July 12, 2009 By David Raths
That's what Dr. Mark Leavitt says about the American Reinvestment and Recovery Act (ARRA) of 2009, which promises to spend nearly $20 billion on technology use in health care.
Leavitt, chairman of the Certification Commission for Healthcare Information Technology, which certifies electronic health records (EHRs), recently compared the challenge of creating a nationwide network of interoperable EHRs by 2014 to NASA's manned spaceflight mission to the moon in the 1960s.
The federal government plans to kick its purchasing power into high gear by offering Medicare and Medicaid bonuses to physicians and hospitals that demonstrate "meaningful use" of interoperable, certified EHRs starting in 2011. The stimulus package also provides billions of grant dollars to federal and state organizations for research and the promotion of health-IT adoption.
One ramification is that state CIOs will begin paying much more attention to health projects, predicts Erica Drazen, managing partner of emerging practices at research firm CSC Global Healthcare Sector. The states pay for a lot of care, she noted, and if there continue to be islands of automation that can't share data, states won't see the quality or cost improvements they hope to achieve. "For states that have made progress on health-information exchange, this is their time in the limelight," she said. "For ones that haven't made much progress, it is time to step up."
The sudden flurry of activity has put a spotlight on public-sector CIOs who have been working in the field for years. The following are profiles of five federal, state and municipal IT leaders; their ongoing efforts to make use of health IT; and their thoughts on the stimulus act's impact on their work.
Dr. Theresa Cullen remembers a day more than 20 years ago when she saw 80 patients in her primary-care practice on the Tohono O'odham Nation reservation in Arizona.
That day she decided technology had to play a larger role in her practice. "I realized we were pedaling as fast as we could," said Cullen, now CIO of the federal Indian Health Service (IHS). "We had to take better advantage of any resources available to us."
Dr. Theresa Cullen, CIO, federal Indian Health Service/Photo by Cade Martin
The IHS faces daunting challenges: It does cradle-to-grave care for 3.3 million American Indians and Alaska natives in the most remote areas of the country. Its population has the highest disease burden and the lowest life expectancy of any U.S. group, according to Cullen. Although the IHS operates 518 hospitals, clinics and other facilities, about 70 percent of its work is primary care. "We face fiscal and human-resource constraints that forced a recognition that we need to leverage IT," Cullen said.
During the late 1980s and early 1990s, Cullen was involved in piloting the IHS clinical information system called Resource and Patient Management System (RPMS), an open source system that uses the same kernel as the Veterans Health Administration's VistA EHR. As CIO since 2006, Cullen has overseen the continued growth of RPMS, including the 2007 rollout of a clinical decision support aid called iCare.
The tool employs a graphical user interface and easy-to-build templates to help doctors and case managers identify patients who need special attention, and compares their charts to clinical quality measures. The main targets are chronic illnesses like diabetes, obesity and heart disease.
"Let's say I am going to see 20 patients today," Cullen explained. "I can run their records beforehand against 24 agency-defined clinical quality measures, and perhaps another 10 that the community has defined as important."
The tool also sorts through patients' records and looks for indications of diseases by predefinitions. "When you log on in the morning, it tells you that three people you saw yesterday meet the criteria for a certain condition," she said. "The providers are not forgetful. They are just overwhelmed. This generates reminders for them."
ARRA provided $85 million for the IHS to use on health IT. Cullen's goals include upgrading the agency's wide-area network to enable more telemedicine and teleradiology work.
"It is a very exciting time, but also a burden because we want to leverage these funds in a way that provides good value and helps the Indian people," Cullen said. "But we also have to be good stewards of the taxpayers' money in terms of application planning."
That's why she likes that RPMS is an open source system that's starting to be reused elsewhere. "We have partnerships with community health centers in West Virginia and Hawaii that are starting to use the software, and we get good input from them that helps us guide development," she said.
Cullen believes that in some ways the IHS has had to play the unfortunate role of test case for the rest of the country. "We have had to deal with childhood obesity and a diabetes epidemic before the rest of the population," she said. "We have been using IT tools and have been aggregating data to help with our response, and the lessons we've learned could extend out."
Photo copyright by iStockphoto
CIOs often note that making EHRs ubiquitous is really just the first step; EHRs by themselves won't automatically transform health care or lower costs. What could achieve those goals is a focus on quality initiatives to deal with issues like chronic disease and resource utilization.
Those types of quality initiatives are already under way at New York City Health and Hospitals Corp. (HHC) under the direction of Dr. Louis Capponi, the system's chief medical informatics officer.
The largest municipal hospital and health-care system in the country, the HHC has a $5.4 billion budget and serves 1.3 million New Yorkers and nearly 400,000 who are uninsured.
Working with the HHC's CIO, Frances Pandolfi, Capponi has overseen a gradual improvement and customization of the EHR system that was initiated in 1991 and is now used at all 11 HHC hospitals and community clinics. "Some health systems may find themselves begging clinicians to use their system, but we have an enthusiastic user community," Capponi said. "These early adopters are sophisticated, and things have been implemented in a highly customized way." Among other undertakings, he led a two-year effort to train more than 3,000 nurses to use the HHC's electronic medication administration record.
Dr. Louis Capponi, chief medical informatics officer, New York City Health and Hospitals Corp. Photo courtesy of Dr. Louis Capponi
Several years ago, Capponi and HHC colleagues began working on an electronic patient registry to improve health outcomes for approximately 50,000 diabetic patients in the system. Patient information is mined from the EHR and sent into a clinical data warehouse. Then a Web-based application allows care coordinators, nurses and physicians to study outcome data concerning the population of diabetics. "They are used to seeing one patient at a time," Capponi explained. "This gives them a bigger view."
The registry helps clinics measure their performance at helping patients control blood pressure, blood sugar and cholesterol levels. They can see whether patients are getting essential eye and foot exams. Decision-support tools are available to help doctors follow best clinical practices. The Web application has been live since 2006, Capponi said. "And we are already seeing improvements in some of these indicators."
Although the HHC may be a pioneer in some uses of health IT, Capponi hopes the system can benefit from ARRA. "We want to take advantage of a service-oriented architecture to add more decision-support tools and integrated workflow engines," he said. "Health IT is still in its infancy. The goal is to make health care more efficient. We need the tools to enable us to gain the efficiencies that you have when you buy a book on Amazon or book your own travel online. Those technologies are not being widely used in health care as they are in other industries. That's why the stimulus is so important."
The HHC also is committed to data interoperability and is involved in the design of three regional health-information exchanges. "As a safety-net hospital group, we see a lot of the same patients as the city's academic and nonprofit hospitals," Capponi explained. "We want to make the sharing of patient data as seamless as possible." But for that interoperability to happen, he said, there must be standards to facilitate the communication, just as in the 19th century when the growth of the railroads required all tracks be the same width.
For health IT leaders in the U.S. military, a longstanding goal -- not to mention a huge task -- has been to improve the electronic health-information sharing between the Military Health System (MHS) and the Veterans Health Administration.
Facing a congressional mandate that the U.S. Department of Veterans Affairs and Department of Defense systems be made fully interoperable by Sept. 30, 2009, the departments say they are seeing considerable progress.
Making those systems work together is a top priority for Chuck Campbell, who has been CIO of the MHS since September 2007. "We are already sharing a lot of data, and the secretaries of the two departments are working on how we can share even more seamlessly," he said.
While applauding the progress, a March 2009 U.S. Government Accountability Office report criticized the joint-agency effort for not identifying results-oriented performance goals and not completing all necessary activities to set up an interagency program office that would be accountable for fulfilling the departments' interoperability plans.
Chuck Campbell, CIO, Military Health System. Photo courtesy of Chuck Campbell
Campbell, who previously served as deputy CIO of the Veterans Health Administration, claims that the involved agencies will meet the provisions of the September mandate in terms of sharing clinical data and will continue to streamline data transfer between MHS's Armed Forces Health Longitudinal Technology Application and the VA's VistA.
Work on interoperability began in 2002, with the creation of the Federal Health-Information Exchange, which sent data on separated or retired military personnel to the VA, Campbell explained. Next, a bidirectional health-information exchange was tackled because 3.2 million people are eligible to be seen in both systems. A more recent development is a clinical data repository connecting the two clinical systems in a "computable" way. For instance, if a patient goes to a VA facility to fill one prescription and goes to the MHS for another, the system automatically searches both databases to ensure there's no negative drug interaction, he said.
A new goal for the MHS and VA is to build enterprise services that can be used by both. It should save time and resources, Campbell said. Another objective is to work with the U.S. Department of Health and Human Services on the development of a national health-information network. "We want to provide access to our data for those who need it," he said. "When you combine the VA, MHS and Indian Health Service, we represent a lot of beneficiaries. We can play a major positive role."
In March, the departments of Defense and Veterans Affairs announced the formation of a working group to pursue a joint lifetime EHR for service members, veterans and their families. The goal is not to replace any of the existing systems, but to create a virtual record that pulls data from both the VA and DoD systems in a Web services approach using service-oriented architecture.
Kathy Frye has learned that some health-IT projects involve breaking down barriers between government agencies and health providers. As the CIO of the Kentucky Cabinet for Health and Family Services, Frye said those projects may sometimes involve redesigning business processes, but the results are often worth the effort.
Five years ago, she was deeply involved when the Cabinet's Office of Information Technology sought to improve collaboration by modernizing and integrating siloed legacy systems in the health and human services arena. For several years she had served as the division director of systems development for the Cabinet, then as deputy CIO from 2006 to 2008, before being named CIO in November 2008.
Kathy Frye, CIO, Kentucky Cabinet for Health and Family Services. Photo courtesy of Kathy Frye
One project she's proud of is KY-CHILD (Kentucky Certificate of Birth, Hearing, Immunization and Lab Data), a Web application launched in 2006 that integrates data from the Office of Vital Statistics, the Commission for Children with Special Health Care Needs, the Kentucky State Public Health Laboratory and the Division for Adult and Child Health.
KY-CHILD allows electronic collection and submission of data related to birth certificates, and newborn metabolic and hearing screenings. The centralized database has eliminated some redundant data-collection systems and manual data entry.
"Now if a child is born in one hospital, but then is transferred for care, the second hospital can look up those records in a Web-based system," Frye explained. "Each child has a unique identifier, and all information about [him or her] is available through a single, integrated Web application."
The project, which won an American Council for Technology interagency solution award in 2007, required working closely with external and internal business partners, including birthing facilities in large and small hospitals statewide. "We had to take the time to listen to their concerns in designing the system," Frye said, because sometimes it meant the hospitals had to change their business practices.
The data gathered in KY-CHILD may become part of a larger effort. Kentucky is planning to use a Medicaid transformation grant to help pay for building a statewide health-information exchange, with the goal of gaining efficiencies and driving down costs. Funding from the stimulus package also may help. "Because some of the stimulus funding is time-limited, there's a sense that we have to work quickly," Frye said. "But we are very excited about it."
State government Medicaid systems are a crucial player in health-data sharing because they insure so many people. One state that has taken the lead in offering physicians access to electronic claims information is Tennessee. Its managed-care Medicaid system, TennCare, is one of the largest players in Shared Health, a public-private health-information exchange.
"We have our entire managed care population of 1.1 million on it and 3,000 registered providers," said Brent Antony, CIO of the Bureau of TennCare.
The Shared Health project was launched in 2005 as a Web-based tool to let providers view claims-based data about their patients, including prescription information.
"We thought this would prompt more questions for providers," Antony said, "because it would offer them details that they may not be aware of."
Brent Antony, CIO, Bureau of TennCare. Photo courtesy of Brent Antony
The claims-based EHR contains diagnoses, procedure or visit information, and prescription histories. It also offers some nonclaim information, such as lab results and immunization records provided by the state public health department. Shared Health published results of a 2006 study that it claims demonstrates a 17 percent efficiency gain among practices using its clinical health record.
The software is a conglomeration of several off-the-shelf products built on top of an Oracle data warehouse.
Some aspects of the system have been popular with clinicians from day one, Antony said. They find it valuable and relatively easy to look at pharmacy claims data, which helps them avoid drug-interaction problems. Other aspects needed to be refined. "Doctors were not thrilled about looking through 48 months of claims data on a screen," he said, "so we added clinical decision-support tools to help them drill down through all that data."
Antony, who previously held IT leadership positions with Boston Children's Hospital and the Beth Israel Deaconess Medical Center, talks weekly with Shared Health's CIO about future plans and new functionality, and gets regular reports on usage statistics.
Antony also works closely with state CIO Mark Bengel on statewide e-health initiatives. "This can't be done solely from the Medicaid office," he said. "We have a very health-savvy governor in Phil Bredesen, and this has been one of his focus areas." He said both Bredesen and Bengel realize that a large portion of state dollars is going to health care and that by improving health-care delivery, there's potential for great cost savings.
The Tennessee Office of e-Health Initiatives has a grant program to encourage EHR adoption in the state, and Antony expects the stimulus funding to enhance those efforts.
So far, TennCare has a head start on most states' health IT efforts in their Medicaid organizations, Antony said, not so much in terms of functionality, but in how broadly deployed it is. "We have an electronic health record for a sizable chunk of the state's population," he said. "We had to build that critical mass to make it work into clinicians' workflow."
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