In July 2004, the U.S. Department of Health and Human Services (HHS) announced a landmark, 10-year plan to build a Nationwide Health Information Network (NHIN) to link health records nationwide. The plan's success, however, depends on eliminating paper medical files and creating an electronic health record (EHR) for every American.
Developing EHRs -- which, like traditional patient files, would contain detailed information about an individual's medical care and health history -- is a high-visibility issue for the HHS because of skyrocketing health-care costs and the dramatic impact they have on public-sector budgets.
Studies over the past several years point to health IT as a tool for improving quality of care, reducing errors and delivering significant cost savings, according to the HHS, and the potential value of the interoperable exchange of health information among disparate entities is substantial.
National implementation of fully standardized interoperability of health information between providers and other health-care organizations could save $77.8 billion annually -- approximately 5 percent of the projected $1.7 trillion spent on health care in the United States in 2003 -- according to the HHS Office of the National Coordinator for Health Information Technology (ONCHIT).
Other studies estimate that 20 percent to 30 percent of healthcare spending in the United States -- up to $300 billion each year -- goes to treatments that don't improve health status, are redundant, or are not appropriate for the patient's condition, said ONCHIT.
It's clear that EHRs and a national health IT strategy can play a huge role in streamlining the delivery of health care to patients across the country.
Roughly two years later, however, widespread adoption of EHRs is far from smooth. Making the transition is clearly a difficult process, but regional efforts within states appear to be accomplishing the most.
Texas and Massachusetts are strong advocates for EHRs, and have begun implementation in various health care facilities. The role of state government in this transition, however, remains unclear.
Though the push toward a NHIN is decidedly top down, prodding physicians, hospitals and health systems to adopt EHRs is necessarily grass-roots.
The best person to persuade a roomful of skeptical doctors of EHRs' efficiency gains and enhanced access to health information is another physician. It's similar to the spread of e-government: State and local governments look to see the root of a particular trend, then talk to the officials from that jurisdiction to pick their brains.
"I think this is probably what President Eisenhower faced when trying to grow an interstate highway system that all of us can use and travel on," said Pat Wise, vice president for Healthcare Information Systems at the Healthcare Information and Management Systems Society (HIMSS).
Designing a highway system capable of carrying all sorts of traffic -- local, regional and national -- requires significant advance planning, Wise said, and EHR adoption is no different.
"You have to map out, in some fashion, how these documents should travel," she said. "And clearly, not only do some people want to travel from the East side of the nation to the West and from the North to the South, but the larger number of people just want to travel in and around the city themselves. They don't even want to go to another state."
This is because most health-care referral patterns are local, Wise explained, and physicians, hospitals and health systems in cities have begun building health information exchanges (HIEs), often funded by federal grant money. According to the HIMSS's latest data, approximately 137 HIEs dot the country, and more crop up every month.
The push behind the HIEs' creation is to improve and simplify health care. HIEs serve as the mechanism for physicians, hospitals and health systems to exchange patient information electronically -- information that, so far, hasn't been readily shared by health-care providers.
"There are very few locales that can do it effectively yet, but they're all kind of at the starting line," she said. "They don't know what their strategies are. This is too new. There are not a lot of success stories out there. There's not a lot of, 'Do step one, then step two, then step three and then step four,' for locales to follow. They're all kind of feeling their way."
The Massachusetts e-Health Collaborative (MAEHC) kicked off its pilot with a conference called "EHR in Your Office -- Let's Get Started!" to introduce physicians to EHRs. The conference focused on the fundamentals of implementation, the daily effect they make in the lives of clinicians and staff, and factors involved in making the transition. The pilot is made possible by a $50 million fund from Blue Cross Blue Shield Massachusetts, said Micky Tripathi, president and CEO of the MAEHC.
Hospital systems serving three regions in the state were selected to participate in the pilot. Physicians, health-care providers, administrators and selected staff from Brockton Hospital, the Good Samaritan Medical Center, Anna Jacques Hospital and North Adams Regional Hospital attended the October training conference.
Over the long term, the pilot will equip the practices of more than 600 physicians with EHR software, support tools and data-exchange capabilities to support patient care, Tripathi said.
In 2004, the Massachusetts physician community formed the MAEHC -- composed of 33 organizations -- to bring together the state's major health-care stakeholders and begin establishing an EHR system. The sole government entity is the Massachusetts Executive Office of Health and Human Services (EOHHS), which is on the board of directors and has representation in the MAEHC's executive committee.
"It's incredibly valuable to have the Executive Office of Health and Human Services at the table," Tripathi said. "So much of what we're doing is what I would call a public good issue. There are certain things that are good for society to get done, and if you depend on the individual actors to do those things, it's not in any actor's individual interest to do it. I would put EHRs in that category for physicians -- particularly in small offices."
Because state government was created to consider societal benefits and the public good, the MAEHC needs that perspective as it starts making EHRs a reality in Massachusetts. In addition, the EOHHS is part of the MAEHC for a much more practical reason.
Because of the amount of money the state spends under its Medicaid program -- MassHealth -- it is an important individual stakeholder, Tripathi said, and stands to benefit as much as any commercial health plan.
"To the extent that any payer has issues with this and is also going to be a beneficiary of this, MassHealth is one of those payers," he said, adding that in a way, by sitting at the table almost as the CEO of a health plan, the EOHHS has a direct interest in this. "Similarly public health is another important angle in all this. There's no other organization that would speak for those issues, except for state and local public health organizations."
The infrastructure that's ultimately created to support statewide EHRs will also play a huge role in how public health agencies obtain and share information in times of emergency, and the EOHHS can give the MAEHC an important perspective on shaping that infrastructure.
East Texas EHRs
In Tyler, Texas, a Regional Health Information Organization (RHIO) called Access Medica is orchestrating the rollout of EHR software to 29 physicians in six independent clinics during the first phase of a regional deployment. The second stage will see 50 to 60 more physicians get the software by mid-2006.
Access Medica was founded in 2005 to provide health-care IT services to physicians, hospitals and patients of east Texas. The nonprofit RHIO includes members of the Physicians Contracting Organization of Texas and other independent practices.
The RHIO's infrastructure is being designed with the ultimate goal of connecting more than 600 regional physicians across 10 counties, said Dr. Kenneth Haygood, CEO of Access Medica. When complete, he said, it will be the first operational RHIO model in Texas.
Though the need to push for these sorts of IT changes in health care is widely accepted by the federal government, and increasingly by state governments, Haygood said, the actual movement in the EHR arena is much closer to the ground.
"If you look at places around the country where these efforts are taking hold and happening, it's really from physicians groups and medical practice associations -- cooperating sometimes with their local hospitals -- really coming together to make the investments in putting together these health information networks, or RHIOs," Haygood explained.
A RHIO can act as a neutral, central collaborator for all the diverse parties across the health-care community, whether that's physicians, medical clinics, hospitals, labs, governments and other entities with an interest in EHRs. One thing Access Medica could use is more funding, Haygood said, which isn't necessarily coming from government sources.
"We're really in a fortunate position because we have a lot of physicians here who realize the importance of making these changes," he continued. "They know that, one way or the other, they've got to make these changes for the benefit of their patients, for the benefit of their practices and to take the health care they provide to a higher level."
As a result, Haygood said, doctors have personally invested in moving toward EHRs. Access Medica has applied for several grants at the state and federal levels, and is waiting for approval.
"We're hoping for funding from places like that because the rate at which we could make progress is very dependent on our level of funding," he said. "As it is right now, we're just
able to keep moving forward with our initial group of doctors."
In Michigan, doctors can turn to the Virtual Community Health Center, owned and operated by the nonprofit Michigan Primary Care Association (MPCA), for help with making the transition to EHRs.
The VirtualCHC is a hosted service that offers a range of medical applications -- practice management, electronic claims interface, general ledger and EHRs -- on a subscription basis to physicians belonging to the MPCA, said Bruce Wiegand, the MPCA's IT director.
Five years ago, the MPCA tapped a federal grant to design and develop an infrastructure that used the Internet as the backbone for providing a centralized medical billing system for the state, Weigand said, and that infrastructure evolved into the VirtualCHC.
It's a way for physicians to get the benefits of modern medical software without having to buy it themselves.
"Seventy percent of EHR implementations to date have failed on two different fronts," he said. "On the IT side, you need a lot more IT than you could ever imagine to maintain EHRs. A lot of doctors went into EHRs thinking it was just paperless. What they ended up doing was putting paper under glass."
The problem is that making the move to EHRs necessitates a radical overhaul of the way physicians run their medical practices -- including electronic interfaces between a doctor's office, pharmacies, labs and clinics; patient management software; and billing systems.
"We're trying to corral all these disparate systems into a single data center, which makes it easier to secure, provides better IT oversight, and we can better manage these interfaces between systems," Weigand said. "We're trying to suck the cost of IT out of health care."
A high-speed Internet connection is all that's needed, he said, and a primary care doctor can tap into the VirtualCHC for all his or her medical software applications needs. In part, the evolution to EHRs is hampered by the stand-alone medical software systems that physicians use.
"You have all these islands of needs," Weigand said. "Most EHRs don't do billing. Most billing systems don't do clinical. So you have to interface the two, and typically you're dealing with two different vendors with two different types of databases."
Need Is There
The medical community and its stakeholders, including the public sector, see the need to move to EHRs. But, as with any technological evolution, not everybody's on board.
Weigand said some older doctors, perhaps a year or two away from retiring, aren't rushing to modernize their practices. On the other hand, he said, younger doctors can't imagine a medical practice without EHRs and related technology.
"It's a tough nut to crack because there are so many variables," he said. "But now you have the feds pushing it. The states are pushing it. Pay for performance is coming down the pike. The reality is that the doctors moving to EHRs quicker are the ones that are going to survive and prosper."
Pay for performance is a new approach to the way the federal government pays for health care under Medicare.
The idea is to use Medicare reimbursements to reward innovative approaches to health care to get better patient outcomes at lower costs, according to the Centers for Medicare and Medicaid Services (CMS). To test pay for performance, the CMS announced in January 2005 that 10 large physician groups across the United States agreed to participate in the first pay-for-performance initiative for physicians under the Medicare program.
The problem is that Medicare's physician payment rates for a service are the same regardless of its quality, its impact on improving patient's health or its efficiency, said Herb Kuhn, director of the Center for Medicare Management, in testimony at a hearing before the Senate Committee on Finance in July 2005.
Kuhn said ample evidence shows that by anticipating patient needs -- especially for patients with chronic diseases -- health-care teams that work more closely with patients can intervene before expensive procedures and hospitalizations are required.
Kuhn told the committee that, as a result of Medicare's payment practices, patients often end up seeing more physicians and using more medical services -- but without obtaining positive results. This, of course, means the CMS spends more on medical care for Medicare members.
"Providers who want to improve quality of care find that Medicare's payment systems may not provide the flexibility to undertake activities that, if properly implemented, have the potential to improve quality and avoid unnecessary medical costs," Kuhn told the committee. "Linking a portion of Medicare payments to valid measures of quality and effective use of resources would give providers more direct incentives to implement the innovative ideas and approaches that actually result in improvements in the value of care that people with Medicare receive."
Private insurers also back pay for performance, and the trend toward this way of practicing medicine will drive physicians and hospitals to improve their electronic records and reporting capabilities to demonstrate positive outcomes in treating patients.
Physicians that lag behind, that can't show positive outcomes -- that they're tackling diabetes, that they're tackling asthma, and that they're managing their patients -- risk losing substantial payments from private insurers and the federal government, Weigand continued.
"There's no other way to do it than to have this stuff electronic -- not in a Word document. You can't pull data out of a progress note, but you can out of an EHR," said Weigand. States have more vested interest today than just six months ago, he added, but the push to EHRs is still so new that the public sector is unsure of the outcome. One thing that is -- patient information must be available to who needs it, in real time. States have begun exploring ways to map information sharing across geographical and political boundaries, but it's not an easy task.
"Another barrier to this has been how incredibly decentralized health care is, as opposed to almost every other industry you look at in the country," said the MAEHC's Tripathi. "The individual entities at the end are these one- and two-physician practices way out there who, up until now, have had absolutely nothing compelling them to be electronically connected with anything else."