By Jonathan Nelson

If any questions remained about the importance of electronic health records and health information technology, they were washed away when the levies broke in New Orleans and Katrina’s storm surge flooded the city. Along with their homes, their businesses and their livelihoods, people up and down the coast lost all records of their medical histories. For patients with chronic conditions, severe drug allergies and the like, the loss of that data might have been a matter of life and death.

Health care organizations, consumer groups and business alliances have extolled the virtues of health information technology for more than a decade, but adoption rates among physicians and hospitals are still abysmally low and efforts to share information across broad networks are just now in their infancy. Anyone can walk up to any ATM machine in the country, insert her card and have access to her financial information. But should she walk into a hospital down the street, the only information the medical staff will have about her will be that which she can recite.

Study after study shows that we have the most expensive health care system in the world and for that price we get average to poor quality care compared to other industrialized countries.1,2,3 Poor disease management, a lack of preventive medicine and care coordination, our growing ranks of uninsured and underinsured citizens, flawed reimbursement systems, redundancy and inefficiency ­— these and a host of other problems plague the system. The implementation of the world’s greatest health information technology network complete with EHRs in every doctor’s office and personal health records accessible to every patient wouldn’t solve these problems alone, but it sure would help.

The U.S. health care system costs about $1.7 trillion annually. For 2003, that came to $5,635 for each American. The median per capita health spending for the 30 member nations of the Organization for Economic Cooperation and Development came to $2,280, more than two and a half times less, according to a study published in the May/June 2006 issue of Health Affairs.4 The study compares the use of health information technology (HIT) among the OECD countries, finding that the United States is as many as 12 years behind the pack.

A RAND study published in the September/October Health Affairs estimates that if the United States were to experience broad adoption of interoperable EHRs among physicians and hospitals, the country could save more than $81 billion a year. If those systems were connected through a national health information network and the entire system were tooled to enable better quality and coordination of care, preventive care and chronic disease management, the researchers estimate savings could be as much as $142 billion to $371 billion.5

We’re a long way from making these kinds of savings a reality. Across all specialties, only 17.6 percent of physicians use EHRs. In practices with 10 or fewer physicians, that number drops to 11.3 percent.6 Although pressure to measure quality and to report to pay-for-performance programs will push more physicians to buy EHRs, start-up costs and a lack of credible information on the hundreds of available products make the digital jump a risky one.

Among the paucity of empirical literature on what value small group practices can expect from EHR implementation is a study of 14 practices of between one and six physicians that appeared in the September/October 2005 Health Affairs.7 Each of the practices had selected one of two systems and had been using it for at least three years before participating in the study. On average the systems cost $44,000 per full-time physician with ongoing annual costs of $8,500 per provider. Use of the technology accounted for an average of $33,000 in savings and additional revenue for each full-time physician, an increase largely attributable to increased coding levels, fewer necessary employees and eliminated transcription fees.

Researchers found that it took an average of two and a half years for the financial benefits of the systems to cover the initial and ongoing costs, but the practices didn’t all fare well.

“Three practices experienced considerable financial risks, other than a long payback period. Two had severe billing problems that were at least partly EHR-related. One had no billing or revenue for three months; another had no revenue for 10 months (and nearly went bankrupt). A third had to redo its billing for the first six weeks after implementation and later endured a complete system crash that resulted in total loss of data and several weeks of providing care with no computer access or paper charts.”8

This paragraph from the study illustrates a major problem with our current business plan for HIT adoption: physicians must bear virtually all the cost and risk but will only reap a fraction of the overall financial benefit. If we succeed in building the health information infrastructure of which the think tanks dream — resulting in increased efficiency, higher quality, better disease management and a healthier population — the lion’s share of the benefit will go to patients, insurers and the biggest payer of all, the federal government.

For anyone interested in the macro-economic implications of HIT implementation for public health and federal health spending, the September/October 2005 issue of Health Affairs is a must-read. The entire edition is dedicated to the topic and one overarching theme is that the HIT market has failed and that this “asymmetrical risk and reward” equation is both a symptom and a cause of that failure. Medical economist J.D. Kleinke writes in his article that the flawed and antiquated reimbursement structure at the heart of our health care system harbors some “dirty little secrets” that subvert the HIT market. Among them: poor quality, redundancy and inefficiency pay pretty well.9

He and several other authors say it’s time for the federal government to play a more direct role in making the HIT market work. They suggest the government should provide direct subsidies to physicians and institutions for implementing EHRs and health information networks, offer guidance in determining which products to buy and establish interoperability standards for systems and networks. Bit by bit, these suggestions may be on their way to becoming reality.

In 2004, President Bush called for the widespread adoption of health information technology, saying that by 2014 most Americans should have EHRs. To carry out that goal, the Secretary of Health and Human Services created the Office of the National Coordinator for HIT, or ONCHIT. Since then some funds have started to flow toward promising HIT projects. The president’s proposed 2007 budget includes $116 million for ONCHIT and allocates another $50 million to the Agency for Healthcare Research and Quality’s IT work toward enhancing patient safety reporting systems. The White House reported that the total proposed investment in health-related IT is $4.6 billion. Of course, a recent study estimates that a robust national HIT system for the United States would cost $156 billion in capital investments over five years and about $48 billion in annual operational expense,10 but a few billion is better than nothing.

Last summer the Secretary of HHS formed the American Health Information Community to oversee the development of HIT standards and interoperability efforts. AAFP’s Executive Vice President Doug Henley, M.D., is one of 16 members in “The Community,” as it’s called, a fortuitous appointment since AAFP’s Center for Health Information Technology has been working diligently on developing standards for interoperability through the Continuity of Care Record project for the last few years.

The CCR is a kind of personal health record — a set of core patient data that can be created at the point of care by an EHR, viewed in a Web browser or exported as an Adobe PDF or a Microsoft Word document, and imported into the EHR system of another health provider. Through the development of the CCR, programmers, EHR and other HIT vendors and national standards organizations hammered out a set of workable standards and late last year, the final CCR schematic was published. AAFP’s CHIT Director David Kibbe, M.D., says the CCR is currently the only standard for personal health records and interoperability between EHRs. “It’s very important because not only is it a way to produce core clinically relevant summaries for patients as a personal health record, but it is also likely to be used as the standard for submission of quality of performance data aggregators and pay-for-performance programs and as a patient-centered file for clinical decision support,” Kibbe says.

The Community also convened the Health Information Technology Standards Panel, which has divided the standards and interoperability issue into three categories: the architecture for a national health information network, data security and privacy, and compliance certification. The group working on compliance certification is called the Certification Commission for Health Information Technology, and Steven Waldren, M.D., AAFP’s assistant director for CHIT, is the co-chair of its work-group focusing on ambulatory EHR certification.

The Certification Commission for HIT published its criteria and began accepting applications from vendors earlier this year. They plan to publish the first round of certifications in July, which means physicians shopping for EHRs can look for the “CCHIT certified” designation and know that those products meet established requirements in the areas of functionality, interoperability, security and reliability.

Helping physicians make a good selection in the EHR market is something AAFP can do, as well. Check out the CHIT Web site at www.centerforhit.org and you’ll find lots of information for shoppers and users at all levels. There’s information on discounts for AAFP members who purchase from certain companies, articles about the right questions to ask potential vendors, what you need to know about EHR contracts, and a tool to assess your situation and the steps you should take to prepare for HIT implementation. One tool Kibbe thinks is making a huge difference is a physician product review site that allows you to search by product, group size and geographic location. With over 500 reviews by AAFP members — 39 from Texas family physicians — on 68 listed products, the site allows you to read what your colleagues think about the products they selected. Kibbe says this kind of transparency not only helps shopping physicians, but it puts pressure on vendors to provide better products and service after the sale. For now, the site is for AAFP members only but Kibbe says CHIT is considering opening the site to other specialties. “Many of our family physicians say they wouldn’t think of buying an electronic health record without first consulting those reviews.”

Kibbe believes that for family physicians, the tipping point may have already been reached. According to AAFP surveys, he says Academy members may be adopting HIT at twice the national average, close to 30 percent, although he acknowledges the survey methods may have skewed the numbers a bit.

Even so, achieving the societal benefits of better quality, coordinated disease management, reduced medical errors and adverse drug interactions, and maximum efficiency in the nation’s health care system will take more than talking physicians into upgrading their practices. It will take strong leadership and dedication at the federal, state and local levels to create and support a secure and convenient health information network. Lucky for us, we don’t have to invent the wheel. Perhaps we have something to learn from our friends in the Organization for Economic Cooperation and Development.

References

1. G. Anderson et al., “Health Care Spending and Use of Information Technology in OECD Countries,” Health Affairs 25, no. 3 (2006): 819-831.

2. S. Asch et al., “Who is at Greatest Risk for Receiving Poor-quality Health Care?” New England Journal of Medicine 2006, 354: 1147-1156.

3. B. Starfield, “Is U.S. Health Really the Best in the World?” Journal of the American Medical Association 284. no. 4 (2000)

4. Anderson et al.

5. R. Hillestad et al., “Can Electronic Medical Record Systems Transform Health Care: Potential Health Benefits, Savings and Costs,” Health Affairs 24, no. 5 (2005): 1103-1117.

6. D. Gans et al., “Medical Groups’ Adoption of Electronic Health Records and Information Systems,” Health Affairs 24, no. 5 (2005): 1323-1333.

7. R. Miller et al., “The Value of Electronic Health Records in Solo or Small Group Practices,” Health Affairs 24, no. 5 (2005): 1127-1137.

8. Ibid.

9. J. Kleinke, “Dot-Gov: Market Failure and the Creation of a National Health Information Technology System,” Health Affairs 24, no. 5 (2005): 1246-1262.

10. R. Kaushal et al., “The Costs of a National Health Information Network,” Annals of Internal Medicine 143, no. 3 (2005): 165-173.

Learn about health IT; earn free CME

By AAFP News Staff

Want to learn more about office health information technology at your own pace and in your own space and earn CME along the way?

The Academy’s Center for Health Information Technology, or CHIT, invites members to take advantage of a new series of online tutorials designed to give FPs and their staff members the information they need to know about health IT in an easy-to-use video format.

The first module in the series, “Health Information Technology for the Family Physician Office: Hardware and Network Basics,” is now available. It focuses on acquiring hardware and preparing for the installation of an electronic health record system. Three more modules are scheduled to launch during the next few months and will cover office redesign and workflow, EHR selection, and EHR implementation.

CHIT Assistant Director Steven Waldren, M.D., said the program format was designed with busy family physicians in mind. “I know that plowing through a lot of written material on health IT can be boring. That’s why CHIT decided to develop something a little more engaging and interactive for the learner, whether it’s the physician or office staff, and at the same time, meet some requirements for CME,” he said.

There’s also no waiting for a long download; at the CHIT CME Web page, users just select the module to access the online flash video. (The latest version of Flash Player must be installed to play the video. Users can download the latest version from a link on the CHIT CME site.) After viewing the video, users answer the post-test questions. The program has been approved for AAFP Prescribed credit.

Waldren said the new video CME modules supplement a wide range of health IT resources already available in a written format from CHIT.