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Complete The Work On Health Information Technology



January 14th, 2009

President-elect Barack Obama and President George W. Bush may disagree on many topics, but they clearly agree on one thing: information technology (IT) is essential to reforming our health care system. They see the evidence that IT prevents errors that kill tens of thousands of Americans each year, reduces waste and duplication that cost up to one hundred billion dollars per year, and helps consumers take better care of themselves. They are joined by physicians, hospitals, governors, members of Congress, the public, and even other countries that see health IT as a necessity in health care.

President Bush set the ambitious goal in 2004 of ubiquitous electronic health records (EHRs) across the nation within ten years. He asked me to lead this effort for our country. Since then, the United States has seen intense and sustained efforts to move us into the era of digital medicine. We are now the world’s leading health IT innovator, even if our hospitals and physicians still struggle to get these tools into daily use.

President-elect Obama recently placed health IT among the critical infrastructures that are essential in the 21st century. He rightly recognizes that health care is one of our few remaining economic sectors where IT has not taken root. His health reform plan relies upon health IT to reduce costs and improve efficiencies. He has pledged $50 billion to bring health information tools into widespread use (which is $49,950,000 more than President Bush gave me to spend).

Now that we are well into the transition, reasonable questions to ask are, What should the President-elect do to get health IT into widespread use? What should he do differently from President Bush? What should he not do?

A Health IT Agenda For President Obama 

First and foremost, President-elect Obama needs to address the growing chasm between the physicians and hospitals that have electronic records and those that do not. Most large and urban hospitals as well as larger physician practices are far along in using EHRs. Rural hospitals, nursing homes, and small physician practices lag far behind. They face many barriers, but foremost among them is the lack of capital to purchase and implement information tools. We were reluctant to offer government incentives for electronic records, preferring market forces to drive adoption as far as possible. Sales pipelines and hospital and physician budgets show that EHR purchases have slowed, indicating that the market wave has gone as far as it can. Now is the time for government incentives to help along those who do not have these systems.

The way these incentives are structured matters. We should not incent physicians and hospitals simply to purchase EHR systems. We get no benefit when a physician or hospital buys an electronic record. What we should do is reward the use of these tools as part of a patient’s care. “Pay for use” can fund the conversion of the health care system to digital records and ensure that we get the life-saving and money-saving benefits they promise. This is how Congress recently approached electronic prescribing — Medicare pays physicians a 2% bonus for using e-prescribing on appropriate patients starting in 2009, and this incentive converts to a 3% penalty for those who do not e-prescribe in 2013.

Second, he has to increase the ranks of people who help bring health care into the digital age. The nation’s transition to digital medicine goes beyond hiring Geek Squad. Setting up an EHR is a complex task, requiring data integration, clinical algorithms, and complex software customization. Likewise, helping physicians and other health care workers learn to work with electronic tools is more than point-and-click training. EHRs change the very nature of health care work — clinical decision making, communications, documentation, and learning. Our national transition to digital medicine requires a large supply of specialists — upwards of 50,000 people, including physicians, nurses, and pharmacists — who understand both clinical medicine and information technology. It takes years to train these people, and they are already in short supply, so now is the time to start.

The Importance Of Information Sharing

Third, the President-elect must push us firmly toward information sharing. Many of the benefits of digital medicine arise not from the technology itself, but from how it allows information to follow patients throughout their care. Americans witness the need for information sharing every time they change physicians, switch health plans, visit an emergency room, or see a specialist — all of whom have to re-collect patient information every time. The capacity to share information will arise only from a long-term, government-led effort to adopt and enforce standards for storing and transmitting health information. The federal government has to lead this effort because of the dominance of Medicare. To lead credibly, the Department of Defense (DoD) and Veterans Affairs (VA) health systems have to use the same standards as the private sector, something that does not happen today.

The President-elect must also develop policies that encourage, or at least do not discourage, health information sharing. The Health Insurance Portability and Accountability Act (HIPAA), the federal statute that governs health information privacy and portability, is a huge impediment to information sharing. Under HIPAA, a physician or hospital does not have to send a patient’s data to their personal health record (they are only required to give it to the patient). They have 120 days to give information to a patient, and can give it in any form they want, usually not electronic. In other words, HIPAA makes personal health records unfeasible for the majority of Americans, and it needs to be updated. While we are fixing HIPAA, privacy rules should be rethought as well. HIPAA was created before patients could use online personal health records. Because of this, we have the ironic situation that our trusted physicians and hospitals are covered by strict HIPAA privacy rules, subjecting them to felony prosecutions for violations, but Web sites like Google Health and Microsoft Health Vault are not covered by these rules at all.

Fourth, President-elect Obama should consider one single change that would do more to reshape medicine into an information industry than anything else: have Medicare treat electronic visits as equivalent to in-person visits. Physicians are increasingly using e-mail to diagnosis or treat patients with simple problems. Radiologists, pathologists, and dermatologists “see” patients from afar through telemedicine, which is often the only way people in rural areas have access to these specialists. Medicare does not pay physicians for electronic visits, even though it has few controls on payments for in-person visits. Nothing else is more symbolic of a health care system looking backwards than Medicare’s failure to recognize the immediacy and value of telemedicine.

We can only hope that, this time, health care reform has a real chance. Regardless of whether this will happen, the incoming administration will shape the character of our health care system through decisions it makes about health IT over the next few months.

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5 Trackbacks for “Complete The Work On Health Information Technology”

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  3. Dr. David Brailer and Electronic Medical Records: Perhaps the Chairman Doth Protest Too Much : Health Reform Watch
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4 Responses to “Complete The Work On Health Information Technology”

  1. James McGee Says:

    I am somewhat skeptical of the high promise held out for the electronic health record. As someone who was involved in an effort to build a very limited Community Health Information Network (Remember CHINs?) and later with efforts to conform to the EDI standards of HIPAA, I have experienced how these efforts stumble over turf.

    Policy makers are tantalized by the allure of high tech and the tempting promise that it can do what they are unable to do – organize the status quo into a more coherent system. The efforts described by Dr. Brailer are a beginning. But as long as the delivery system is fragmented along countless political, geographical, practice and ownership lines, they will falter on those fault lines. Meanwhile consultants will earn lots of money. I recall an adage I learned early on – automated stupidity is still stupidity.

    I would be curious, though, to know more about why Dr. Brailer considers HIPAA such an obstacle.

    I would also suggest that doctor attitudes toward using computers in their practice is something that needs to be understood and overcome. My direct experiences with the health care delivery system are only as a patient or family member of a patient. Only once, have I encountered a physician who sat at a computer in his office for any reason other than to see a computerized image.
    And that was in Ireland in 2003. They will speak their patient notes into a recorder in the hall. They will rifle through an inch thick file looking to discover the last prescription they wrote for me. But sitting in front of a computer seems somehow unnatural.

    Am I wrong in that perception? What are the barriers to physician acceptance? Is it generational?

  2. Mark Leavitt Says:

    It’s great to see Dr Brailer return to our national dialog on health IT and health reform!

    I am in complete agreement with him about the shape health IT incentives should take.

    I also second the motion that we train a health IT workforce. This will create new jobs, but we also need to recruit clinician champions from successful implementations to get on the road and inspire others.

    Nobody knows better than David what the challenges are to health information exchange, and it seems clear that industry isn’t going to develop spontaneously. We need some significant incentives for information sharing, and we need to figure out if these exchanges are ‘thin’ (basically a directory service) or ‘thick’ (accumulators of data, partly supported by extracting aggregate statistical knowledge from those databases, provided we can find a privacy policy that we can trust). We do have some standards now for data exchange. CCHIT has been requiring EHRs to be able to send and receive a CCD since July 2008, but the transport mechanism and protocol for an EHR to interact with an HIE/HIO wasn’t quite proven at that time. We are on track to test that mechanism starting in July 2009. Since we also test HIEs, at that point we’ll be checking both ends of the connection, getting closer to plug-and-play than ever before.

  3. acavale Says:

    It is very encouraging to read Dr. Brailer’s comments. I certainly hope the new administration will take up his fourth and most important suggestion for implementation immediately. This bolg seems quite timely, since I just received a detailed email just today from one of our state’s largest insurers stating that it would not reimburse for any e-visit because it does not involve direct “hands-on” interaction between the physician and patient. Nothing could be further from the truth with respect to e-visits and exchange of data via e-mail. Ironically, we also received the monthly bulletin from the same insurer today stating why HIPAA forbids any exchange of patient-specific information via e-mail. I suddenly realised that the government and insurance companies are still in the 20th century as far as electronic medical records are concerned, while they are well into the 21st century as far as coding, claims-processing and recovery audits are concerned. Although my liability insurance company has learnt the value of full implementation of electronic records by discounting my premium, the health insurers and Medicare have a very long way to go. Perhaps, they find it to their detriment to accept this as a reality.

    Being a solo practitioner operating an electronic (paperless) medical office for over 6 years, I have yet to see a penny of financial incentive from either government or private payers. Most doctors don’t want a government hand-out in order to computerise their records. Rather, they would like to see concrete measures that would make such a huge expense financially worthwhile in the long run, i.e. ability to collect higher reimbursements in return for appropriate use of technology in daily practice. They would also like to know that interoperability of systems is mandatory and the cost is not dumped on physician practices.

    The most valuable and immediate method for the government to spur adoption technology by small physician practices would be get out of the business of price-fixing for medical care by the CMS. Allowing each practice to set (and collect) its own market-based rates, and allowing patients to select their medical provider based on the value they assign to the service provided, will enable practices to slowly catch up to current and appropriate levels of revenue, whereby they will be able to afford the high costs of converting to an electronic medical office. Otherwise, it will be impossible for physicians stuck at 2001 reimbursement levels (absorbing 8 years of declining revenues) to be able to afford the initial and ongoing costs of digitization.

    I have to respectfully disagree with the whole concept of PQRI and e-Rx initiatives. The notion of claims-based reporting is such an enormous blunder, that it will be a near-impossible task (especially for small offices without data-entry staff) to complete these onerous tasks in order to qualify for bonus payments. One has to just see the results of the 2007 PQRI process to realise the scale of this disaster. Any clinician worth his degree will confrim that remembering to add extra CPT-II codes to a superbill at the time of patient visit is a near-impossibility, in the midst of a busy schedule.This scheme was obviously designed with large group practices in mind, and to minimise any incentive payment obligations while still appearing to foster reporting of “Quality care”. For most folks who did get the bonuses, it was all about adding a very fancy cover to a rather ordinary book.

    Finally, the new government will need to set up a non-partisan body with adequate authority to regulate IT vendors and level the playing field between physician practices and IT companies, whereby disputes can be quickly resolved and fair play ensured in the health IT field.

  4. Dennis Cotter Says:

    Dr. Brailer provides very timely advice regarding the new Administration’s move toward health care reform, namely: standardization of physician and hospital electronic records; expand the ranks of those who participate in the “digital age,” catalyze increased information sharing, and, finally, have Medicare treat electronic visits as equivalent to in-person visits. The tasks might appear to be herculean (approx. 304 million U.S. beneficiaries), but the pay-off will be immense in understanding what really works in health care.

    I certainly believe that there is an important role to be played by Medicare in collecting and promulgating information about the effectiveness of health care technologies and that such efforts can help make the health care system more efficient overall as well as helping individual patients receive the best possible care at the lowest possible cost. The challenge can be exemplified by looking at pharmaceuticals used to treat chronic conditions.

    Analyzing effectiveness in the real world, as opposed to efficacy in trials, is difficult, however. The need to capture information that reflects the breadth of experience of actual patients requires large populations and makes controlled clinical trials prohibitively expensive. In such populations, there are many factors that can cloud the connection between patient outcomes and the treatments, specifically pharmaceuticals in real word usage and make it difficult to infer causality.

    One possible data source for capturing data on drug use among large populations is administrative or claims data resulting from the process of billing insurance carriers for medical care. Such data sets enable the analysis of patient histories over extended periods by accumulating claims for services, which including diagnoses and procedures. However, such claims rarely include clinical information in needed to assess the need for treatment or the severity of disease.

    We have been actively engaged in research using data from one of the rare cases where such clinical data is collected as part of the claims process. – the case of epoetin to treat anemia (see: http://www.mtppi.org/frameset.asp?Pg=/&MI=1). In this case, Medicare requires providers to report the hematocrit, or red blood cell level of patients in order to be reimbursed for their anemia treatment.

    Since anemia is the primary driver of epoetin dosing, we have applied advanced statistical techniques to correct for the tendency of patients with the most severe anemia to receive the most aggressive treatment. We feel that this example can be used as a pattern for the possibilities of collecting limited clinical data via the claims process to be used for measuring effectiveness.

    In addition, using the claims process to collect such information will only be useful when the prescription is itself billed to the insurance provider and is accompanied by an encounter with a provider that is also billed. If the test yielding the physiological data to be analyzed can be required for payment, and the connection between that measurement and the prescription can be reliably made.

    As we wait for electronic records to come online, collecting even limited clinical information in these circumstances could greatly enhance the ability of researchers to develop evidence of effectiveness based on administrative data that include large populations.

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