Jan

24

Economic Stimulus Package & HIT:  What will not work?

The much anticipated new administration has arrived and with it comes the promise of new and expanded investments in health information technology (HIT) which has also been one of the oft referenced requirements of healthcare reform at the state and national level. I grant it is much needed but I remain the cynic, having been too closely involved in the past administration and legislative efforts (state and federal) to expand the use of HIT.

Let’s take a trip back in time six or so years. An executive order emerges from the White House – all (or most, depending on when you actually read the executive order) Americans will have an electronic medical record by 2014. The new administration has committed to investing in HIT and with similar lofty goals. Let us hope the new administration and Congress does a little research before throwing money at HIT and electronic health information exchange (HIE).

There are several federal initiatives, some on-going and some set to end soon, that have targeted the expanded use of HIT and the expansion of HIE. Also, state and regional initiatives abound, following along much the same lines. It would be a shame if the new administration and Congress jumped into the HIE/HIT expansion and enhancement movement without making sure they were not merely throwing money at projects that duplicated what had already been done.

Take the Health Information Security and Privacy Collaboration (HISPC), a national project funded by the US Department of Health and Human Services Office of the Coordinator (ONC), as an example. HISPC, now in year three, is set to demonstrate at a March national conference that yes we can work across state lines and develop the tools needed to expand HIE. HISPC Phase III, with a project end date of March 31st, actually produced workable outcomes that will not only work within a given state but across state lines and across business models. Initiatives such as provider education, rollout of a common authentication/consent form, rollout of authentication and audit minimum standard policies and so forth will be available for all to see and, guess what, some of them have even been tested.

Here we have an example of something that works but needs to continue to progress forward because we still have a long way to go. At this point, though, there is no more funding which means following the end of March, HISPC ends and with it the momentum associated with the rollout of these initiatives that need expanding on and the likely loss of the brain trust associated with the project because we all have to pay the mortgage and a number of the key individuals who were drivers in this project will move on to other endeavors which will not necessarily be focused on the expanded use of HIT and the expansion of HIE in the US.

Another issue has arisen over the past few years that I hope the new administration and Congress does not repeat. Some well meaning initiatives were launched but one of the significant flaws was a lack of coordination between projects, the lack of a clear HIT/HIE roadmap and the lack of clear leadership at the federal and state levels. Project participants didn’t talk to each other (at least not in a coordinated fashion), there was duplication of effort and contradictions in outcomes. It is very difficult to move towards national standards (or even state standards) if no one knows who really is on first.

The new administration and Congress needs to pay attention to one of the most dangerous myths related to HIT and HIE – that is the myth that giving all providers an electronic medical record (EMR) will solve all the problems of the world and instantly create nirvana in the way of flawless HIE. Nothing could be farther from the truth.

A prime example – in Oregon, Oregon Health and Sciences University (OHSU) and Kaiser both use the enterprise electronic health record (EHR) Epic. Guess what – the two organizations cannot use their EHRs to communicate with each other. In fact Kaiser NW has great difficulty communicating with Kaiser NE (nationally Kaiser uses Epic). If that is the case with the big guys, how do we expect the small to medium providers to implement EMRs that can actually communicate with each other?

This is often an issue of culture or business practice as much as it is technology. There are technical problems regarding interoperability and EMR/EHRs but there is also a more significant issue related to how EMR/EHRs are implemented. An EMR or EHR may be interoperable “out of the box” but it is usually customized to meet the business needs of the practice, hospital or other provider setting. What is needed, just as in finance and on the healthcare administrative transaction side are translators that allow that sharing of patient data between organizations.

What is disappointing is some of these translators exist and are not used. The incentives need to be not to immediately go out to buy and use an EMR but to conduct a business analysis of the practice, hospital, etc.; determine appropriate business practices; take advantage of evidence based medicine and develop a plan to implement better ways to practice medicine before deciding which EMR to purchase and implement. That is where dollars need to be first invested – not just providing funds to small to medium practices to purchase an EMR. Give some thought to the process first and then buy the technology. This includes taking into account the ability to securely communicate patient information right out of one organization’s EMR to another organization’s EMR.

I had the pleasure of spending an hour talking about EMRs with a retired surgeon from OHSU a few months back. It reinforced my perceptions regarding the use of EMRs. He said that yes Oregon is ahead of the national curve in the implementation of EMRs but that didn’t mean those EMRs were actually being used. He said providers often purchase EMRs and customize them to “do business” just like they have been practicing medicine for the past however many years rather than change business practices to practice higher quality medicine and more efficient medicine. The end result was a number of providers owned EMRs but ended up refusing to use them because they were unable to get the EMR to work in the same manner as they were accustomed. Again, this gets back to pay for the planning up front before investing in the EMR itself.

Also, it would be wise to require interoperability, directly or through a translator, day one of the EMR implementation and to provide reports back to either the federal or state government (whoever is paying the bill) that the EMR or EHR was actually being used and was being used to communicate with other providers.

We are not at a point where we can launch massive regional health information organizations (RHIO) or health information organizations (HIO). All needs to start at the organizational level while planning and implementing the RHIOs and HIOs in states and regions. If organizations cannot communicate between themselves (or many times even agree on mutual standards/policies), it is difficult to picture organizations in mass agreeing to exchange data through a RHIO or HIO.

This is not to say stop the planning and implementation of RHIOs and HIOs. It is to say that, especially in urban areas, the jump to agreed upon practices that allow RHIOs and HIOs to be effective and sustainable will take time if success is on the agenda. We’ve seen a few spectacular RHIO failures across the country. The idea would be to avoid the failures and learn from the mistakes of others.

My hope is that the new administration and Congress take the time to review what is happening now, the successes and failures and then make a deliberate and planned investment in HIT and HIE rather than jump to dole out money in a rush to meet a promise of investment in this area of the economy. I would hope that there are strings attached – it shouldn’t be just hand out the money and let the industry (and government) spend as they see fit. There should be outcomes to be measured and that infamous concept of accountability.

My final hope is the successful projects that have been started are continued. I look to the HISPC project as a prime example. There has been measurable progress made in advancing the use of HIT and the advancement of HIE across state lines and there is an acknowledgement that much more work is needed. Unfortunately the purse is almost empty and what has been a demonstrated success may soon begin to collect dust on the proverbial shelves where so many past projects have found themselves. It’s interesting to look back and note that yes we have spent money and effort on this before and if something does not change, we’ll look back in four or five years and find we’ve just spent another fair chunk of money repeating those past efforts once again.