In a perfect world, there would be a national system in which each hospital and doctor were connected. A patient would arrive at a hospital he’d never visited, and all his records would be available. That would mean tests wouldn’t have to be repeated, and those tests that were ordered would be in the hands of doctors as soon as the results were ready. Doctors would have access not only to patient records but also to software that provides recommended drugs and treatments. And patients would feel confident that their medical records were secure.
—Ina Fried, CNET News, May 18, 2009
It seems the time has come for a national health information system. It’s become clear to nearly everyone that the continuing rise in health care costs, currently one-sixth of our Gross Domestic Product, is unsustainable. The hope is that information technology can lower costs while improving quality.
As the Obama administration moves forward with health care reform, both the Electronic Health Record (EHR) and the Personal Health Record (PHR) are getting a lot of press. EHR systems are designed for doctors to keep track of patient information, replacing paper files, and allowing (in theory) for easier exchange of information between doctors treating the same patient. A PHR, on the other hand, is intended to help an individual keep track of all their health-related information in one place.
(You may also hear the term “electronic medical record,” or EMR. Although nearly everybody seems to be using EMR and EHR interchangeably, EMR sometimes is used to distinguish between the electronic data about a patient and the larger system which permits that information to be shared by different organizations.)
EHRs and PHRs are obviously related. Neither, however, is in widespread use. The most recent numbers show that only 18 percent of U.S. medical organizations use an EHR system. And the percentage of individuals using a PHR is almost zero. Unless we travel frequently or have oddball medical conditions that may land us in the hands of an unknown doctor, we’re more than happy to let our doctors keep track of our medical history.
The American Recovery and Reinvestment Act of 2009 (ARRA), provides $17.2 billion as “incentives for adoption and meaningful use of certified EHR technology” to doctors who adopt Electronic Health Records. An individual doctor will receive between $35,000 and $44,000, spread out over three to five annual payments, to help pay for the conversion from paper files to electronic record-keeping (more if they do it in 2011 or 2012, less if they wait until 2014, which is the last year to qualify). Oh, and you have to accept Medicare patients to get a piece of this stimulus money, since payments are based on doctors’ Part B Medicare billing. They may also be eligible for an extra 10 percent if their practice serves a “health professional shortage area.” Surprisingly, there are such areas in Lake, Marin, Mendocino, Napa and Sonoma counties (see http://hpsafind.hrsa.gov).
The ARRA legislation also contains the phrases “meaningful use” and “certified,” each of which is its own tempest in a teapot. The “meaningful use” phrase is there to make sure doctors and hospitals use these government-subsidized systems as more than just doorstops, and that the data being collected is available to the Department of Health and Human Services (among others). You can’t improve a process if you’re not measuring it, and that seems to be the focus of the Obama administration: measuring what’s going on, tracking the impact of changes and mining the data stream for patterns that invite improvement. By creating strong incentives for doctors and hospitals to “go digital,” the government hopes to unleash a torrent of data that will enable cost savings and greater effectiveness. Of course, it’s politics, so who knows what will emerge—or whether it will extend beyond the four- to eight-year window of a single president’s influence.
What will the government do with all the data? One area of interest is Comparative Effectiveness Research (CER), which basically means using the data to assess whether less-costly treatments are as effective as more expensive ones.
The “certified” phrase in the ARRA legislation is likewise contentious. Some allege that the nonprofit Certification Commission for Healthcare Information Technology (CCHIT), which performs certification of EHR systems for the government, “works to the benefit of a small number of large EMR vendors that can command a high price from the relatively small segment of the market able to currently afford their products.” It’s almost certain that certification reduces innovation and increases costs.
And since there’s no single EHR system in use nationwide, this push toward digital health records opens up a whole new can of worms: getting disparate systems to understand each other, or health care information exchange (HIE), as it’s called in the acronym-laden world of health care technology.
Is any of this going to work? Kaiser Permanente has spent more than 10 years and $4 billion creating a highly integrated and largely paperless system that’s considered one of the best EHR implementations in the country. Moreover, Kaiser benefits from being both the insurer and the provider of its members’ health care, with its own hospitals and salaried doctors. It’s hard for me to imagine that other organizations will be able to do better in less time for less money.
And there are legitimate concerns. Data about your health can save your life, but it can also cause a health insurance company to deny you coverage. Electronic records can be altered or destroyed. People trust their doctors, but they don’t often trust the government.
On the other hand, there will never be a good time to undertake the twin challenges of lowering costs and improving quality in the health care industry. There’ll always be vested interests. At the heart of it are some very basic questions about what sort of dollar value we place on human lives.
If you’re a doctor or other health care professional in the North Bay, please feel free to send me your thoughts about EHRs, EMRs, PHRs, ARRA or anything else I’ve mentioned in this month’s column.
