March 9th, 2012
Adoption of health information technology (IT) throughout the health care system is “on the march,” according to Farzad Mostashari, the national coordinator for health IT. Nearly 2,000 US hospitals and more than 41,000 doctors have now met the standards for achieving meaningful use of health IT, and have received $3.1 billion in federal incentive payments as a result.
In an interview in the recently released March Health Affairs with David Brailer, the first national health IT coordinator, Mostashari predicts that 50 percent of primary care providers will have adopted basic electronic health record (EHR) systems within a couple of years—up from just 20 percent in 2009. He adds that 90 percent of hospital chief information officers say that meeting federal meaningful-use standards for EHRs is one of their top two priorities. And with the second stage of meaningful-use regulations now rolling out, Mostashari says the federal government’s goal is to make sure that all of America’s health care providers make the grade. “Our goal is to do whatever we can to see to it that no one gets penalized” for not using health IT in 2015, the year after federal incentive payments end and when providers who haven’t adopted the technology and demonstrated meaningful use will face lower Medicare and Medicaid payments.
Additional papers in the March issue examine adoption of EHRs and other forms of health IT as well as ways to support the broad exchange of health information that is considered so crucial to transforming health care. The papers also highlight areas of health care where EHRs and other forms of health IT still have a minimal presence—and point out the limits of health IT in transforming care in the absence of other changes, such as payment reform.
The importance of health information exchange. To capture the benefits of health IT, the information it captures, through EHRs and the like, has to get into the hands of the people who need it. That means, for example, that a primary care doctor needs hospital discharge data about her patient, so she can help manage that person’s care and prevent her from being readmitted to a hospital unnecessarily. The unfortunate truth is that there is little such electronic information sharing today in proportion to what is needed.
- In an article by Claudia Williams and colleagues from the Office of the National Coordinator for Health Information Technology (ONC), the ONC discusses steps it will take during 2012 to advance the health information exchange agenda. One example: leading the development of policies to advance “query-based exchange,” such as when someone arrives at an emergency department with sudden chest pain, and a physician seeking information about the patient’s cardiac history requests access to an EHR from another health care provider. The article notes that “giving every provider the means to securely send and receive patient information to support better care coordination [is] a top priority for 2012.”
- Achieving ambitious goals for the adoption of EHRs and the nationwide exchange of health information will require overcoming a number of hurdles, writes Marsha Gold of Mathematica Policy Research and colleagues. First and foremost, providers and patients have to be persuaded of the value of exchanging information and have to be supportive of steps to make it possible. For example, there are broad concerns about the trade-offs between sharing information electronically and still safeguarding patients’ privacy and the security of their data. A case in point: existing federal law provides for the use of a single identification number for every US patient, but Congress has blocked the use of federal funds to develop this ID system because of privacy concerns.
- One key goal of health information exchange is to use it to improve the health of individual patients as well as the health of populations—but to do so in a way that still protects patients’ privacy. Robert Miller of the University of California, San Francisco, writes about nine principles for electronic information exchange formulated by 16 organizations representing patients and consumers in California and his study of whether five health care organizations were conforming to those principles in early 2011. His study found that there had been only modest progress in exchanging information among unaffiliated organizations, and that patients had little control over their data. He advocates establishing clear rules—for example, spelling out which data can be shared, how, and with whom—as well as launching campaigns to educate patients about health information exchange so that they will demand more of it from their providers.
- Federal and state agencies are investing considerable resources in the creation of community health information exchanges, which are consortia that enable independent health care organizations to exchange data about patients’ care across hospitals and physician practices. Could mergers of medical groups and formation of accountable care organizations reduce the usefulness of these community-based exchanges and lead to more use of private health information exchanges that would only share information selectively among providers? A study by Robert Rudin of the RAND Corporation suggests not because even the largest medical groups in a given community account for only a small percentage of health care transitions, so private exchanges would have little utility. On the other hand, the community exchanges will still need to recruit many medical groups in a given community to make sure they can perform a useful role in fostering information exchange among independent community providers.
Is the nation reaping the projected benefits of health IT? A number of papers in the March Health Affairs focus on areas of the health care system in which health IT is not spreading fast enough, on some claimed benefits of health IT that don’t always pan out, and on other steps that will need to be taken to capture other benefits.
- Federal meaningful-use incentives aimed at increasing EHR adoption are clearly having an impact on many hospitals and physician practices. But a large segment of providers—including long-term acute care hospitals, rehabilitation hospitals, and psychiatric hospitals—are ineligible for those incentives and their rates of EHR use are “dismally low,” according to a study by Larry Wolf of Kindred Healthcare and colleagues. Policy makers should consider other ways to encourage EHR adoption among these providers, the study authors say.
- A study by Harvard Medical School’s Danny McCormick and colleagues raises questions about whether greater electronic access to imaging and lab test results will result in some expected health IT-related cost savings. The study found that—contrary to widely held expectations—giving office-based physicians electronic access to their patients’ imaging and lab results did not decrease test orders; in fact, such access was associated with a 40 to 70 percent greater likelihood that imaging tests would be ordered. The findings “raise the possibility that, as currently implemented, electronic access does not decrease test ordering in the office setting and may even increase it,” possibly because features of electronic systems actually encourage more tests ordering, the authors say.
- Since health IT is quickly becoming a fact of everyday care, physicians need to be trained in how best to use EHRs and other computerized tools. Pierce Graham-Jones of the ONC and colleagues propose a plan for incorporating health IT training into all levels of physician education and professional development, and suggest six opportunities for professional organizations involved with physician education and training to incorporate health IT-related learning and skills into their requirements.
- Most EHRs capture aspects of medical encounters between patients and practitioners, but only from the perspective of those practitioners or from payers. To understand and improve health outcomes, these records will need to incorporate information from patients about areas such as their health habits, including tobacco use and, in particular, their mental health or distress and any behavioral concerns. Russell Glasgow of the National Cancer Institute and colleagues argue that “patient-reported measures” covering these areas need to be incorporated into EHRs and outline a plan for adding them. Incorporating such measures will help build awareness that “the ultimate outcome that health care should be working to achieve is quality of life,” the authors write.
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