As in nearly every other sphere of modern life, technology has delivered enormous improvements in medicine. Once unimaginable diagnostic tools and treatment modalities are now commonplace; they also can be quite expensive. Health care information technology - among physicians, hospitals, other health care professionals, and patients - has not kept pace. We must move Texas physicians' offices from the days of stand-alone, paper-based medical records and transactions into an era of shared health information technology in which physicians can easily access their practices' clinical information, find the treatment protocols that help them make evidence-based decisions on patient care, and participate in data-based quality improvement activities in their own practices.
Texas must devise a plan to bring interoperable electronic health records to all physicians' practices to save lives and save money.
Widespread adoption of electronic health records (EHRs) and other health care information technology (HIT) in U.S. hospitals and doctors' offices will be expensive. Very expensive. Estimates range from $7.6 billion per year over 15 years [50] to install EHRs in all hospitals and physicians' offices, to $31 billion a year over five years [51] to build a national health information network.
The potential savings - in human terms and financial terms - make the expenditure well-worthwhile.
- The Rand Corporation estimates that EHRs can save "several tens of billions of dollars per year" by keeping patients with high-cost, chronic diseases such as asthma, congestive heart failure, and diabetes out of the hospital and the emergency room. Such systems will save more money and more lives by increasing the timely use of screening exams, recommended immunizations, and other preventive measures.
- Rand also estimates that EHRs can save nearly $5 billion a year by eliminating more than 2 million adverse drug events (ADEs) annually. Systems that warn doctors about possible drug interactions or suggest alternative courses of treatment could prevent up to half of the estimated 8 million ADEs that happen each year in physician's offices and outpatient clinics. Each ADE avoided saves $1,000 to $2,000 in health care expenditures, improves patient care, and prevents unnecessary patient suffering.
- Empirical evidence from physician practices that have installed effective EHRs shows that the systems make physicians and office staff more efficient and productive, allowing them to see more patients by "eliminating time lost waiting for charts, lab results, and other paper-based data." They also reduce the time patients waste in the waiting room. [52]
More broadly, David Brailer, MD, PhD, national coordinator for health information technology at the U.S. Department of Health and Human Services, sees technology as a driving force for all participants in the health care system:
Health IT will transform the way Americans regard their health and the way they participate in healthcare. The important aspect of health IT is not software and computers - it is physicians making better treatment decisions, nurses and pharmacists delivering safer care, and consumers making better choices among treatment options. It is the way people connect across a fragmented delivery system - from physician offices to hospitals to skilled nursing facilities and even to the consumer's home. It is putting consumers in control of their health status and customizing care delivery to meet their needs. [53]
The global vision of health information technology breaks down into nine interrelated tools that put computer networking at the center of information management. [54] Taken together, these tools provide complete, updated, accurate information at the point of care. An interoperative EHR not only includes input from a single practice, but it also integrates medical information from any treating clinician who has network access to the patient's record. An electronically entered prescription will appear in the EHR regardless of whether the physician was in the office while writing it. Test and imaging study results reach the ordering physician rapidly, and automatically become a part of the EHR. As a clinician enters a prescription order, warnings appear on the screen of any allergy problems or interactions with the patient's other prescriptions. [55]
The Houston/Harris County Public Health Task Force envisions a "community health information network" that would link the region's vast public health safety net with individual physicians' offices and clinics. The network would prevent the all-too-common instance in which physicians and emergency room personnel must repeat a patient's expensive tests and treatments because they have no accurate record of what happened the last time the patient visited a different clinic or hospital. [56]
Despite the many benefits that HIT brings to medical practices, its adoption in physician offices has been low. In a 2003 survey of office physicians, routine use of HIT tools was the exception rather than the rule, particularly in smaller practices. It found:
- Only 18 percent routinely used electronic health records;
- 17 percent routinely used electronic ordering of tests, procedures, and drugs; and
- 37 percent routinely accessed patients' test results electronically. [57]
In the long term, HIT strengthens the health care system by making medical practices both producers and users of data. Physician office data will greatly enlarge the ambulatory care databases of developing regional health information organizations (RHIOs) and other locally based health data warehouses. Quality assurance in the medical office will move from a laborious, one-by-one review of medical records to an automated process in which information is continuously analyzed. Finally, the vision of networked medical communities also has great potential to meet the severe public health problems that plague Texas, including low immunization rates and the growing prevalence of obesity, tuberculosis, and diabetes.
In November 2005, the TMA Special Funds Foundation received a $1 million grant to improve patient safety by increasing Texas physicians' understanding, adoption, and appropriate utilization of vital information technologies. The foundation's three-pronged plan is to educate physicians about the value of health information technology for better patient care; teach physicians how to acquire and implement the technology; and help physicians use the newly created data to improve patient care in their offices and through confidential, regional data warehouses. That $1 million, obviously, is only a fraction of what is needed to achieve this enormous transformation. TMA hopes, however, that this investment will help jump-start the process, especially in light of the mounting national political and economic momentum for HIT.
To spur physicians' use of HIT, TMA recommends:
Educating physicians, hospital executives, and political and business leaders on the value of EHRs and other HIT, especially its return on investment in both financial and human terms.
Encouraging all physicians' offices, hospitals, clinics, and other health care facilities to acquire interoperable EHRs as quickly as they can afford it.
Promoting health care data sharing to enhance efficiency and effectiveness while maintaining patient privacy and physician ownership of business operations records. This will not only enhance the efficiency of health care safety net facilities, but also give physicians access to valuable data that allow them to compare themselves with their peers and adopt continuous quality improvement.
Promoting the use of patient-owned, electronic personal health records.
Texas and the nation must encourage public/private sector collaboration on a plan that will make developing and using health information technology affordable for physicans, hospitals, and providers.
As it currently stands, those who must pay for EHRs and other HIT tools are not those most likely to benefit from their widespread adoption. "Barriers to wider adoption of HIT include … payment systems that result in most HIT-enabled savings going to insurers and patients, while most adoption and care improvement costs are borne by providers," the Rand Corporation reports. Rand also lists as barriers high costs, uncertain financial payoffs, and the disruptions that accompany any new technology.
In a 2003 survey of office-based physicians, the four most frequently cited barriers to acquiring HIT were startup costs (56 percent), lack of uniform standards (44 percent), lack of time (39 percent), and maintenance costs (37 percent). [58]
Given the technologies' multibillion-dollar price tag, these are strong disincentives to keep physicians and hospitals from moving forward.
On the other hand, we have good reason to share those costs across the entire system: A January 2005 study found that a well-designed system linking patient records among physicians, hospitals, health plans, and others "could yield $77.8 billion annually, or approximately 5 percent of the projected $1.661 trillion spent on U.S. health care in 2003." [59]
To help bring these valuable technologies to patient care rapidly, TMA recommends:
Developing government grant and loan programs for physicians to purchase EHRs, install them in their offices and clinics, and train themselves and their staff on how to make best use of them.
Investing taxpayer money in creating regional health information organizations.
Ensuring health plans and government health programs adopt policy initiatives that accelerate market forces and provide physicians with incentives to invest in HIT.
Urging the federal government to continue to develop uniform standards for electronic health care data collection and sharing.
- Encouraging health plans, Medicare, Medicaid, and other health care purchasers to include in their reimbursement systems provisions that reflect physicians' HIT-related costs.
Next: Goal 4: Protect Patient Safety
[50] Rand Corporation. Health Affairs; Sept./Oct. 2005.
[51] Commonwealth Fund. Annals of Internal Medicine; Aug. 2, 2005.
[52] Health Data Management; October 2005.
[53] Brailer, D, MD, PhD. Remarks made at the Healthcare Information and Management Systems Society; 2005. Accessed October 2005 at http://www.os.dhhs.gov/healthit/BrailerSpch05.html .
[54] Audet AM et al. Information Technologies: When Will They Make It Into Physicians' Black Bags? 2004. Available at http://www.medscape.com/viewarticle/493210 .
[55] Garg AX et al. Effects of Computerized Clinical Decision Support Systems on Practitioner Performance and Patient Outcomes: A Systematic Review. JAMA, 2005; 293 1223-38.
[56] Greater Houston Partnership. Public Health Task Force Report. Accessed October 2005 at http://www.houston.org/pdfs/ PHTF/Summary.pdf .
[57] Audet et al.
[58] Ibid.
[59] Walker J, Pan E, Johnston D, Alder-Milstein J, Bates DW, Middleton B. The Value of Health Care Information Exchange and Interoperability. Health Affairs; Jan. 19, 2005. Accessed October 2005 at http://content.healthaffairs.org/cgi/content/ full/hlthaff.w5.10/DC1 .