The Prognosis for Electronic Health Records
President Obama's stimulus package addresses very diverse segments of the economy, including health care, education, research, and infrastructure. However, all of these components have one thing in common: the reliance on information technology as the engine powering these stimulus initiatives.
A key initiative in the stimulus plan is addressing the issue of establishing electronic health records to reduce health care costs and improve the care itself by making all medical information for a patient available to anyone who treats her. The federal government has advocated for such a system for a decade, but little visible progress has been made.
So what about the Obama plan would change the equation? It's designed to tackle one of the two biggest barriers: the financial penalty that has existed so far for adoption. But it does little to solve the technology issues that will hinder large-scale deployment.
Problem No. 1: Electronic Health Records Reduce Profits
Up until now, the benefits of electronic medical records that have occurred accrue to just about everybody -- patients, employers, state and federal governments, and medical insurers -- but the actual health care providers. Doctors get the least benefits, especially in small practice groups (those with fewer than five physicians) that make up most medical practices.
But even those who might benefit from electronic health records don't, says Homer Chin, associate medical director for clinical information systems at Kaiser Permanente Northwest. Why? Because there is little incentive to share information, the core of an electronic health record (EHR; also called an EMR for "electronic medical record"). For example, hospitals make money by doing tests. But once EHRs are up and running, a doctor ordering a test electronically might immediately receive an alert saying the test was unnecessary because the patient had the same test or procedure at another location. "There is not much revenue and profitability in putting in an EHR. There is little financial incentive," Chin says.
An ironic consequence of EHRs is that, by helping raise the quality of health care, they penalize doctors and other medical providers for success, says Wes Rischel, a vice president at Gartner. The bottom line: Doctors will see fewer patients.
Beyond the income factor, the high cost of EHR systems today -- not only the systems, but the setup and training -- also dissuades adoption by doctors, especially those in small groups. Physicians have been unwilling to invest anywhere from US$20,000 to $50,000 in an EHR system where the economic benefits tend to go to someone else. Today's EHR systems are not as easy to use as they could be, so there is a large learning curve required, Chin says: "There is something intuitive about paper chart and prescription pad."
Recognizing these factors, the stimulus package tackles these financial challenges head on by offering money to health care providers. Hospitals submitting via EHR systems to Medicare and Medicaid will receive up to $6 million a year in additional payments for sending data electronically. This incentive will remove much of the adoption inertia seen so far, says Richard Archer, a principal in the health care IT advisory practice a KPMG.
And every medical practice that uses an EHR system to submit an invoice to the government Medicare and Medicaid insurance systems will be reimbursed at a higher rate than those who submit a non-electronic invoice: up to about $44,000 extra per year. To a physician in a small practice, this incentive is large enough to get doctors' buy-in, says Michael Lake, principal at Circle Square a health care consultancy. "It is a lot money, and we will see physicians adopt it," he adds.
Problem No. 2: Solving the Technology Issues
About $17 billion of the $19 billion allocation for EHR goes to incentive payments. Most of the rest goes for IT research in how to address all the technology issues. Industry analysts warn that roughly $2 billion is far from enough. The stimulus does not really address the Rube Goldberg task of making all the IT infrastructure work together.
Consider the case of Kaiser Permanente, which has rolled out EHR systems in all eight of its regions in the United States. The first region to implement an EHR system was Northwest, which by 1998 reached its goal of no paper records for its 450,000 to 500,000 members. Everything from lab test results, radiology tests, X-rays, and medications dispensed from the pharmacy is stored electronically. "We are ahead of the rest of the health care industry with the exception of the VA [the U.S. Veterans Administration]," Kaiser's Chin says.
But does that mean if you are a member of Kaiser Permanente in any of its eight regions, your records are available to any other region? The answer is a surprising no. Chin says that the Epic Systems EHR application that Kaiser Permanente uses is so complex that Epic will not work with any medical group with less than a hundred physicians due to the cost of implementing the system.
The problem is that the small medical groups that make up about 75 percent of all practices in the United States can't manage an EHR system and its ongoing cost of maintaining an IT department.
The expectation is that such small practices will either band together for EHR cooperatives or use a managed EHR service delivered over the Internet. But such sharing and cloud-based provisioning raises the tricky issue of keeping patient records offsite, which in turn brings up many legal issues due to the strict patient privacy requirements of the 1996 federal HIPAA (Health Insurance Portability and Accountability Act) law.
The good news is health care IT is likely to become a magnet that will surely attract IT professionals in other industries who know how to manage and maintain big enterprise systems, whether used by large hospitals and medical groups, provider collectives, or cloud-based EHR providers.
What exists today is an alphabet soup of governing bodies, protocols, standards, near-standards, suggested best practices, and competitors, all well-intentioned but also contributing to the complexity. That situation requires both simplification at the process and standards level, as well as serious integration work at the IT level.
For example, among the many unresolved IT-related issues are decisions about coordinating how records and prospective readers of those records are authenticated, the adjudication among the different privacy policies across states so that information exchange can occur, and the creation (and management) of a single glossary or dictionary of procedural and diagnostic terminology to be used by all health care providers. Standard communications and networking protocols also have to be agreed on to permit data exchange, as well as a file format or file standard for interoperability.
Sorting Out the Standards
At one time, the solution to all these issues seemed simple enough. The Veterans Administration pioneered electronic medical records with its Vista system, and many lawmakers thought the best idea was to mandate the adoption of Vista as the single, national system, making it available at no charge to health care organizations along with subsidies to speed its adoption.
Of course, private medical software providers hated the idea, as it put the government in direct competition with them. They suggested that government couldn't do the job as well as private businesses could, and certainly couldn't be as innovative. A decade later, EHR efforts remain stalled, though vendors have continued to push the technology.
In the meantime, the policy debate has shifted to a discussion over creating interoperability standards using SOA, middleware, and standard file formats, not unlike the idea behind the Open Document Format (ODF) and the Resource Description Format (RDF) standards for information mediation based on extensile but structured meaning, says Jeff Bauer, a partner in management consulting for ACS Healthcare Solutions.
At the moment, an effort is under way to create the Continuity of Care Document, an XML-based standard intended to become the equivalent of an RDF or ODF file that lets the various EHR vendors write to the same file format.
That effort won't be easy. But the stimulus bill does encourage this effort by requiring doctors to make "meaningful use of certified EHRs." The part-private, part-government CCHIT (Commission for the Certification of Health IT) does the certification, and it creates interoperability and definitional guidelines in three key EHR areas: privacy, format, and content.
But agreeing upon an interoperable framework doesn't address another key issue: the creation of a unique glossary of terms to describe both medical procedures done to a patient as well as to describe a diagnosis.
Currently, most hospitals and practices use IDC-9, the International Statistical Classification of Diseases and Related Health Problems9th Revision, which has a highly limited language of about 17,000 terms. Its successor, IDC-10, has about 155,000 codes and will permit the tracking of many new diagnoses and procedures. But deploying IDC-10 will be yet another challenge for doctors, nurses, and IT personnel.
The fact is, the information needed to treat a patient today exceeds what a physician can handle, says ACS's Bauer. "We are moving toward a genetic and molecular understanding of disease, and there is no doctor smart enough to handle all of the data. They need information support systems to make better decisions," he contends. And those systems need a comprehensive, flexible, and manageable way to handle complex health information.
Tackling the Information Exchange Issues
HL-7 (Health Level 7) certification sets the transmission standards among different systems, such as how to transmit lab information, prescription data, and a diagnosis. So this information exchange component is largely in place.
But privacy issues remain, and they are a more difficult challenge. Most states have added their own requirements to HIPAA's privacy standards. Thus, for the most part, if you are a hospital in one state trying to send patient data to a hospital in another state, it can only be done on a one-to-one basis, typically with a phone call and proper identification.
However, both nonprofits and for-profit organizations have been trying to meet this challenge through the creation of something called RHIOs (regional health information organizations), consortia composed of small hospitals and health plans that work out how to share data among themselves, and often with nearby RHIOs. It's an ad hoc approach that tries to get some of the key EHR exchange benefits in place without waiting for federal or state standards
A dot-com-era provider, Covisint, has entered the RHIO fray. Covinsint was one of the first e-marketplaces created for the auto industry, but it now has a health care arm deploying the same tools for medical practices that it used to let auto industry vendors and suppliers communicate, buy, and sell while keeping information shielded from competitors.
Covisint checks credentials, makes sure all participating organizations are compliant with regulations, and supports more than 200 APIs so that medical providers can connect to the various practice management systems. Covisint has become the statewide backbone for Minnesota's medical providers; it also connects nine RHIOs to each other.
The usual service providers like Accenture, Hewlett-Packard, and IBM have health care practices. But now Microsoft, Google, and AOL founder Steve Case's Revolution Health are looking at entering the health care information exchange market. All three offer individuals a personal health record, which puts the patient in control of his medical information. But the business aspect is in giving health care providers access to a person's complete health record from a single site.
There are two major questions around the reliance on health records from these providers, say industry analysts. One is whether users will trust a for-profit organization to care for the most personal kind of information. The second is whether each of us can be trusted to manage and keep such a life-and-death record up to date or if it's safer to leave that responsibility to organizations whose only job it is to keep the health data updated.
The Prognosis for EHRs
EHR providers are, not surprisingly, bullish on the future of EHR efforts. Greg Mancusi-Ungaro, a senior director at Exigen Systems, says deploying an EHR system is just like implementing any big enterprise application, only the enterprise in this case is bigger and the stakes are higher. "The technology exists today and despite the fact that we lack some core standards, we are enabling the development of a flexible infrastructure to stay in tune with requirements. I can visualize a successful national system," he says.
As Kaiser's Chin points out, there is a convergence occurring around health care technology regarding how to share it and use it to assist delivery of services and treatment. But the challenge of orchestrating and satisfying so many stakeholders remains. Plus, even if the solutions are mandated rather than eventually negotiated, the task of gathering the many pieces that are still in flux, then integrating them remains a complex technical and process task.
Over time, both industry representatives and analysts expect that every U.S. citizen will have an EHR available nationwide. But to make it happen will require a great deal of cooperation, innovation, and an investment in health-oriented IT. This shift will likely start at a less ambitious level than the political rhetoric suggests, with local practitioners sharing patient information in a local health care ecosystem.