Health Information Technology

Health Information Technology “Moving Healthcare into the 21st Century – A President’s Goal” by Kelly Lavin, Regulatory Policy Analyst American Osteopathic Association

“By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.” --President George W. Bush, State of the Union Address, January 20, 2004

INTRODUCTION

Last year, President Bush pushed health information technology (HIT) to the frontline of the American agenda by addressing its importance in his State of the Union Address. Today’s healthcare sector is plagued with high costs, uncertain value, medical errors, variable quality, administrative inefficiencies, and poor coordination. Could this be connected to our failure to use health information technology as an integral part of medical care?

The innovation that has made our medical care the world’s best has not been applied to our health information systems. Other American industries have harnessed advanced information technologies, to the benefit of American consumers. Our air travel is safer than ever. Consumers now have ready, secure access to their financial information. Unlike other industries, medicine still operates primarily with paper-based records. Our doctors and nurses manage 21st century medical technology and complex medical information with 19th century tools. America’s medical professionals set the standard for the world. It is a testament to their skill that they are able to achieve high-quality care in this antiquated system.

The Institute of Medicine (IOM), the National Committee on Vital and Health Statistics (NCVHS), and other expert panels have identified health information technology (HIT) as one of the most powerful tools for reducing medical errors, lowering health costs, and improving the quality of care. They recommend that health care organizations adopt IT systems to support the electronic collection and exchange of patient information. The goal is for these systems to operate seamlessly as part of a national health information infrastructure (NHII), which would enable health care providers anywhere in the country to access patient information at the point of care. While supporting the delivery of high-quality patient care, experts emphasize that a NHII also must meet the nation’s needs for public health surveillance, biodefense, biomedical research, and protect the privacy of individuals.

The U.S. health care industry lags well behind other sectors of the economy in its investment in IT, despite growing evidence that electronic information systems can play a critical role in addressing the many challenges the industry faces. There are significant financial, legal, and technical obstacles to the adoption of HIT systems.

The AOA is committed to advancing the utilization of technology in the practice of medicine. We believe that HIT, if developed in conjunction with the physician community and other stakeholders, can contribute to the improvement in quality, safety, and efficiency of the healthcare delivery system.

The rapid development and implementation of medical informatics is changing the face of the healthcare delivery system. There are a number of private and public forces moving physicians toward the adoption of EHR technologies. The AOA commends the Department of Health and Human Services (HHS) for its efforts to receive input from the various stakeholders regarding the development of a National Health Information Network.

It is imperative that these technological advances occur through a deliberative process in which physicians and other interested parties are able to provide input and ultimately shape the end product. An HIT system that is rapidly arrived at with little input and recognition of operational realities is of little benefit to patient care and the quality and efficiency of the healthcare delivery system if it is not workable in practical settings.

COMMON HIT TERMINOLOGY

The world of HIT is complex, with the many acronyms and terms. The following are helpful definitions of frequently used terms.

Electronic Health Record (EHR) The EHR provides a clinician with real-time access to patient information, as well as a complete longitudinal record of care. A fully integrated EHR enables a physician to update clinical and other patient information on a continuous basis. Such an integrated system permits a physician to view the history of a patient’s medical condition and visits to health providers (with sub-menus for notes from those visits), images and reports of diagnostic procedures, current medications, functional status and social service eligibility, schedule of preventive services, allergies, and contact information for family caregivers.

Clinical Decision Support (CDS) Linking a patient’s EHR to a computerized CDS system provides physicians with real-time diagnostic and treatment recommendations. CDS systems, which include a range of technologies from simple clinical alerts and warnings of prescription drug interactions to detailed clinical protocols and procedures, facilitate the practice of evidence-based medicine by providing physicians with state-of-the-art medical knowledge at the point of care.

Computerized Physician Order Entry (CPOE) CPOE minimizes handwriting and other communication errors by having physicians and other providers enter orders into a computer system. Originally designed for ordering medications, more advanced CPOE systems include orders for x-rays and other diagnostic procedures,
referrals, discharges, and transfers. CPOE also may be linked to a patient’s EHR and various decision support functions.

Health Information Exchange The final and most important element of an NHII is electronic connectivity (via the Internet and other networks) enabling health care providers to exchange patient health information. Networks that permit electronic communication among providers must be secure in order to safeguard the information from unauthorized access, use, and disclosure. They also require the development of data and messaging standards to establish the critical goal of interoperability, that is, the ability of two or more IT systems (computers, networks, software, and other IT components) to communicate with one another and make sense of the data they exchange. A small but growing number of communities and health care systems around the country have developed EHRs and established secure platforms for the exchange of health data among providers, patients, and other authorized users (e.g., the Veterans Health Administration, the Indiana Network for Patient Care, the Santa Barbara County Care Data Exchange, and the New England Healthcare Electronic Data Interchange Network).

Personal Health Records (PHR) A Personal Health Record is a collection of important information about one’s health or the health of someone being cared for (such as a parent or child) that can be maintained and updated. The information comes from the healthcare provider, and from the patient. A PHR should include most of the following:

• Personal identification, including name, birth date, and social security number

• People to contact in case of emergency

• Names, addresses, and phone numbers of your physician, dentist, and other specialists

• Health insurance information

• Living wills and advance directives

• Organ donor authorization

• A list and dates of significant illnesses and surgeries

• Current medications and dosages

• Immunizations and their dates

• Allergies

• Important events, dates, and hereditary conditions in your family history

• A recent physical examination

• Opinions of specialists

• Important tests results

• Eye and dental records

• Correspondence between you and your provider(s)

• Permission forms for release of information, operations, and other medical procedures

• Any information you want to include about your health – such as your exercise regimen, any herbal medications you take and any counseling you may receive.

Continuity of Care Record (CCR) The CCR is a subset of a patient’s health information. Its purpose is to improve the continuity of patient care, reduce medical errors, and ensure a minimum set of data is available when patients are referred or transferred among care providers. Basic useful information identified for the continuity of patient care includes patient and provider information, insurance information, the patient’s health information, recent care provided, recommendations for future care, and the reason for transfer or referral.

Regional Health Information Organizations (RHIO) RHIOs are non-governmental state or local entities that will oversee and support local health information exchange initiatives. They would have multi-stakeholder governance, a public health and quality improvement role, and direct the business policies for data sharing in a particular region/market or state. They would also represent consumers’ interests with regard to access to health care information. RHIOs also would support physician office implementation of health information technology and the technical assessment and deployment of the National Health Information Network. The National Coordinator for Health Information Technology currently is working on a formal definition and a set of minimum guidelines for what would constitute a RHIO. The National Coordinator recommends that RHIOs be recognized by the Federal government through private accreditation of compliance with minimal guidelines.

ONCHIT On April 27, 2004, President Bush called for the widespread adoption of interoperable EHRs within 10 years and signed Executive Order 13335, which established the position of National Coordinator for Health Information Technology (ONCHIT) within HHS. Then, Secretary Tommy Thompson appointed David Brailer, MD, PhD, one of the country’s foremost health IT experts, to serve in the new position. The Executive Order directed the National Coordinator, within 90 days, to develop a strategic 10-year plan outlining steps to transform the delivery of health care by adopting EHRs and developing a NHII to link such records nationwide.

On July 21, 2004, Brailer and Thompson released a Framework for Strategic Action entitled, The Decade of Health Information Technology: Delivering Consumer-Centric and Information-Rich Health Care. Although the federal government has taken the lead in setting the health IT agenda, the framework sets out a bottom-up approach in which the role of HHS is to promote and encourage the private sector to build community-level networks. Adopting interoperability standards will, over time, permit these local networks to connect with one another to form an NHII.

The framework identified four major goals, with strategic action areas for each:

1. Inform clinical practice. This goal focuses on bringing EHRs into clinical practice by providing incentives for EHR adoption, reducing the risk of EHR investment, and promoting EHR diffusion in rural and medically underserved areas.

2. Interconnect physicians. This goal centers on building an interoperable health information infrastructure so that EHRs follow the patient, and clinicians have access to critical health information when treatment decisions are being made. The strategies for realizing this goal involve fostering community-based health information exchange projects, developing a national health information network, and coordinating federal health information systems.

3. Personalize health care. This goal involves using health IT to help individuals manage their own wellness and become more involved in personal health decisions.

4. Improve population health. The final goal requires the timely collection, analysis, and dissemination of clinical information to improve the evaluation of health care delivery, public health monitoring, and biosurveillance. It also helps accelerate research and the translation of research findings into clinical products and practice.

The framework identifies several potential policy options for providing incentives for EHR adoption. They include:

• Regional grants and contracts to stimulate EHRs and community information exchange systems;

• Improving the availability of low-rate loans for EHR adoption;

• Updating federal rules on physician self-referral that may unintentionally restrict the development of health information networks;

• Using Medicare reimbursements to reward the use of EHRs; and

• Funding Medicare pay-for-performance demonstration programs.

RESEARCH FOR HIT ADVANCEMENT

The IOM’s March 2001 report on health care quality, Crossing the Quality Chasm: A New Health Care System for the 21st Century, emphasized the need for improvement in six key areas: safety, effectiveness, responsiveness to patients, timeliness, efficiency, and equity. A growing number of published studies suggest that IT can play a key role in improving the quality of care in each of these areas. In the area of safety, CPOE systems with decision support functions can reduce errors in drug prescribing and dosing. Clinical decision support systems have been shown to improve efficiency, for example, by reducing redundant lab tests. They can also improve the effectiveness of care by promoting compliance with clinical practice guidelines.

Health IT may be especially beneficial for inner city and rural populations and other medically underserved areas. Real-time access to specialty information, including consultations between rural physicians and leading specialists at academic medical centers, helps promote an equitable health care system by reducing the geographic variability in access to the best quality care. The secure transmission of patient information among physicians will improve significantly the coordination of care for the 60 million Americans with multiple chronic conditions. Studies have shown that poor coordination of care among Medicare beneficiaries with multiple chronic conditions leads to unnecessary hospitalization, duplicate tests, conflicting clinical advice, and adverse drug reactions as a result of over-medication.

An HIT infrastructure has great potential to contribute to achieving other important national objectives, such as homeland security and improved public health services. Linked health information networks are key to reducing the time it takes to detect and respond to disease outbreaks, whether they occur naturally or are the result of a bioterrorist attack. They are also an important tool for helping organize and execute large-scale vaccination campaigns and for monitoring the health of the population. Finally, health IT is becoming increasingly important for various forms of biomedical and health services research, and for translating research findings into clinical practice more quickly. By some estimates, it may take as long as 17 years for new research findings to be fully integrated into general medical practice

BARRIERS TO HIT ADVANCEMENT

The U.S. health care industry, which represents about 15% of GDP, lags far behind other sectors of the economy in its investment in IT, despite growing evidence that electronic information systems can play a critical role in addressing many of the challenges the industry faces. There are significant obstacles to the adoption of EHRs and the creation of a NHII, some of which are discussed below.

Financial

There are two key financial obstacles to the adoption of EHR and the development of an NHII: investment costs, and the misalignment between costs and benefits. Investment in IT is expensive and must compete with other priorities, including new buildings as well as other technologies with more direct application to clinical care and greater certainty for increased revenues. A full clinical IT system that includes CPOE and an EHR, grouped with clinical decision support functions, can cost tens of millions of dollars for a large hospital. That does not include the costs of training and systems support. The start-up and maintenance costs of IT systems may be especially burdensome for small physician practices. While those costs vary tremendously, depending on the nature of the practice and the applications involved, the average cost of an EHR can range from $16,000 to $36,000. The complexity of the technology, the time to complete implementation, and the changes in office workflow patterns create additional barriers to adopting IT systems. Perhaps the most critical issue for physicians is the perception that the IT-related benefits of improved efficiency and quality of care accrue largely to the payers and patients, not to the providers who bear most of the implementation costs.

Rather than reward quality, most physician reimbursement systems emphasize volume of services. Physicians are paid for each procedure or service they provide, regardless of its quality. This approach encourages providers to see as many patients as possible and to emphasize the provision of a billable service, such as an MRI, over technology that might improve the quality of many services. A physician group that invests in a clinical IT system to improve the way it manages the care of patients with chronic conditions can reduce the number of complications and the hospitalization rate. Unless the change results in additional office visits, however only the payer sees a financial benefit. Some potential solutions have been addressed including: providing direct payments to physicians who use IT systems and adopting a pay-for-performance scheme that rewards clinicians who deliver the best quality of care, according to standardized measures, as opposed to the highest volume of care.

Standards

Enormous amounts of data needed for clinical care, patient safety, and quality improvement currently reside on computers. However, EHRs and community-based health information networks have been slow to develop because of a lack of interoperability standards to support electronic data exchange. Physicians and other providers are hesitant to invest in IT systems, fearing that they might not be able to exchange patient information with local pharmacies, hospitals, or even other physicians. Common standards for organizing, representing, and encoding health information permit the efficient exchange of clinical and patient safety data. They also support the assimilation of external data sources into decision support tools for providers, such as alerts for possible drug-drug interactions.

The federal government plays a leading role in encouraging the development and adoption of interoperability standards for health information throughout the U.S. health care system. The Departments of Health and Human Services (HHS), Defense (DOD), and Veterans Affairs (VA) are partners in the Consolidated Health Informatics (CHI) initiative, one of 24 eGov initiatives to support President Bush’s Management Agenda.

The goal of the CHI initiative is to establish federal health information interoperability standards both to promote information sharing across the three federal departments that deliver health care services and to serve as a model for the private sector. To date, the agencies have adopted 20 sets of standards developed by private sector Standards Development Organizations (SDOs). They include messaging standards, standards for the electronic exchange of clinical lab results, standards for retail pharmacy transactions, and standards for the retrieval and transfer of images and associated diagnostic information.

HHS signed an agreement to license Systematized Nomenclature of Medicine — Clinical Terms (SNOMED CT), a standardized medical vocabulary developed by the College of American Pathologists and available for free to users in the United States. SNOMED CT, which is now available through the National Library of Medicine, is the most comprehensive clinical vocabulary available and covers most aspects of clinical medicine. It will help structure and computerize the medical record and reduce variability in the way the data are captured, encoded and used for clinical care of patients and for medical research.

In May 2003, HHS requested that the IOM provide guidance on a set of basic “functionalities” that an EHR should possess, that is, the types of information that should be available to providers when making clinical decisions (e.g., diagnoses, allergies, lab results), and the types of decision-support capabilities that should be present (e.g., alerts to potential drug-drug interactions).” The IOM did not address specific data standards (e.g., terminology, messaging standards, diagnostic codes). Health Level Seven (HL7), a leading SDO working on the development of an EHR standard, has taken the core functionalities identified by the IOM and incorporated them into its draft standard. The draft standard is undergoing a two-year trial before it becomes an official standard.

Coordinating the care a patient receives from multiple providers does not require the transmission of the entire EHR with each referral. In most cases, the physician to whom a patient is referred needs only the most relevant and timely facts about the patient’s condition. ASTM International, in collaboration with the Massachusetts Medical Society, the Health Information Management and Systems Society, and the American Academy of Family Physicians, is developing the Continuity of Care Record (CCR) to meet that need.

The CCR is intended to be a national standard for all relevant information necessary for continuity of care. It consists of a minimum data set that includes provider information, insurance information, patient’s health status (e.g., allergies, medications, vital signs, diagnoses, recent procedures), recent care provided, as well as recommendations for future care and reasons for referral or transfer. The data contained within the CCR are a subset of the patient’s full record that exists in an EHR. Each new provider that sees the patient is able to access the CCR and update the information as necessary. Thus, the CCR provides a vehicle for exchanging clinical information among providers, institutions, or other entities. It also may be used by the patient as a brief summary of recent care.

Congress laid the groundwork for establishing an NHII when it enacted the Health Insurance Portability and Accountability Act (HIPAA), P.L. 104-191 in 1996. HIPAA instructed the HHS Secretary to issue electronic format and data standards for several routine administrative transactions between health care providers and health plans (e.g., reimbursement claims) and adopt security standards to safeguard electronic patient information against unauthorized access, use, or disclosure. Developing a secure platform to protect confidential health data is central to the growth of an NHII. Under HIPAA, HHS also issued health privacy standards that give individuals the right to access their medical information and prohibit plans and providers from using or disclosing such information without the patient’s authorization, except for routine health care operations and other specified purposes. The growing use and exchange of electronic health data raises serious privacy concerns among the public and some lawmakers, who question whether the privacy standards are sufficiently broad in scope to protect confidential patient information.

Legal

Health IT experts have identified several federal laws that unintentionally may impede the development of electronic connectivity in health care. Because these laws do not address health IT directly, health care providers are uncertain about what would constitute a violation or create the risk of litigation. The Medicare physician self-referral (Stark) law and the anti-kickback law, which covers all federal health care programs, are of chief concern. Both are intended to counter fraud and abuse.

The Stark law prohibits physicians from referring patients to any entity for certain health services if the physician has a financial relationship with the entity. Entities are prohibited from billing for any services resulting from such referrals, unless an exception applies. The law discourages physicians from accepting IT resources (e.g., hardware and software) from a hospital or other health care entity out of concern that they would be in violation if they subsequently referred patients to that entity. The anti-kickback law, like the self-referral law, also impedes arrangements between health care entities that promote the adoption of health IT. It prohibits an individual or entity from knowingly or willfully offering or accepting remuneration of any kind to induce a patient referral for, or purchase, of an item or service covered by any federal health care program.

On March 26, 2004, CMS published a final interim rule creating several new exceptions under the physician self-referral law, including one for IT items and services furnished to physicians to enable them to participate in “community-wide health information systems.” Experts questioned whether this term is sufficient to cover all the various health IT arrangements. They also criticized the lack of a parallel exception under the anti-kickback law.

HIT LEGISLATION IN THE 109th CONGRESS

The “Medicare Prescription Drug, Improvement, and Modernization Act of 2003” (MMA) (PL 108-173) promotes the development and use of electronic prescribing technology in an effort to increase patient safety and improve the delivery of quality health care. Enactment of these provisions in the MMA served as a catalyst in the development and utilization of electronic prescribing standards and technologies. As a result, there are a number of entities reviewing standards and procedures, which can be utilized to ensure the development of effective, efficient, and interoperable systems to facilitate electronic prescribing and the greater use of integrated electronic health records.

US House of Representatives

Members of Congress have expressed substantial interest in exploring legislation to advance the development and adoption of health information technology. Several Members of the House formed the 21st Century Health Care Caucus during the 108th Congress to promote further modernization of the healthcare system. Various bills have been introduced in the House and Senate and in light of extensive interest in and importance placed on HIT, it is probable that additional legislation will be introduced throughout the 109th Congress to advance the adoption of HIT within individual office settings and within the broader realm of a national health information network.

Reps. Charles Gonzalez (D-TX) and John McHugh (R-NY) introduced the bipartisan “National Health Information Incentive Act of 2005” (H.R. 747). This legislation would, among other things, establish an Office of the National Coordinator for Health Information Technology; require the Secretary of Health and Human Services (HHS) to include additional Medicare payment incentives to assist small health care providers move toward a national health care information infrastructure; and, amend the Internal Revenue Service Code to provide a refundable tax credit for a portion of the expenses associated with the establishment of a health care information technology system.

US Senate The Senate Health, Education, Labor, and Pensions (HELP) Committee recently approved by voice vote the “Wired for Health Care Quality Act” (S. 1418). Prior to approving S. 1418, the legislation was amended to include provisions contained in the “Health Technology to Enhance Quality Act of 2005” (S. 1262) and the “Better Healthcare Through Information Technology Act” (S. 1355). The compromised legislation, would among other things, authorize competitive grants to hospitals, group practices, and other health care providers; authorize the Department of Health and Human Services (HHS) to award grants to health education centers; require the establishment of a Health Information Technology Center; and, establish a National Coordinator of Health Information Technology in HHS.

The development and implementation of health information technology will remain an important issue for physicians and ultimately will impact the care available to patients. We continue to monitor this important issue.

CMS SPONSORED PHYSICIAN FOCUSED QUALITY HIT INTIATIVIES

DOQ-IT

Doctors' Office Quality Information Technology (DOQ-IT) promotes the adoption of electronic health record systems and information technology in small-to-medium sized physician offices with a vision of enhancing access to patient information, decision support, and reference data, as well as improving patient-clinician communications.

The DOQ-IT project offers an integrated approach to improving care for Medicare beneficiaries in the areas of diabetes, heart failure, coronary artery disease, hypertension, osteoarthritis, and preventive care. By educating physician offices on EHR system solutions and alternatives, as well as providing implementation and quality improvement assistance, DOQ-IT aims to assist physician offices in migrating easily from paper-based health records to EHR systems that suit their needs. DOQ-IT does not endorse any particular vendor product or service.

The Centers for Medicare and Medicaid Services (CMS) awarded Lumetra the role of lead Quality Improvement Organization (QIO) in partnership with the Center for Health Information Technology of the American Academy of Family Physicians' (AAFP).

VistA-Office EHR

CMS and the VA are helping to stimulate adoption of EHRs in the physician office setting. They encourage the use of private sector vendor EHRs that are affordable, high quality, interoperable and standards-based. Together, they provide VistA-Office EHR, a high-quality public-domain solution to supplement EHRs available from private vendors.

Medicare Care Management Project Demonstration Project

The HHS Secretary is required to conduct a three-year demonstration program in which physicians will be rewarded for the adoption and use of health information technology and evidence-based outcome measures to promote continuity of care, stabilize medical conditions, prevent or minimize acute exacerbations of chronic conditions, and reduce adverse health outcomes.

The program is limited to four sites meeting certain eligibility criteria. Payment can vary based on performance. However, total payments must be budget neutral. QIOs could help enroll physicians and provide technical assistance. The Secretary is required to submit a Report to Congress with appropriate recommendations, not later than one year after projects conclude.

CONCLUSION

It is recognized that the U.S. must improve the efficiency of its healthcare system and that the increases in healthcare spending must be aligned in value with improved health outcomes and patient safety. The federal government’s role in accelerating the adoption of HIT is multifaceted and provides both opportunities and challenges. Change is coming. Osteopathic physicians and their patients need to be aware of the options and the great barriers that are currently part of the development. Like other technical revolutions in the past, the consumer will be the ultimate beneficiary of the widespread adoption of HIT.

HELPFUL HIT WEBSITES

Federal Government

AHRQ - Healthcare Informatics - http://www.ahrq.gov/data/infoix.htm

CDC - Public Health Informatics - http://www.cdc.gov/epo/dphsi/index.htm

CMS – Physician Focused Quality Initiatives - http://www.cms.hhs.gov/quality/pfqi.asp

HHS - Nat. Committee on Vital and Health Statistics - http://www.ncvhs.hhs.gov/

HHS - Nat. Coordinator for Health IT - http://www.hhs.gov/healthit

Professional Associations

American Academy of Family Physicians - http://www.centerforhit.org/

American Health Information Management Association - http://www.ahima.org/

American Medical Informatics Association - http://www.amia.org/

Association of Medical Directors of Information Technology - http://www.amdis.org/