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.