Health care is serious business.
Spending on health care in the nation reached almost $2 trillion in 2005, or $6,697 per person, according to the most recent research from the U.S. Centers for Medicare and Medicaid Services (CMS).
State and local governments bear a significant portion of the burden, the CMS's research discovered, with the public sector accounting for 45 percent of total health-care spending in the nation.
The spending drains government budgets, and public-sector leaders have devoted much effort to finding solutions to vexing health-care issues. Especially over the last several years, technology has had a profound impact on those solutions, and on health-care delivery and information systems used by physicians, hospitals and hospital systems.
Texas, like many other states, spends a significant amount of money on health care.
Health and human services funding consumed 34 percent of Texas' total state budget for the 2004-2005 biennium, according to Texas Medicaid in Perspective, Sixth Edition, a report released in January 2007 by the Texas Health and Human Services Commission.
Though no state can control every aspect of health-care spending, they can control is the administrative costs associated with health care -- and health IT can help states reduce administrative spending.
The U.S. Department of Health and Human Services broadly defines health IT as technology that allows medical information to be comprehensively managed and securely exchanged between health-care consumers and providers. The cornerstone of health IT is electronic medical records (EMRs) -- a fully electronic medical history for patients that is entirely interoperable within a health enterprise, whether it's a hospital, clinic or private practice.
Over the last couple of years, the federal government has prodded the health-care industry to adopt health IT and EMRs -- but progress has been limited. The world of medicine is slow to migrate to electronic information because medicine is separated into such small economic units, said Dr. Spencer Berthelsen, chairman of the board of directors for Kelsey-Seybold Medical Group, which operates more than 20 neighborhood health centers in the Houston area.
"If you just look at physician practice alone, there are many solo physicians and physicians operating in very small group practices of anywhere from two to 10 physicians," Berthelsen explained. "With so many separate businesses, it's difficult to make a joint decision for everybody to go onto a common electronic medical record."
The cost of upgrading technology to support EMRs in medical practices or hospital systems is another formidable barrier, he continued, especially because of funding limits.
"The funding of health care has been restricted because of the attempts to control the overall cost of health care," he said. "There is very little left over for investment in such things as electronic health records."
On Good Authority
Gov. Rick Perry is one example of a state executive focusing on technology to reshape the health-care environment.
In October 2006, Perry issued an executive order creating the Texas Health Care System Integrity Partnership to advise him on the "finance and governance structure for a public-private collaborative, tentatively named the Texas Health Care System Integrity Authority (THCSIA)."
The order defined the THCSIA's mission as promoting a safe, high-quality, transparent and efficient health-care system in Texas, and charged the authority with: enabling the secure electronic exchange of health information; providing consumers with access to information on the price and quality of health-care goods and services, and health insurance products; and fostering a robust and competitive small-employer health insurance market.
Prognosis for Progress
Perry's 15-member health-care partnership included various stakeholders, such as physicians, insurers, and health plan and hospital systems specialists.
combination of perspectives was critically important in analyzing the THCSIA's form and identifying potential funding sources, said Berthelsen, who was on the partnership, and helped define strategies to address the problems presented by electronic health information, transparency of health-care information for consumers and growing a lively health-insurance market to serve small employers.
"It helps us discuss possible solutions and assess the likelihood of success more quickly with the 15 members than we would with a smaller or less diverse group," Berthelsen explained, adding that the partnership's last meeting was held at the end of February.
"The purpose of the partnership is not really to recommend definitive solutions, but to review the concept of establishing this ongoing health-care system integrity authority through the Legislature to approach these problems."
The Legislature has the power to create private-public collaborative authorities such as the THCSIA, and legislators are increasingly paying attention to health IT.
State Sen. Jane Nelson, who serves as the chair of the senate's Health and Human Services Committee, introduced SB 40 in November 2006 to create a proposed electronic health information coordinating committee.
According to the bill, the proposed committee would consult with practicing physicians, advisory groups and organizations to explore policy changes, and give recommendations about the design and implementation of an electronic health information exchange framework to regional stakeholders.
"The goal of SB 40 is to improve our state's ability to streamline health services by taking advantage of new technology for medical record keeping," Nelson said. "We believe it has enormous potential for reducing medical errors and ensuring that patients receive efficient health services."
SB 40 tracks the recommendations of the Health Information Technology and Advisory Committee, which was established during the Legislature's 2005 session, according to Nelson's spokesman. The senator views SB 40 as a work in progress, her spokesman said, and will also consider the partnership's recommendations.
Nelson is interested in efficiency, her spokesman said, and as the bill travels through the legislative process, and public testimony is heard, the senator's office will have a better sense of what SB 40's final product will look like.
The need for the THCSIA is clear, Berthelsen said, as is the authority's potential importance to the practice of medicine in Texas, which is mired in paper-based, medical records systems -- though Texas is hardly alone.
"Medicine remains largely paper based," he said. "Whereas other major industries have converted to the digital age, we have so much information that is still paper based, and therefore only accessible in physical form, one at a time. There's no particular reason why this information cannot be computerized so that it's available in multiple locations whenever it's needed, but interoperability standards and cost issues stand in the way."
The partnership released its final recommendations to Perry on March 1, 2007, and though the report explored potential solutions to many of the challenges facing EMRs, many questions remain unanswered.
The partnership recommended the creation of a public-private venture, suggesting a state-chartered public corporation to promote the exchange of clinical data by providers and facilities.
However, the partnership acknowledged that questions linger as to whether such an entity could be financially self-sustaining. If Texas did create a state-chartered public corporation, the partnership advised, its purpose should be to develop and operate a portal for health information exchange (HIE), and to provide technical support to promote the establishment and operations of regional HIE initiatives throughout the state.
Charting the Future?
In many states, grass-roots health IT projects sprouted without any overt effort from state government to nurture their growth.
These projects typically take the form of regional health information organizations (RHIOs), which assist hospital systems, hospitals, clinics and physicians' private practices in making the transition from paper-based health records to EMRs. Several
RHIOs already flourish in Texas -- including the North Texas RHIO and the East Texas RHIO.
Despite the important role the THCSIA could play in shaping health care in Texas, it's unclear how the authority would work with existing RHIOs, which play a key role in the federal government's vision of the future of medicine.
RHIOs form the building blocks of the proposed National Health Information Network, an initiative directed by the Office of the National Coordinator for Health Information Technology, created by President Bush in April 2004.
At the national level, the Healthcare Information and Management Systems Society (HIMSS) is actively working in more than 30 states to stimulate the creation of RHIOs. The HIMSS consists of members from the health-care industry, and focuses on promoting the use of health IT in the world of medicine.
Three HIMSS chapters exist in Texas, and each of these chapters created its own Chapter RHIO Liaison Roundtable to support RHIOs in the chapter's respective geographic area and to collaborate in local, state and national health IT efforts.
Because the federal government is making a concerted push to drive health-IT adoption at the national level, Perry's executive order outlines a strategy for the proposed THCSIA to drive health-IT adoption in Texas to complement federal health-IT initiatives.
In its report, the partnership advised that the proposed state-chartered public corporation could play an important role in aligning the governor's goals with already-existing grass-roots efforts to build RHIOs.
The report also recommended that the Texas Legislature consider providing initial financing of at least $1 million for the 2008-2009 biennium to support the proposed authority's initial operations. Ongoing financing may be possible through transaction or subscription fees associated with the delivery of electronic medication-history information to hospitals, the report suggested.
The private sector, too, is attempting to solve the problem of health IT adoption, Berthelsen said, though acknowledging that these efforts sometimes stall because of an inability to create consensus.
It's at this point, he said, that a state government can help jump-start stalled health IT efforts. One valuable aspect of the THCSIA is that it could serve as a central repository of information related to all ongoing health IT projects in Texas, Berthelsen said, which would allow the THCSIA to convene a state-sponsored gathering of best practices and ideas to spark solutions to faltering projects.
"State government should be a facilitator and recognize that there are many ongoing efforts with regard to quality reporting of medical care and to promote health IT," Berthelsen said. "And rather than displace those efforts, the state should seek to do whatever is necessary to promote those efforts. The state can be helpful if there's a need to convene a body to set standards, for instance, if that doesn't happen in the private sector."