new state agency does not exist, TMA leaders say. There already are a number of initiatives under way across the state to create regional health information organizations to provide HIT. See "Dallas-Fort Worth Group Launches Data-Sharing Pilot."
TMA also has concerns about funding. The governor's partnership report suggests launching the proposed Texas Health Service Authority Corp. with start-up funding of $1 million, and with ongoing, sustainable financing from transaction or subscription fees associated with the electronic delivery of medication history information to hospitals.
Dr. King, the TMA Council on Legislation chair, says money also needs to be provided to help physicians invest in EMR systems.
"The concern of physicians is that all of a sudden this is going to be mandated and it's going to be a burden for them," he said. "For pediatricians or family physicians in areas where their practices are just barely financially viable already, having to spend $50,000 to $60,000 on an electronic medical record system is a considerable investment at this point."
Texas physicians have been slow to adopt EMRs. According to a 2005 TMA HIT survey, only 27 percent of the state's physicians have EMR systems in their offices. (You can read the survey on the TMA Web site.)
TMA's Healthy Vision 2010 says Texas must devise a plan to bring interoperable EMR systems to all physician practices to save lives and money. To read Healthy Vision 2010, click here.
Physicians who are using HIT say it's made them better doctors and helped the management of their practices.
For example, Edinburg pediatrician Martin Garza, MD, told Texas Medicine last year that he has used an EMR system for more than two years. Dr. Garza, interviewed for Texas Medicine 's special symposium issue last July, says his billing is streamlined to where he needs only one billing coordinator. That reduces his overhead because he needs fewer employees than if he were still using paper. It also saves time.
"The costs for a paper office are there, physicians just have to add them up. In the long run, EMRs are probably less expensive. If you go electronic and the costs come out even, think about the time you saved. At the day's end, I don't have to ask someone to run around and retrieve charts for me."
Dr. Garza and another physician using EMRs, Denton obstetrician-gynecologist Christina Ann Dooley, MD, say HIT helps ensure proper payment for their services. Their systems require them to know billing codes to fill out charts.
"I have a better understanding of coding and billing," Dr. Dooley explained. "It's improved reimbursements because I'm personally billing what I do. Essentially, the coding is more correct than if someone has to read my chart and try to figure out what the heck I'm telling them."
But the systems are expensive. TMA believes government grants and loans will be needed to help physicians purchase EMR technology, and that health plans and government health programs should give physicians financial incentives to invest in such systems. The association also believes health plans and government payers should boost physician fees to reflect physicians' HIT costs.
Dr. Berthelsen says whichever approach lawmakers take to encourage HIT adoption must have funding guaranteed into the future to ensure long-term viability.
"The governor's goal of making health care information more readily available is a laudable goal," he said. "But the financial incentives need to be sustainable. An electronic medical record and data collection reporting up to a central repository as envisioned in the governor's proposal require sustained investment because computer systems become obsolete and need to be replaced."
Protecting Patient Privacy
Finally, physicians have expressed concerns over who will control the data when HIT is fully implemented. TMA believes that physicians, not health plans or the government, should be the guardians of patient information and protect their patient's privacy interests and concerns.
In some models being used in other states, physician entities control the data. In New York, for example, the Medical Society of the State of New York was selected to implement legislation creating a grant program to promote development of health information exchange technology.
And in San Diego, the county medical society has partnered with local employers to create the San Diego Medical Information Network Exchange to house patient information, such as address, phone number, family unit, insurance carrier and policy number, and basic health history. This system is seen as a first step in creating the technological infrastructure that will benefit all physician offices.
TMA leaders are exploring similar ideas and approaches to house patient information here in Texas. There is consensus that three things can be collected and stored that would serve physician offices: census information (address, phone number, family unit, etc.), insurance information (carrier, policy number, etc.), and basic health history information (chronic diseases, allergies, medications, immunizations, etc.).
The idea is that efficiencies would be improved for physician offices so that patients won't be required to fill out a clipboard at each encounter. The information would be completed once and then presented to the patient at each encounter to confirm the information and/or enter updates and changes as they occur. The medical office would then forward these changes back to a central database. This could be a first step in creating the technological infrastructure for future needs as more physicians adopt HIT.
Ken Ortoloncan 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.
Dallas-Fort Worth Group Launches Data-Sharing Pilot
Sharing patient data electronically among physician practices, hospitals, and health plans is what electronic medical record systems are all about. But can the computers correctly identify one patient out of potentially millions that may eventually be part of such a system and do it every time?
That's what a coalition led by county medical societies in Dallas and Fort Worth hopes to find out.
The North Texas Regional Health Information Organization (RHIO) Steering Committee - a coalition that includes the Dallas County Medical Society, the Tarrant County Medical Society, and the Dallas-Fort Worth Hospital Council - is using $500,000 in grant money from The University of Texas System to prove whether computerized patient record systems can identify individual patients across physician practices or hospital systems.
"It's really hard to imagine having a centralized RHIO or database for sharing electronic records among doctors if you're not absolutely sure you've got the right person," said Michael Darrouzet, executive vice president of Dallas County Medical Society. "That's where we're beginning our process."
The group is seeking requests for proposals from software vendors to create a master patient index using patient data from several area hospitals, including Texas Health Resources, which operates the Presbyterian Hospital System in Dallas and Harris Methodist Hospital in Fort Worth, and a large pathology group. The data for the pilot project will include only demographic information, such as patient names and addresses. No clinical data will be included.
Mr. Darrouzet says the idea is to dump 2 million to 3 million patients from various institutions and physicians into the database hoping to come up with about 1 million patients that cross between the institutions. Then, they will test to see if the software vendors can accurately identify patients.
If successful, the group hopes to eventually add clinical data, such as prescription information or x-ray or MRI images, into the database and to pilot test the project in private physician practices in the Dallas-Fort Worth area. Patient permission would have to be obtained to use clinical information, and the group likely would approach physician practices that already have adopted electronic medical records to test the system so there would be no additional investment required of the physicians.
"Our strategy would be to use any kind of funding we might get to have a no-cost pilot year or two so that physicians could begin using the tool for free but find benefit or value in it," Mr. Darrouzet said. "We're very sensitive to the upfront costs and trying to keep from requiring physicians to pay anything at this point to play in the data-sharing game."
If the pilot proves successful, the group would then have to develop a business model and find sustainable funding for the RHIO. That could include charging physicians, hospitals, health plans, or others a fee to access data from the system.
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TMA Reviews Electronic Medical Record Certification
With more than 250 vendors out there eager to sell you electronic medical record (EMR) software, how can you make the best purchase for your practice? Certification by an independent organization is one measure to consider.
"The Certification Commission for Healthcare Information Technology [CCHIT] tests whether an EMR meets certification standards. A time will probably come when physicians will need to use certified EMRs to get paid for performance from Medicare and insurers," said Joseph H. Schneider, MD, MBA, a member of CCHIT's Commercial Certification Process Advisory Work Group and chair of TMA's Committee on Health Information Technology.
TMA has developed a white paper [ PDF ] to help physicians understand the importance of considering EMR certification when selecting health information technology.
TMA's Health Information Technology Department is dedicated to helping physicians successfully implement office technologies. For more information, call TMA at (800) 880-5720 or email HIT.
Now Available: Free EMR Implementation Guide
Watch your mailbox for Texas Medical Association's Electronic Medical Records: The Link to a Better Future , a guide for selecting and implementing electronic medical record (EMR) systems. This important, free resource is being mailed to all practicing TMA members.
TMA's goal is to help ensure that health information technology positively impacts you, your patients, and your practice by improving quality of care, patient safety, and practice viability. The nontechnical view of this guide can help you successfully select and adopt an EMR system, with an emphasis on the needs of smal practices.
The guide covers efficiency and quality benefits of an EMR system, EMR readiness in terms of financial and operational variables, and the necessary steps for product selection, implementation, and maintenance of an EMR system.
Physicians can earn 3 continuing medical education (CME) credits by reading the guide, completing an evaluation, and paying a processing fee. In addition, the Texas Medical Liability Trust (TMLT) will grant TMLT-insured physicians who complete the CME requirements a 3-percent reduction on their professional liability premiums (not to exceed $1,000).
To request additional copies of the guide or for more HIT information, contact the TMA Health Information Technology Department by calling (800) 880-5720, emailing HIT, or visiting the TMA Web site.
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