Cover Information Technology
A National Health IT Policy Proves ElusiveThe power of an integrated system is clear. The path there is long and winding.
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Throughout the election season, H&HN will analyze some of the most critical health care issues facing voters and candidates. Our aim is to provide a deeper understanding of the political and business environment that surrounds these areas. This, the first of a five-part series, explores health information. Upcoming stories will look at wellness, cost, quality and access. |
During the next several years, health information technology leaders predict, hospitals and physicians will increasingly adopt electronic health records, forge better interoperability between provider systems and create national standards for quality reporting that will be harnessed into new payment mechanisms. From those functional improvements, hospitals and other providers are expected to develop robust, quality-driven clinical decision support systems and reduce costs through better and less redundant care. Support for improved health care information technology infrastructure has widespread bipartisan support; last November, former U.S. House Speaker Newt Gingrich, a Republican, joined with Sen. John Kerry, a Massachusetts Democrat, to support a bill pending in Congress that would fund e-prescribing for physicians, considered a critical first step in the implementation of an EHR. Another bill, the Wired for Health Care Quality Act of 2007, currently under consideration by the Senate, also has broad support, with 12 co-sponsors representing eight Republicans and four Democrats.
“This is an issue that brings us together,” says Gingrich, who now operates the Center for Health Transformation, a think tank. “Paper really does kill. It’s very important to go to a paperless system as rapidly as possible.”
Robert Kolodner, M.D., national health information technology coordinator at the U.S. Department of Health & Human Services, envisions a coming transformation in care that will harness improved EHRs, quality reporting and more sophisticated genetic information on patients to create a consumer-focused, personalized health care delivery system. “We don’t yet understand how profound the model of health and well-being versus illness will be,” Kolodner says. “As information becomes mobile, transportable and secure, it will be used for a multitude of purposes and become available for individuals to manage their health. A very patient-centric health care system will have the information it needs to provide the best care.”
Despite broad political support, there are significant hurdles providers, payers and politicians must overcome before a viable national framework for health IT is in place:
- Adoption rates still lag among smaller organizatons, particularly those outside urban areas, and some health care leaders say the current level of federal funding is vastly inadequate to spur more adoption.
- A serious lack of interoperability prevents sharing patient information and quality data among various providers’ systems, and there are philosophical differences over whether the federal government should mandate interoperable standards or rely more on public-private collaborations.
- While experts envision a long-term shift in payment that rewards health outcomes, the quality measures needed to make that possible are still under development.
- More trained informatics professionals are needed to operate and improve EHRs.
The Money Issue
According to a 2007 American Hospital Association survey, 68 percent of hospitals had fully or partially implemented electronic health records in 2006. But only 11 percent were considered fully implemented by the survey’s standards, which included 15 EHR functions. Hospitals needed to have at least 12 functions in place to qualify as fully implemented.
Karen Bell, director of the Office of Health IT Adoption for the Office of the National Coordinator, estimates that fewer than 10 percent of physicians and hospitals meet the government’s standards for EHR adoption and implementation, which stipulate that EHRs must be able to oversee the collection of patient data, results management, order entry and decision support. The cost of implementation is the major roadblock, she says.
“EHRs are not inexpensive,” says Bell, who estimated that they cost roughly $17,000 per bed for hospitals and roughly $20,000 per physician’s office. About 54 percent of hospitals surveyed by the AHA in 2006 said the initial cost of EHR adoption was a significant barrier to implementation, while 32 percent said the ongoing cost of maintaining an EHR was a significant barrier.
The AHA survey also reports that urban and teaching hospitals are far more likely to have EHRs than rural hospitals and nonteaching facilities. Fifty-six percent of hospitals in urban areas reported moderate or high information technology use in 2006, while only 33 percent of rural hospitals did.
Meanwhile, 74 percent of hospitals with more than 500 beds had moderate to high IT use in 2006, compared with 23 percent of hospitals with fewer than 50 beds.
Financial motivations, both in terms of government funding and incentives from payers, are expected to move more physicians and providers to EHRs. In Congress, the 2007 Wired for Health Care Quality Act would authorize matching grants with states for providers to purchase health information technology systems, loans to states to help with adoption, and demonstration projects to develop information technology curricula for medical schools. The bill includes roughly $280 million in funding. But many say that far more funding is necessary to truly level the playing field for smaller hospitals and other cash-strapped providers.
“The amounts of funding people are talking about are trivial relative to the overall capital needed,” says Scott Wallace, president and CEO of the National Alliance for Health Information Technology. The motivation may ultimately come from other directions; Wallace notes that some larger employers, including General Motors, have begun putting pressure on providers to adopt EHRs to save money. In 2006, Cisco, Intel and Oracle teamed up to found the Silicon Valley Pay-For-Performance Consortium, which offers financial incentives to physician organizations to promote IT adoption. Of the 1,800 physicians the group worked with in its first year, 28 percent instituted EHRs.
AHA President Rich Umbdenstock also believes smaller institutions will need more federal support to adopt and implement EHRs.
“I haven’t seen anyone promise to throw big amounts of money at it,” Umbdenstock says. “There has to be funding to help people adopt. It’s out of reach for some smaller hospitals.
There also has to be some payment incentive for going electronic. The savings have heretofore gone to payers. If there’s a lower cost per case, there’s less reimbursement. A clear financial motivation will spur IT.”
That motivation is expected to increasingly come from the Centers for Medicare & Medicaid Services, in the form of reimbursement tied to specific IT adoption.
In December, Health & Human Services Secretary Michael Leavitt asked Congress to consider allowing physicians who adopt certified electronic health information technology to escape planned cuts in their Medicare payments. “Physicians who do not adopt appropriate, available technology should receive a lower payment than those who do,” Leavitt wrote in a letter to lawmakers.
Those cuts were later reversed by Congress, which voted to extend current funding levels for physician payments through June. Linking payment to IT adoption is expected to be revived when Congress takes up physician payments later this year. The American Medical Association steadfastly opposes the concept, saying Medicare payment levels are already inadequate.
“Medicare payments already fall well below medical practice costs, making it difficult for physicians to run their practice and continue to accept new Medicare patients,” said AMA Chair Edward Langston, M.D., in a statement. “In order to fund investments like health IT and other practice improvements, Medicare must first cover the costs of patient care.”
Interoperability: Mandates or Collaboration?
With better connectivity between systems, the ONC’s Bell and other experts hope clinical data will flow easily through all points of care, improving quality and reducing redundant tests. Interoperable EHRs rich in clinical information would also allow researchers access to de-identified patient data for community public health analyses, Bell says.
Along those lines, ONC is developing the National Health Information Network, which is expected to begin demonstration projects this year to test the exchange of secure health information among providers, patients and payers. Several states are also in the midst of developing regional health information organizations to spur interoperability, though many of those efforts are still in their infancy. A December 2007 study by the journal Health Affairs identified 145 potential RHIOs in the United States, of which 32 are currently facilitating clinical data exchange between independent entities.
The Healthcare Information Technology Standards Panel is currently identifying interoperability standards that the federal government has begun to use for its own agencies, including the Indian Health Service, the Department of Defense and Veterans Affairs, according to John Loonsk, the ONC director of the Office of Interoperability and Standards.
“We’re pursuing this not to have federally legislated or required standards developed from the top and asserted downward,” Loonsk says. “It should be a public-private process that identifies appropriate standards.”
Other experts, though, say the federal government’s stature as a payer necessitates that it take a leading role in creating, and in some instances mandating, interoperability standards.
“There’s so much chaos in this marketplace, a voluntary, uncoordinated alignment is beyond improbable to impossible,” says the Alliance’s Wallace. “There has to be guidance by some sort of market-leading forces. In health care, the market leading force is the federal government. We’re not seeing that coalescence in the private sector.”
Charlene Underwood, director of government and industry affairs for Siemens Medical Solutions, a HIMSS board member and former chair of the HIMSS Electronic Health Record Vendors Association, stakes a middle ground between voluntary collaboration and regulation. While not in favor of widespread mandates, Underwood believes the federal government will need to help hash out some areas of dispute so that the EHR industry can “collaborate on interoperability and compete on functionality” of products.
“The need for national leadership in defining direction and plan and strategy is necessary,” Underwood says. “There’s a role for government to drive this if they want to focus on it.”
Quality Control
As interoperable EHR systems continue to develop, industry leaders hope they will be increasingly linked with standard quality measures that can be used to improve and measure care. The long-term vision sees those measures linked to payment, as pay-for-performance schemes shift from claims-driven process data to outcomes.
For the alignment of interoperable quality measures, the National Quality Forum has convened the Health Information Technology Expert Panel, a group of 20 health care experts working to identify common data elements for hospital and ambulatory quality measures. HITEP member John Halamka, chief information officer for Harvard Medical School and CareGroup Health System, says HITEP would like to set frameworks for standards ahead of any federal intervention.
“I prefer bottom-up, rather than top-down mandates,” Halamka says, adding “before we start doing HIPAA all over again.”
The development of standardized quality measures is still in its infancy, though, and in the short term, hospitals will continue to rely on claims-based reporting, Underwood says. Most experts do not expect a shift to more outcomes-based quality measures for several years.
“Today it’s still process measures,” she says.
The Role of the Consumer
Interoperability and more widespread EHR adoption is also expected to bring about a sea change in the storage of and access to patients’ clinical information. The AHA is among the groups calling for the development of unique personal health information numbers—PHINs—that would be linked to a patient’s records as he travels among various providers.
David Brailer, M.D., formerly the national coordinator for health information technology who founded the investment group Health Evolution Partners last year, believes interoperability will lead to adoption of a consumer-directed model, where empowered patients control their medical record much as they handle their financial investments, with the option to delegate authority over its accessibility if they so desire.
“My paradigm is consumer-controlled,” Brailer says. “The unit of management cannot be an institution.” Others, including the AHA’s Umbdenstock, believe consumers will continue to rely on health care institutions to store their medical data, choosing which institution to trust, while also creating and updating a more informal personal health record to keep track of their medical and personal history.
“I’m not sure they’re going to literally carry [records] with them as opposed to move it within the system,” Umbdenstock says, adding, “it ought to move electronically on their behalf.”
Another major area of concern revolves around whether patients would have to authorize every health care institution gaining access to their medical records, also known as “opt-in,” or whether patients would simply retain the right to opt out of sharing their records.
The Health Privacy Project, an advocacy group, supports an opt-in approach, on the grounds that the public is wary of having its medical information shared among providers. That group is advocating for incorporating more privacy protections into the Wired for Health Care Quality Act.
“The public believes that a computer-based medical records system is less secure than a paper-based one,” Janlori Goldman, director of the Health Privacy Project, wrote in a letter to Congress in July 2007.
But many experts worry that privacy concerns could potentially derail meaningful interoperability by slowing down the transfer of and access to medical records during the care process.
“We need to be very clear in the distinction between confidentiality and privacy,” Umbdenstock says. “Confidentiality is absolutely important. Your records shouldn’t go to someone you don’t want [them] to go to, and they shouldn’t be disclosed by somebody else on your behalf. It seems hard to keep your information private. Caregivers in an extended episode of care also need to work with it.”
The Center for Health Transformation, which favors an opt-out approach, suggests assuaging privacy concerns by making it a felony for unauthorized individuals to access or disseminate medical records.
Gingrich believes privacy advocates in favor of an opt-in approach do not represent the views of the general public, pointing to the widespread acceptance of shared access to financial records by the banking community. “I find privacy advocates are professionally militant,” he says. “I find the average person is not.”
Wanted: Informatics Professionals
As interoperable, quality-based systems begin to take shape over the next several years, experts predict a larger pool of informatics professionals will be needed to operate EHRs. Last year, the Bureau of Labor Statistics estimated that the number of medical records and health information technicians would grow from 170,000 in 2006 to 200,000 by 2016, an 18 percent rise. Roughly 40 percent of those technicians work in hospitals, according to the Bureau.
Kolodner is preparing recommendations that call for more funding for informatics training, which would then be integrated into medical training. “We need a lot more in the way of the implementation folks,” he says.
Already in place is the American Medical Informatics Association’s 10x10 program, which is designed to take curricular content from existing informatics programs and create a framework for training that covers everything from from EHRs to standards to health care quality and prevention. The program hopes to train 10,000 new informatics professionals by 2010.
“We’re calling for supported programs for training informatics experts,” says Jonathan Teich, M.D., chair of the AMIA 2007 Scientific Program Committee. “It’s clear that the success of clinical decision and computerized physician order entry are better when there are trained people on- site.”
Many experts believe that interest in informatics as a career will grow around the same time EHR adoption and implementation become widespread. As more providers adopt and implement EHRs, the general public will take an increasing interest in informatics as a career path, says the AHA’s Umbdenstock.
“Until we can show a young student what this system is, how it contributes to improved patient care and how they can be part of the process, it’s a little hard to entice people into the field,” Umbdenstock says, adding that more interest in informatics will emerge “when we start to build systems out and start to help clinicians change care.”
This article 1st appeared in the February 2008 issue of HHN Magazine.
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