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.

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.

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

See Live Streaming Video of Bipartisan Meeting on Health Reform Thursday, February 25, 2010, 10:00AM EST

Return here on February 25th, 2010 at 10:00am EST for live streaming video coverage of the bipartisan discussion on health reform.  Listen for issues where health information technology provides solutions especially during discussions about quality of care.  A White House website provides more information on this meeting. 

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