Digitized Medicine

Progress being made to splice information technology into the healthcare industry's genome in Texas

It's amazing-the progress being made to splice information technology into the health care industry's genome.   When I first dove into health IT a decade ago the use of electronic health records (EHRs) was dismal and healthcare stakeholders rarely sat at the same table with mutually beneficial, collaborative objectives in mind.   Even within the same healthcare organization it was not uncommon for individual department leaders to disrupt an integrated health IT effort in order to protect some of their department's self-interests.   Less than 5% of hospitals had implemented fully functional computerized provider order management (CPOM) systems; less than 1 in 5 physicians were using an ambulatory EHR; and less than 5% of those were fully functional EHRs.    Today the percentage of physicians and hospitals using robust EHRs is rising at a rate that was unthinkable back then.  

This progress parallels the launch of health IT initiatives established through the federal HITECH funds such as the EHR Incentive Program.   In the past two years these funds have been a catalyst here in Texas to engage diverse groups of healthcare stakeholders  to use health IT to improve quality of care.   As a result:  

• Increasing numbers of Texas physicians are using EHRs (approaching 50%)
• More and more hospitals are using CPOM
• Over a dozen of community-wide health information exchanges (HIEs) are up and running
• New health IT workforce training programs are established
• Four regional extension centers were formed covering all geographic areas of the state and are doing a phenomenal job assisting thousands of physicians with EHR selection, implementation and meaningful use
• Texas became the first state to have it’s HIE plan approved by ONC
• Texas was one of the first states to stand up the Medicaid EHR incentive program making our program a model for other states
• Texas was one of four to receive a SHARP grant
• And Texas leads the way with the number of physicians attesting to meaningful use; Texas physicians and hospitals have received over $270 Million in EHR incentives

This rate of progress is only possible when individuals with diverse backgrounds and from different healthcare stakeholder groups are able to collaborate.  In Texas these stakeholders have demonstrated an ability to park their self-interests in order to drive forward with a common vision to improve the quality and delivery of patient care in our communities.

Health Information Exchanges and Physicians Share Accountability for Safe Patient Care

The $800 billion 2009 American Recovery and Reinvestment Act (ARRA) set aside $36 billion toward health information technology (health IT) initiatives, including over $500 million for the State HIE Cooperative Program.  This federal program provides funds to each state for the successful planning and development of infrastructure that supports the exchange of electronic health data between physician electronic health records (EHRs), hospital EHRs, lab systems, radiology centers and other clinical IT systems.    For example, in Texas we are using these funds to support the development of local health information exchange entities, called HIEs, across the state and to concurrently develop the policies, standards and infrastructure needed to safely/securely connect these HIEs to each other.     The statewide HIE network will also be built to be compatible with national standards and efforts.      

Each state's effort to develop a network of community HIEs and/or a statewide HIE will be more successful with physicians involved upfront with governance and policy development.   When working with local HIEs most physicians will generally understand and appreciate the importance of protecting the privacy and security of electronic patient health information.  Their inherent knowledge on this issue will help guide policies in the right direction.   A more complex issue for physicians to understand is the relationship between HIEs and patient care.   A heightened awareness of this issue will allow physicians to properly inform HIE policymakers about the need to establish an environment where local HIEs, HIE networks and physicians share accountability for safe patient care.   

To deepen physician's understanding of this issue I encourage them and others to think about an HIE as a tool physicians use as a part of patient care, similar to a surgical tool.   If a patient is harmed by a surgical tool that broke because the physician used it incorrectly, the physician is negligent.  If the physician used the tool correctly but it still broke, but it has only broken 8 times in over 10,000 surgeries and the patient consent explains this remote risk of breakage, then no one is negligent.  However, if it broke and the issue had been reported to the vendor by many physicians on a repetitive basis, but the vendor failed to investigate the issue and fix the problem, or failed to inform physicians and patients of the increased risk in the meantime, then the vendor is negligent. 

This perpsective will help physicians advocate for policies that lead to an environment where HIEs and physicians share accountability for safe patient care.   Effective policies will lead to contracts and agreements which acknowledge that:

1. HIEs and HIE infrastructure are tools used by physicians during the course of patient care
2. HIEs are responsible for informing patients and doctors about the inherent risks of  the electronic health information exchange including changes in risks when issues are identified
3. HIEs have a responsibility to continually monitor for and mitigate risks associated with their services that may impact quality of care provided by physicians

 

Bipartisan Health IT Support and ARRA Insulate EHR Incentive Funds From Budget Cuts

A physician colleague recently asked me why I am confident that CMS will not cut off EHR incentive funding in the future.   This question is important to him and other physicians who plan to qualify for up to $44,000 in CMS incentive payments by achieving the meaningful use of EHRs.   They fear that the dragging economy and political discord will result in budget reductions that will cut this and other important health IT funding programs.    What I see, though, is a decade-long track record of bipartisan support for health IT initiatives and a 2009 federal law that requires CMS to provide funding for the EHR incentives and other health IT programs.

In his 2004 State of the Union speech President Bush envisioned the adoption of EHRs for all Americans by 2014.   Since then bipartisan support at both the state and federal levels for health IT initiatives toward the achievement of that vision has held strong.   At the federal level CMS  not only established a new office in 2004 to support health IT, the Office of the National Coordinator of Health IT (ONC) but has also increased funds to support ONC initiatives which promote the adoption and use of EHRs.  CMS works collaboratively with ONC and has consistently shown an understanding that the broad adoption and effective use of EHRs are necessary to better manage spiraling healthcare costs.   CMS understands that the data captured by EHRs is superior to claims-based data when attempting to analyze quality and establish benchmarks.    Physicians have long complained that claims-based data is incomplete and does not fairly demonstrate the quality of care they provide.     EHRs must be broadly adopted in order to capture accurate and meaningful data that can then be used to improve quality or save costs.  

It is important to recognize that CMS is required to provide EHR incentives to physicians by law.   Specifically, the $800 billion American Recovery and Reinvestment Act (ARRA) of 2009, commonly refered to as the Stimulus Bill, allocates over $36 billion to health IT programs through the Health Information Technology for Economic and Clinical Health (HITECH) Act.   This funding includes an estimated $34 billion for the Medicare and Medicaid EHR Incentive Program and over $300 million to support state-wide health information exchange efforts.

In order to cut funding for EHR incentives, this means that bipartisan support would have to be garnered in the House and Senate to rescind ARRA or part of ARRA.   The intent of ARRA  initiatives is to stimulate economic activity and produce jobs.   In the current economic environment it would seem very risky, perhaps even foolish, for a politician to drum up support for new legislation that eliminates economic stimulus activity, especially if that activity is already producing jobs.

So, is the EHR Incentive Program stimulating the economy and producing good jobs?   I am not an economic expert, but from what I see around me the answer is clearly, "yes".    I see job openings in the local paper for healthcare system IT analysts and other staff, I speak with IT consultants most of whom are actively seeking personnel, I hear about physician offices investing into the economy $10,000-$70,000/doctor to implement EHRs or upgrade other office technologies, I read about physicians receiving $44,000 federal incentive payments and about hospitals receiving larger amounts, some of which is surely returned into local economies.  The graph below is a composite view of the 3-year stock performance of the health IT sector since 2009.   EHR vendors and other health IT companies appear to be thriving well since ARRA was passed despite the depressed economy.

I suspect that several years from now when experts analyze the impact of the $800 billion stimulus package, the puny $36 billion provided to health IT initiatives through the HITECH portion of ARRA will go down as perhaps the most bang for the buck in terms of stimulating the economy.  

The EHR incentive funds appeared to be well insultated from budget cuts for these same reasons. 

Texas Medical Association video provides in-depth look at meaningful use, how RECs can help physicians

This video does a good job of describing Meaningful Use, the electronic health record (EHR) incentive program and how the four regional extension centers (RECs) in Texas leverage federal grants to subsidize services for physicians that help them select/implement or upgrade an EHR, and then use their EHR to improve quality of care and meet the Meaningful Use requirements.  

The four RECs in Texas currently charge primary care physicians only $300 for consulting services valued at $5,000.  These services include:

o    Select and implement a certified EHR (or upgrade your current EHR to a certified version)

o    Optimize your practice workflow,

o    Achieve meaningful use,

o    Qualify for EHR incentives, and

o    Obtain CME credit hours      

 

Community HIE decisions are best made in collaboration with local physicians who use EHRs

Physicians who use electronic health records (EHRs) in their offices are increasingly being called upon in their communities to participate in the development of local health information exchanges (HIEs).    During the early stages of HIE planning there are important decisions that are best made in collaboration with local physicians.   As with any health information technology usage, the anticipated benefits of exchanging electronic health data must be balanced against the inherent risks of the technology.   Physicians who use EHRs already have valuable experience with some of the inherent risks associated with electronic health data usage, but may not have experience with the clinical risks associated with the exchange of electronic health data.    The following case scenarios are intended to raise awareness and understanding of key patient safety risks associated with the clinical use of electronic personal health information (PHI) that could be obtained through a community-wide HIE.  

Conflicting data scenario:  A nurse records a penicillin allergy in the hospital EHR when a patient experiences GI symptoms after receiving a penicillin injection.   The next day, the patient is seen by her primary care physician (PCP).   After reviewing the history, the PCP is convinced that the reported symptoms were unrelated to the penicillin injection.   She records “No Known Allergies” in her office EHR.   The local HIE retrieves “allergies” from both EHRs and displays this patient’s allergies as both “no known allergies” and “penicillin.”  

In such cases, the physician will have to reconcile the data by considering the sources, dates, and times of each and decide whether additional investigation is necessary.   

Segmented data scenario (this applies only if the HIE will allow patients to exclude some or all of their data as a part of the consent process):   For privacy reasons an HIV patient decides to exclude his diagnoses from the HIE which results in a problem list so that it does not disclose his HIV status.   He also excludes data from two sources: his psychiatrist and a psychiatric hospital.   This patient had suffered an episode of neuroleptic malignant syndrome secondary to an antipsychotic medication a year ago while under the care of the psychiatrist at that hospital.   Since records from the psychiatrist and hospital are excluded, the HIE will not contain this information.   A physician viewing the patient’s information through the HIE will see no record of the patient’s susceptibility to a life-threatening event from a certain class of medications.  

Informing the viewing physician that the patient has excluded some data from the Problem List and some data from both a physician and a hospital may prompt important additional questions and dialogue with the patient that could prevent an avoidable adverse event.  

 Clinical Risk Management

Community-wide HIE initiatives are increasingly turning to local physicians who use EHRs to assist with assessments of both the benefits and risks associated with the clinical use of electronic health data shared across their community.  The clinical risks outlined in these scenarios can be managed through the following principles: 

1.  An HIE must provide physicians access to the source, date and time for all displayed data

 2.  An HIE must alert clinicians when data or data sources are excluded  

• The alert should specify the type of data (“lab results”) or type of source (“hospitals”) that have been excluded from the HIE through the patient consent process

3.  An HIE must inform physicians about:

• The patient consent policy used by the HIE (and of policy changes when they occur
• A list of the specific types of data they are generally able to access through the HIE
• A list of the specific sources of data that the HIE exchanges with

Improve Physician Leadership Through Recruitment, Education and Training

A recent discussion among my colleagues about increasing physician leadership in this age of electronic health records (EHRs), Meaningful Use, healthcare reform and Accountable Care Organizations (ACOs) caused me to think about how a physician even starts to go about becoming a leader.   I considered physicians in my own community who are recognized leaders and appreciated that their rise to leadership started by simply getting involved in something.   Their leadership was born out of getting involved just like my colleagues were doing when they began discussing solutions to this particular issue!

Getting involved is a common attribute of physician leaders because there is obviously little merit or trust when a physician leads an effort without previously participating in a similar effort.   Participation is the initial step to gain such trust.   Once a physician gets involved with a successful initiative their community deposits a “coin of trust” into his pocket.    If the physician obstructs progress, though, some coins of trust are removed.   A physician who eventually collects a pocketful of coins is looked upon as a trusted “community leader” who is knowledgeable and experienced, even if he did not actually “lead” any effort.  This is because many successful healthcare initiatives are known to be moved forward by people who are catalysts for collaboration and effective at resolving conflicts between stakeholders.   One does not have to be an ACO board chairman or a formal project leader to be such a catalyst.  In fact, it is often advantageous to be in a more neutral position when exerting that type of influence.

So an increase in physician leadership will initially involve an increase in physician participation in healthcare initiatives.   A good place to start is with local health initiatives such as a Regional Extension Center (REC), health information exchange (HIE)  or Accountable Care Organization (ACO).   Participating in a local initiative provides physicians with the valuable experience of working together, perhaps for the first time, with multiple stakeholders.  Physicians will see the types of communal efforts that are successful at promoting change.  They will gain valuable knowledge about healthcare reform, health IT or other important topics.   They will learn how public policy is developed. They will encounter the frustrations and complexity of efforts that fail.   But they will learn to keep their focus on the long term and not be deterred by a short term failure that they come to realize will not matter at all in 40 years.     

Understanding this process illuminates a path to increase physician leadership.  It starts with the active recruitment of physicians into local, statewide or national activities.  It is accelerated through concurrent education and training to hone leadership skills.  County and state medical societies, who have established physician relationships and are experienced with physician education/training, are ideal entities to facilitate the growth of leadership.  The medical societies could actively identify new and ongoing healthcare initiatives and contact them to ensure there is adequate physician participation.   They could also assist with physician recruitment and training when needed.

Why should primary care physicians enroll for Regional Extension Center services?

Why should primary care physicians sign up for REC services?   What are the unique selling points and assistance they will receive as compared to other consultant organizations?  

These are excellent questions I am hearing from physicians in Texas regarding the four RECs that cover our entire state.  The RECs are subsidized by the federal government through the Health Information Technology for Economic and Clinical Health (HITECH) Act which appropriated $640 million in REC grant funds to create 62 RECs across the nation, including the four in Texas. 

Primary care physicians in Texas should use REC services because they will receive a steep discount for high quality services that are provided through a trustworthy, physician-centric organization that was specifically created to meet the technological needs of physicians in their region.

In Texas the four RECs have collaborated to develop a shared business plan that leverages the federal subsidies to provide onsite technical consulting for a token fee of $300.    For this $300 enrollment fee Texas physicians receive over $5,000 in consulting services which include:

• EHR implementation and project management;
• HIT education and training; 
• Vendor selection and financial consultation; 
• Practice and workflow redesign; 
• Privacy and security compliance education; 
• Meaningful use analysis, tracking, and monitoring; 
• Assistance in meeting meaningful use requirements for CMS incentives; 
• Collaboration with state and national health information exchange (HIE); 
• Ongoing technical assistance; and 
• Opportunities for CME credit hours

In addition to this steeply discounted enrollment fee, the Texas Medical Association (TMA) works closely with the RECs to help ensure that the RECs are physician-centric and focused on meeting physician needs.    Physicians hold 50% of the seats on each REC's governing board as a result of the TMA’s early efforts.

Another unique selling point is that the REC technical consultants are specifically focused on, and experienced with, the small physician practice.    Other IT consultants naturally give priority to large practices or healthcare systems where they get large amounts of money from a small number of contracts.    The REC consultants, on the other hand, only get a small amount of money per contract, but they get a large number of them.    This business strategy allows them to become more experienced with and more focused on the small practice.    The REC administrative staffs enable this strategy by facilitating the enrollment of a large number of physicians and by using the REC federal grant funds to offer physicians the steep discount.

The four RECs in Texas are:

• Gulf Coast Regional Extension Center (GCREC)
• CentrEast Regional Extension Center (CEREC)
• North Texas Regional Extension Center (NTREC)
• Texas Tech University Health Science Center

Crossing the Quality Synapse: Interoperability is the Neurotransmitter Propagating 21st Century Healthcare

Yesterday at the 2010 ONC Grantee Meeting in Washington, D.C  I was invigorated by the optimistic energy, realistic networking and paucity of pessimism from over 1,000 participating grantees whose collective repository of health IT knowledge is astounding.   And it got me thinking, maybe the Institute of Medicine (IOM) got it wrong and that it is not actually a chasm...maybe we are...crossing the quality synapse?

Imagine for a moment that electronic health information is a charged impulse using health IT neuronal circuitry to propagate 21st century healthcare.  This neuronal circuit provides the infrastructure needed to enable charged impulses of the right information on the right patients to be sent or received wherever it is needed, whenever it is needed.  However, as we physicians know, the neuronal circuit is made up of many individual neurons that are not physically connected to one another.  Each neuron can individually propagate a charged impulse along its long, tubular-shaped axon, but the axon ends blindly at its terminal end.  Between it and the next neuron there is a space, called the synapse, across which the electrical impulse cannot travel.  This constraint prevents an individual neuron from transmitting the electronic impulse to its final destination.  On the other hand, an absence of such constraints and uncontrolled releases of electrical charges between the neurons of our brain would result in seizures.   So, some type of trusted intermediary is needed to enable the neurons to talk with one another in a standard and controlled manner...to be an interoperable neural circuit that coordinates and directs the traffic of electrical charges to their permitted destinations.     

In medicine we recognize the complexity of this synapse.  Although we have learned much about it, we remain humbled by what we do not yet know.  What we do know is that at the "receiving" end of a neuron there are tiny tentacles, or dendrites, that stick out into the synapse toward the "sending" neuron's axonal terminal.  When the charged impulse reaches the axon terminal, the action potential stimulates the chemical release of neurotransmitters from the terminal into the synapse.    The neurotransmitters physically travel across the synapse to the dendrites.  At that point the neurotransmitters become a catalyst for the transformation of the chemical process back into an electrical one.  The new electrical impulse travels from the dendrite into the neuronal axon and propagates down to the next synapse, where interoperability will again have to occur. 

Health IT interoperability is the 21st century neurotransmitter that is catalyzing the transformation of the healthcare system.  Without interoperability we know that electronic health information is severely devalued as it remains trapped in individual silos, just as an an absence of neurotransmitters would limit electrical impulses to a single neuron. 

Concurrent with ongoing neuroscience research on the complex synaptic neurotransmitters, medical researchers used what we already knew to initiate trials and studies in an effort to improve psychiatric care.  Breakthrough research demonstrated that a synaptic deficiency of one of the neurotransmitters in our brains, serotonin, can cause depression.  Through additional trials and experience we then discovered that SSRI medications, which elevate serotonin levels by inhibiting their "reuptake" in the synapses after being released, are useful when treating people with depression and other mood disorders.   Similarly, a deficient level of interoperability between EMRs depresses our ability to transform our healthcare system.  We need to use what we already know about interoperability to initiate trials and studies in an effort to raise our interoperability to optimal levels that will propel our healthcare system into the 21st century.     

Watch Recording of Dr. Blumenthal Speaking to Texas Medical Association on EMRs, Meaningful Use and Quality Medicine

Dr. Blumenthal anticipates that Regional Extension Centers (RECs), such as the North Texas Regional Extension Center (www.ntrec.org), will be helpful to physicians who want to successfully implement electronic medical records (EMRs) and use them to enhance our ability to provide high quality of care.  He notes that the federal EMR incentive payment program (through the HITECH legislation) is a one-time offer from the government that physicians should strongly consider, especially if they plan to still be practicing medicine in 10-15 years when EMR use is likely to be an expectation. 

http://www.ustream.tv/recorded/10218624

EMRs create a new medical liability risk-- physician's failure to chase after the non-compliant patient

It is clear that electronic medical records (EMRs) improve patient safety and quality of care in many ways.  It is unclear, however, whether these improvements will result in an overall reduction in medical liability risks and costs.  Consider the following scenarios:

Scenario 1: You are the doctor and you have a 20 year-old female patient, Ann, with insulin-dependent diabetes mellitus who has been an ideal and compliant patient.  When you last saw her 3 months ago you wrote an office note about how her paper log of glucometer readings (that she faithfuly brings in each visit) showed an exellent trend of glucose levels and compliance with her diet and insulin regimen.  A Hgb A1C test was done and the result satisfactory.  Today an emergency room doctor calls you and reports that Ann is comatose with a blood sugar of 650 with other signs of severe ketoacidosis.  You admit her to the intensive care unit where she is treated aggressively but cerebral edema develops resulting in a stroke.  Upon recovery from her metabolic crisis she requires rehabilitation for residual left-sided weakness.  As you piece together her story you discover that since you last saw her she had apparently become acutely depressed after breaking up with her boyfriend.  She now admits to straying from her usual dietary restrictions, failing to take her insulin regularly and not monitoring her blood sugar.  You explain to Ann and her family that her depression obviously led to non-compliance with her diabetes therapy which unfortunately resulted in her poor outcome.

Scenario 2: You are the doctor and you have a 20 year-old female patient, Ann, with insulin-dependent diabetes who has been an ideal and compliant patient.  You last saw her 3 months ago and in your EMR you noted an excellent trend in her daily blood sugar readings that she faithfully sends to your office in real-time (by connecting her home glucometer to the internet through her Xbox).   A Hbg A1C test was done and the result satisfactory.  Today an emergency room doctor calls you and reports that Ann is comatose with a blood sugar of 650 with signs of severe ketoacidosis.  You admit her to the intensive care unit where she is treated aggressively but cerebral edema develops resulting in a stroke.  Upon recovery from her metabolic crisis she requires rehabilitation for residual left-sided weakness.  As you piece together the story you discover that since you last saw her she had apparently become acutely depressed after breaking up with her boyfriend.  She now admits to straying away from her usual dietary restrictions, failing to take her insulin regularly and not monitoring her blood sugar.  When you look in your EMR it is obvious that she stopped sending in her glucose levels 8 days ago.  You were on vacation and the alerts generated by the IT tools were somehow missed by your office personnel.  You explain to Ann and her family that her depression obviously led to non-compliance with her diabetes treatment which led to a severe ketoacidosis complicated by a stroke.  Ann’s parents ask why you would not have checked up on her when she stopped sending in the glucose readings.  They blame you for the poor outcome and file a medical liability suit against you for failing to follow-up on their daughter after your records showed she had become non-compliant. 

The above scenario demonstrates one of several new liability issues raised by the use of electronic health records (EHRs) and other health information technology (IT) tools.  Technology not only changes the way clinicians manage patient care, but also creates new patient care issues to manage.  Other situations prompted by health IT and prone to liability issues include: 

1. New ways physicians manage population health
2. Access to previously unavailable patient information through the use of health information exchange (HIE)

EMRs have been shown to improve patient care and patient safety which will hopefully serve as a strong counterbalance to any new liability risks.  However, if medical liability insurance companies discover a need to raise premiums on physicians who adopt health IT tools, then there needs to be open dialogue over who pays for the increase.  Any rise in liability premiums due to health IT adoption needs to be shared by all stakeholders (liability insurance companies, health plans, consumers, employers, hospitals, government, etc...) and not just the doctors.  The rule of thumb for health IT adoption is that, since it is for the public good, all stakeholders get to play and all stakeholders have to pay