Today we live in a full-blown Information Age, a revolutionary time in which the digitization of information has transformed (and continues to transform) our lives. Amazon announced yesterday that in the last three quarters of last year, it sold more e-books for the Kindle than it did paperback books. I'm thinking of streaming a movie from Netflix later. And what drastic step did the Egyptian government take this weekend in an effort to hold onto political power? Attempting to disrupt the flow of information in and out by cutting off Internet access.
But, even as this technological revolution marches on, it's been decades since information technology forever altered the way organizations process information and companies do business, hasn't it? Surprisingly, perhaps, there's at least one major industry that has largely resisted entering the Information Age and taking advantage of all that the information revolution can offer it. I'm speaking here of the medical field.
Of course medicine does use an impressive array of cutting edge technology; as I'm sure Jim can discuss much more knowledgeably than I can, new equipment and techniques are incorporated into modern medicine all the time. But in one particular area--the use of health information--the potential of the Information Age seemed, until very recently, to have passed medicine by. In particular, I'm referring to electronic health records. Now, you might say, don't most doctors use electronic health records? Paper went out of style a while back, didn't it? Actually, no.
A study published in the New England Journal of Medicine in 2008 found that:
Four percent of physicians reported having an extensive, fully functional electronic-records system, and 13% reported having a basic system.
A similar study of hospitals published in NEJM in 2009 found:
... only 1.5% of U.S. hospitals have a comprehensive electronic-records system (i.e., present in all clinical units), and an additional 7.6% have a basic system (i.e., present in at least one clinical unit).
The surprisingly low prevalence of electronic health records in our health system is one of the reasons George W. Bush created, via executive order, a new office in the Department of Health and Human Services back in 2004 with the mission of fostering the adoption of electronic health records: the Office of the National Coordinator for Health Information Technology (ONC).
But it wasn't until 2009 that the opportunity arose for the government to really give the nation's fledging health information technology (HIT) efforts a big shot in the arm. I'm speaking here of the stimulus package, a law whose very name--the American Recovery and Reinvestment Act of 2009--underscored its goal of investing in the nation's infrastructure. Two distinct pieces of that law (for legislation nerds: Title XIII of Division A and Title IV of Division B) are together known as the HITECH Act. And as Joe Biden might say, the HITECH Act is a BFD.
Why is it a big deal? What's the real difference between recording patient records electronically instead of on paper? Well, first there's the issue of health information exchange (HIE), getting health information from point A to point B. If your records are locked in a filing cabinet in a singe physician's office, what happens when you go to a different facility or even an emergency department? A pain in the ass, that's what. Having your information in hand makes it much more likely a doctor will make better decisions regarding your care. That may mean fewer medical mistakes and fewer redundant or otherwise unnecessary procedures.
But HIE is about more than just ensuring your records quickly get to where they're needed when they're needed. It also opens the doors to reporting for quality improvement and public health purposes. There's a tremendous amount of data locked up in the aggregate of everyone's health records. Suppose in the future we want a much greater shift toward paying doctors for performance. In order to make that work, you'll need some way to quickly and accurately assess that performance. Being able to extract and exchange information right out of health records makes it much more plausible that ideas like paying for performance can work. Improving health care quality means being able to adequately measure that quality and then hone in on areas where improvement is needed. That's significantly easier with electronic health records than with paper records. So if we want to encourage data-driven improvement in the health system (and we do), HIE and the use of electronic health records have a significant role to play.
And beyond the actual exchange of health information (which by itself is potentially huge), there is the added functionality of electronic health records.
A paper health record can't prompt a doctor to adhere to evidence-based protocols, which seem to be effective at preventing errors:
In recent years, the growing use of a “checklist’’ in hospital facilities, modeled after those routinely used by airline pilots before takeoff, has resulted in a significant reduction in patient harm. The British Medical Journal, for example, recently reported that patient deaths in three London hospitals dropped by 15 percent after introducing the practice.
A paper record won't provide automatic reminders about recommended screenings or other preventive procedures.
Paper records can't provide clinical decision tools to help doctors make the right call in choosing tests or even diagnoses, like this pilot program in Minnesota:
Instead of waiting hours or longer for approval by phone, the doctors get an answer instantly. A popup screen invites them to fill in patient symptoms and other information, and the program rates the usefulness of the proposed test, based on guidelines from the American College of Radiology and other medical specialty groups. If another test is an option, that will pop up, too.
Not long after the pilot project started, Bershow said, one colleague came up to him with a surprise admission. "I've been ordering the wrong test," the doctor told him, but didn't realize it until he started using the program.
That's not surprising, Bershow said, given the information overload in medicine.
Paper records won't pop up a warning if a doctor prescribes a medication that's likely to negatively interact with something else a patient is on.
Electronic health records, on the other hand, can do all of these things and more.
So what is the HITECH Act? It's the policy intended to propel us into a future where EHRs are commonplace. And, reflecting its legislative structure, it's got two major parts; it's helpful to think of them as 1) building the roads and 2) buying the cars.
Building the Roads
The first order of business in the HITECH Act was establishing George Bush's Office of the National Coordinator for HIT as a matter of statute and not executive whim. And ONC was given $2 billion and a directive as simple as it was monumental: build us the roads. Well, okay, it was a little more complex than that but that's the gist of it.
By "building the roads" I mean building the infrastructure to really make HIE work: ONC is funding and working with every state to build the infrastructure they need to make HIE work in their state. The "infrastructure" I mean here includes: governance structures so that someone has the responsibility for building consensus and the authority for making state-level policy around HIE; financial strategies to ensure that HIE is sustainable; technical standards and structures to make sure records can get from Doctor's Office A to Doctor's Office B; and updates to state-level policies or laws on health information that reflect the differing natures of electronic and paper records.
Beyond that foundational work, ONC is also funding entities known as Regional Extension Centers, whose purpose is to provide the technical assistance and training that doctors need to use electronic health records effectively. They're essentially a nationwide network of help desks for doctors who adopt EHRs. ONC is also funding new training programs at universities and community colleges to produce the HIT workforce that will be needed to make all of this work. University research departments are also being funded to produce "breakthrough advances" in unresolved issues in health information technology.
The point of all this activity is to ensure that, as a practical matter, when it comes time to exchange health information, the pathways and structures are in place to enable this.
Buying the Cars
Of course, having the highways along which health information will be exchanged doesn't amount to much if very few providers are actually using electronic health records (the "cars" in this analogy). Indeed, there are network effects here that make an active HIE more valuable as more providers take advantage of it. For example, my spiffy new iPhone 4 has FaceTime, meaning it can be used to chat with other similarly-enabled phones. But if no one in my phone book has a phone that can also do this, that feature is essentially worthless to me. It becomes more valuable as more people become able to use it. So the question here is how to encourage providers (e.g. doctors and hospitals) to start using electronic health records.
That's where the government's role as a payer (i.e. an insurer) come in. As the insurer cutting the checks to doctors who accept Medicare or Medicaid patients, the government has the power to pay them. In this case, through the HITECH Act, the government will be making bonus payments to Medicare or Medicaid providers who start using EHRs. The two aren't treated in quite the same way: Medicaid doctors are eligible for larger bonuses than Medicare doctors ($63,750 vs. $44,000) and, eventually, Medicare doctors who don't start using EHRs will be penalized. The penalty isn't all that big; in several years, Medicare doctors who still use paper records instead of EHRs will be paid 97% of what they would normally be paid by the government for Medicare patients.
Of course, there are standards. A doctor couldn't just buy some crappy system, not use it, and collect his free money. They have to buy certified technology and they have to "meaningfully use" their EHRs. The exact definition of what constitutes meaningful use is being developed by HHS in three stages through the administrative rulemaking process. If you want to know what Stage 1 of the definition looks like, it doesn't get clearer than this article (from the head of ONC himself). The definition for Stage 2 should be coming out sometime later this year.
What's Next
At present, we're about a year into the road-building process. The federal-state partnerships to put in place the necessary infrastructure for HIE is intended to last for four years. The car-buying incentive process is just taking off: the first incentive payments started going out this month. Providers, however, don't have to start meaningfully using EHRs right now (although for Medicare providers, the value of the incentive payment decreases with time). Medicare providers can start as late as 2014; the program wraps up in 2016. Medicaid providers can start as late as 2016; that program continues until 2021.
HITECH is of special interest to me but I haven't been able to bring myself to outline its contents and subject matter on here before. I think it's extraordinarily tough to offer a concise intro that doesn't contain too much detail or too little, and also doesn't happen to be mind-numbingly boring or dry (despite the fact that this is actually a very exciting area, I swear). I don't know how successful I've been here at avoiding that but I was motivated to finally lay out the background today after I noticed this headline:
GOP Bill Could Rescind Funding Under Meaningful Use Program
The Spending Reduction Act of 2011, sponsored by Rep. Jim Jordan (R-Ohio), seeks to cut federal spending by $2.5 trillion over the next 10 years.
Under Section 302 of the legislation, more than $27 billion authorized for meaningful use incentive payments likely could be repealed if the measure were enacted, according to Health Data Management.
Section 301 of the bill could affect other programs under the HITECH Act, which includes the authorization of:
* Expanding HIPAA transaction sets;
* Health IT programs at colleges and universities;
* Regional extension centers; and
* Strengthened privacy and security rules.
This section states that any unused funds from the act's $2 billion in discretionary spending allocated to the Office of the National Coordinator for Health IT would be rescinded if the funds are considered "un-obligated balances."
The bill also would prohibit appropriating funds to implement any programs under the federal health care reform law.
It's not going to pass (one hopes) but it's an important reminder of the political climate in which we find ourselves today.
