President Obama, in his joint speech to Congress this week, emphasized that he wants electronic health records to be established for all Americans over the next five years. His recently passed American Recovery and Reinvestment Act earmarked US$19 billion for health information technology spending, $17 billion of which is designated for incentive payments for Electronic Health Record use beginning in 2011. To date, only about 25% of the nation's 5,000 hospitals have rolled out electronic health records systems, and only a small fraction of physician practices have done the same.
The EHR funds will be controlled by the U.S. secretary of Health and Human Services (HHS), which has discretionary use over US$2 billion of the funds.
The legislation also allocates, among other things, $85 million for health technology investments to the Indian Health Service, $1.5 billion for Community Health Centers and $50 million to HHS to improve its technology security.
Computerworld spoke with three health technology experts from private corporations and the IT vendor side to get their take on the new bill and whether the billions being spent will succeed in establishing EHRs.
The three experts are:
Dr. Charles Kennedy, senior vice president for Health IT at Indianapolis-based WellPoint Inc., the country's largest health benefits provider. WellPoint provides health coverage to about 34 million members through its subsidiaries, primarily under the Blue Cross and Blue Shield name. Kennedy is a founding member of the Certification Commission for Healthcare Information Technology and a board member of the National eHealth Collaborative.
Frances Dare, director of the health-care consulting practice for the Cisco Internet Business Solutions Group. Dare recently testified on Capitol Hill and has advised the Obama administration regarding the stimulus package. She has spent more than 25 years in the health-care industry as a hospital administrator for two facilities.
Phil Fasano, CIO at Oakland, Calif.-based Kaiser Permanente, a $38 billion nonprofit health-care system. Kaiser Permanente offers health care services through a network of nearly 14,000 physicians at Permanente Medical Groups; 32 medical centers and more than 400 medical offices that form the Kaiser Foundation Hospitals; and the Kaiser Foundation Health Plan, which has 8.7 million members. Kaiser is finishing up a 5-year EHR system implementation that cost $5 billion and created 5 petabytes of data on spinning disk serving 32 hospitals, more than 400 medical clinics and 14,000 physicians.
The following is an edited version of those interviews.
How will the billions of dollars help spur adoption, particularly when you consider many small hospitals and physician practices have not even begun an EHR rollout?
Kennedy: Well, that's where the challenge is. If you look at the penetration of [electronic medical records], they're highest where there's enough of a facility there to be able to support the infrastructure costs. When you look at solo and small physician groups, which still represent the majority of how physicians practice, we are going to have to take advantage of the inherent scalability of the Internet as well as some of the existing infrastructure.
For example, most health plans have a provider portal. Those infrastructures could potentially be leveraged to make the deployment of these tools easier and more effective. I also think we're going to look at [application service provider] models and strategies. Many of the EMRs have been constructed where application itself has been on site. That has to be hosted and supported and maintained by the group. I'm really just saying that should be done centrally and all the physicians' office has to have is Internet access.
Fasano: The country's [technology] challenges are larger than that initial $17 billion installment, and that's what I think it's going to turn out to be, an installment for electronic medical records and for making the entire healthcare industry electronic. ... I know what it took for [Kaiser Permanente] to implement our electronic medical record system [$5 billion over five years] and know what it costs us to support that on an ongoing basis [$100+ million annually] and it's a significant amount of money and commitment on the part of any organization like ours, and I suspect when you get down to smaller individual physician practices it will be a substantial cost and something that will need continued support from our government. I think it will require the paying model to be changed somewhat to help support that investment over time. There will consistently be need for maintenance.
Dare: It's important to note there are specific time frames in the bill. Those incentives are first available as early as 2011. What the bill does provide is timeframe certainties and especially in the case of physicians, specific numbers in terms of the dollars available to them in the incentive payments. If you're a physician, and you get your system up in place, you're eligible for a total of $44,000 in incentives over a four-year period. If you're a physician that practices in a professional shortage [rural areas] it is as much as $48,000.
If many of our health-care facilities don't have EHRs set up today, how will they have time to collect on the EHR-use incentives?
Dare: For hospitals, it's a larger undertaking than for a medical practice. It's not a long window of time for a hospital or health system that hasn't even begun thinking about doing this sort of system.
Honestly, knowing some funding is available fairly soon will help them progress. We would certainly say to hospitals, health providers and physicians, you would want to start now, planning and moving ahead in part because the incentive payments are bigger in the early years. If you wait until 2013 or 2014, whether you're a hospital or a physician practice, the amount of money available to you is less.
At the back end, it's a carrot-and-stick system. For those hospitals and physicians that don't adopt the EHRs, their Medicare reimbursement is reduced over time.
Kennedy: The funds don't start coming on line until 2011. I thought that was a reasonable compromise between the need to spend money today for economic reasons versus the need for organizations to get a project in place to begin deploying health information technology.
Secondly, I would define the problem more in terms of market segments. If you have the large integrated delivery systems or large groups, they already have much of the foundation in place. Even if they don't have full-fledged DMR [digital medical records], many have LANs in place. Many have provider authentication processes in place. So it's not like you're starting from scratch for many of these organizations. While I agree it's a challenge, I'm not sure given the restraints you can expect much else.
So should EHR information be shared regionally, statewide or nationwide, and how do you do that?
Dare: Health-care organizations of all types ... need to be able to share information in a variety of ways. Public health programs need to have a communitywide view. So the answer to national, regional, or local is, yes. So a patient first goes to a physician and then maybe a hospital and then maybe to a specialty hospital or long-term care setting and then back home with home care. We need to connect that continuum of care.
Secondly, we need flexible approaches. Honestly, there's no one technology architecture. There's not one technology portfolio. There are big health systems, and small health systems, health care organizations that are payers and providers combined. There's public health, which this bill addresses and sees the need for public health organizations to use IT to transform what they do. I think the bill does a nice job of not being too dictatorial. There's money to support regional and sub-national health information exchanges, but that money is available to the broad range of those exchanges out there. It doesn't say you have to use this architecture or this solution set. That's a positive thing.
Kennedy: You're going to have to make room for innovation. Health information exchanges are one approach that can make sense, but we think there will be additional approaches required to get the value out of these solutions. In Dayton, Ohio, we partnered with Kettering Medical Center , and they brought their clinical data sources - the radiology, lab systems, etc. - and we brought our administrative resources to the table and that information was integrated into a single patient record that the patient controls and that the doctor uses.
There are federated models, centralized models and hybrid models. This would be a hybrid data sharing model. You keep the core information necessary to manage the patient on an ongoing basis centrally, and you leave things like the radiology image in the system where it's stored. Those approaches are very scalable and could be rolled out in a relatively rapid and significant way.
EHR's aren't standardized. So how do you share information if it's in different formats?
The bill does address the data standards piece. It asks the Office of the National Coordinator for Health Information Technology to establish a standards committee. And, of course, we already have the Health Information Technology Standards Panel , which has been working for three or four years now to harmonize standards. It is a challenge for health care. There's continued progress to be made in that realm. We're not there yet.
Kennedy: Should we create a centralized data base from which all patient information is shared, or is it more about standardizing the interconnectivity to the various databases? It's some of both. Standards help in allowing data in system B to get into system A, but let's not forget there have been interface engines around for years. So it makes the work easier to do, but it's not a panacea in and of itself.
The more important questions is, what is your data architecture? What we'd like to see is an approach where the patient's clinical status can be represented electronically, not just what the primary care doctor is doing or specialist is doing, but an integrated view of the patient. Once you have that single representation of that patient electronically, then you can begin to run rules off that single electronic representation. That's where we'll see real value. Instead of taking 17 years for clinical research to make it's way into practices, we'll be able to create rules where it may become 17 days. It's that single representation of the patient and applicability of clinical rules to the data in real time that offers us the foundation to deliver on what people hope health IT can do.
Should the EHRs be controlled by the patient or the health-care organization?
Kennedy: We think in order for this to be successful it needs to be patient driven, patient controlled. The reason is that if you look at what's costing so much money in health care today, it's chronic disease management. Chronic diseases are not something you go to the doctor and get fixed. They're something you manage over time. To deploy tools that don't have a patient-centric approach and expect, by automating the physician's office alone, to see substantial improvements in the cost of care really isn't that rational.
Dare: You need a good clinical record that care providers can rely on. And, you need consumers who want to be healthy to have access to that information and be able to augment it, and I think that's a partnership. People don't just stay put in one place. We are mobile. What's the more significant piece is that your health information can follow you.
Fasano: There are a number of models out there. Some RHIOs [regional health information organizations] are more successful than others. I have a personal opinion that there will be trusted clearinghouses that become connectors in this industry. The model I point people to is the Visa model in the financial services industry. Your financial information certainly moves around that industry quite seamlessly, both nationally and internationally, and it's considered pretty secure. The same will be necessary in the health industry.
I don't think it's going to be easy for us to say one model is the right model versus another - regional versus national versus a broad clearinghouse. I think the industry will have to go through some learning, because obviously health information is different from the few bits and bytes that get transferred about your credit card transactions.
The vast majority of money in health care is spent on chronic diseases, such as diabetes. That's the responsibility of the patient to maintain. How much control should consumers have versus health care organizations over their e-records?
We did a survey of consumers over a year ago. Do they want to be the person totally in control and managing their own care? Do they just want to tell their care team what to do and when to do it? The research was clear. People don't want to be out there on their own. They want to be connected to their primary care physician.