March 18, 2007

Not every snowflake is unique*, but…

Filed under: — mlazoff

The strongly pro-electronic health record (EHR) American Academy of Family Physicians just published a sobering article in their Family Practice Management, EHRs Fix Everything—and Nine Other Myths. Authored by David Trachtenbarg, MD, a family physician who disclosed a financial relationship with one EHR vendor, the take-home message of this readable essay begins the final paragraph: “Every EHR implementation is unique.” 

*According to wikipedia’s entry on Snow

February 13, 2007

Tooting their own horn

Filed under: — mlazoff

Missing from among the initiatives on Health and Human Services (HHS)’s Health Information Technology list of Major HIT Accomplishments: 2004-2006 is the creation of their much improved Web site.

The list provides a nice review of past major government initiatives and, more important, what projects the federal government will support in 2007 and beyond. Leading the list is the National Healthcare Information Network, followed by future recommendations from HHS’s advisory board, the American Health Information Community; and the coordination of state with federal laws on privacy and security of patient data. Details on each can be accessed from the site’s left navigation panel.

January 30, 2007

The NEPSI Challenge

Physicians who already signed up for the free Web-based e-prescribing software eRx NOW, provided by the National e-Prescribing Patient Safety Initiative (NEPSI), will begin receiving their free software tomorrow (January 31). According to their online FAQs, NEPSI  is a coalition of large corporations led by Allscripts and including Dell, Google, Microsoft, Intel, SureScripts, among many others. NEPSI sponsors are investing $100 million over the next five years to provide free Allscripts’ e-prescribing software to every U.S. physician as a way to jumpstart the use of e-prescribing software, and eventually electronic medical records, to reduce preventable medication errors and overall health care costs. NEPSI says,”We are not trying to lock providers into a one-vendor solution – we have a solution that works with any Electronic Health Record, Personal Health Record or practice management system from any vendor certified by the Certification Commission on Healthcare Information Technology (CCHIT).” For more information from NEPSI, see the press release from earlier this month.

From ”Coalition Offers Doctors Free Electronic Prescriptions,” an article posted two weeks ago on Ziff-DAvis’ eWeek: “The [NEPSI] system will be able to transmit prescriptions electronically to over 95 percent of the nations’ pharmacies. Two of the health insurance companies in the coalition, Aetna and WellPoint, said that they would provide incentives for physicians to write electronic prescriptions. Another coalition member, Sprint Nextel, is offering free pocket PC phones to doctors who sign up early…The initiative is offering a free Web-based system that would instantly check prescriptions for interactions with other medications (powered by a database provided by Wolters Kluwer Health) and would also check how much a patient or plan would have to pay for a drug. Google is providing a custom search engine to help physicians find relevant information for themselves or patients. Patient information will be stored remotely so that it will not be compromised if a doctors’ phone or computer is stolen.” 

This is not the first such effort. The article recalls how, in 2004, one coalition member—health insurer giant Wellpoint—invested $42 million in an effort to provide free e-prescribing software. “Doctors took the free stuff, but did not use it for the intended purposes. Since then, however, health IT evangelists have made large headways to create more positive attitudes toward health IT. ”

That same year, a second e-prescribing initiative involving many of the same NEPSI founders, Cafe Rx, also dissolved. Digital Healthcare & Productivity’s article, Free ePrescribing S/W Initiative Stirs Interest and Debate, goes into greater detail regarding Cafe Rx and quotes several competitors who speculate regarding NEPSI’s ulterior motives, along with replies from Glen Tullman, Allscripts CEO. “Tullman is clear that neither Google nor anyone else will mine data collected as part of the eRx NOW program and use the results for marketing purposes. ‘Patients and physicians will have unique access to all the information…Google will have no access to data we receive as part of the electronic prescribing process.’ Other questions raised about the e-prescribing program focus on accessibility of patient demographics and drug formularies. Notably absent from the list of NEPSI sponsors and supporters was RxHub, a joint venture of major pharmacy-benefit management companies that provides real-time electronic connectivity to patient-specific formulary and drug-benefit information. Tullman acknowledges that many users would have to find a third party to link the prescribing software to existing practice management and billing systems, but says that eRx NOW follows established standards to make the link. ‘We’re happy to interface with any practice management system.’ Tullman also addressed the formulary question by saying that Allscripts has access to eligibility and preferred-drug lists of more than 95 percent of payers nationwide via SureScripts and through the company’s own business relationships. He said that Allscripts was having discussions with RxHub and with practice management vendor Per-Se Technologies—now a part of McKesson due to an acquisition that closed last week—to find ways to pre-populate eRxNOW.”

January 2, 2007

Brailer on Health IT

Before the holidays, the former National Coordinator for Health IT David Brailer, MD, gave an interview for iHealthBeat, the news digest of the California HealthCare Foundation. The full interview, released today, is available as an audio file (excerpts above, downloadable mp3 file below) or a PDF transcript.

From the interview:

  • “I always told people that the battle over health IT adoption was over. It was just a matter of time. The real fight, and this one I don’t have such optimism about, is the fight over patient centricity, or patient control of their health care, and, therefore, control over their health care information…And that’s not so much a health IT battle. That is a battle over the heart and soul of who owns controls and who sets the priorities for the health care system.”
  • “I think we don’t have the right privacy and security regiment. The one that we have under HIPAA and state laws was created largely in a world that didn’t anticipate electronic information that was stored for, or by, or used on behalf of the patient…And I think the American public has been very clear that they want to see privacy protections in place before they’re really willing to jump into [electronic medical records].”
  • “…incentives for adoption [of health IT]. We had the one-year fix to the sustainable growth rate…which gave physicians a bonus for submitting quality data. That has no effect whatsoever on health IT adoption. So it’s time to come back to the question that we’ve put aside during the whole pay-for-performance discussion for three years about the market incentives and the policy incentives to bring us into full adoption of electronic records. I, as a very keen supporter of incentives, withheld my judgment on that during the pay-for-performance period. I think it has now had its chance, and it hasn’t been able to deliver a policy with the impact that I think convinces me that it’s going to help us with adoption, particularly among doctors in rural areas, in a safety net and even small practices.”
  • “Well, I think the change…comes from every place but Washington…in states and in the private sector…I see states moving quickly, and they will do more in 2007 to create a more fertile environment for health IT.”
  • “But I think the promise of personal health information being shared goes beyond a record. I’m particularly excited by remote monitoring, remote patient management; things where it’s not just a static database but where we’re monitoring someone in their home so they don’t have to be in a nursing home or where someone can be monitored in an ICU bed and a doctor doesn’t have to be present all the time but can be tele-present…That is the same concept of a personal set of health information that is centered around the person, but it probably doesn’t meet our definition of what we would call a PHR today. I view more convergence happening between that concept of the database and the streaming set of information, as we really ask the questions about what problems the PHR solves or what opportunities it creates. I think as we start thinking that way, we will come back to this set of functional tools that help us improve the patient role in health care, just like health information has helped us in traditional care delivery beyond the electronic health record — medication administration, reduced errors in inventory management, the way communication occurs, let alone computerized physician order entry. These things that are unheralded heroes of how IT does help are a broad bundle of change, and I think you’ll see that on the personal side as well.”
  • “I think there are two subdebates that will play out, so it creates kind of a two-by-two table with four outcomes. The first one is whether we will go beyond all of the lip service. The patient should be in control of the health care system, in control of their care. They should have information to make treatment choices. They should have information to make a choice about a doctor. They should have the information to be able to make tradeoffs when it comes to various outcomes. And I think this is quite pronounced as we start thinking about the genomic world, where you have so many genomic risks, like, you know, you might have heart disease in the future, or you may have breast cancer, or you may have memory loss. And you have to decide if you’re going to act on that 20 or 30 years in advance. This question about whether we are going to move beyond the promise and actually make the health care industry centered on that, which is profoundly disruptive to the established interests that rely upon a very high volume of hospitalizations, or bouncing patients around, and churning patients a lot because we can’t quite create integrate care processes around them, you know, that’s disruptive. And I think that’s a debate about how far the industry will come towards focusing on patient control and consumer choice. And so you could think about that as either happening or not.
           Secondly, and I think apart from that, there’s a debate about the role of government. We’re sitting in a hybrid system now. Government intrusion in private sector, or participation — neither one is dominant and neither one has the leverage to make it cohesive. The industry can’t do what it’s done in other industries, which is squeeze out the inefficiencies and create, really, a seamlessly integrated experience. Look at the financial sector, elsewhere. Nor can government do this because it doesn’t have control, and I think it has a lot of conflicts of interest with respect to how to make health care work versus the Medicare Trust Fund be solvent. And so you see kind of that being … now sitting at a point of maximum agony. I think that’s going to flip one way or the other. So we could have a very government-controlled system that’s consumer responsive or a government-controlled system that is quite provider-driven, and we could have a private-sector system that’s one or the other.”

January 1, 2007

Privacy Rites

Filed under: — mlazoff

Spread of Records Stirs Patient Fears of Privacy Erosion made Page One of The Wall Street Journal’s December 26th issue. The article opens with the story of a middle aged tax attorney who was denied accident disability benefits based on information her insurer obtained through her medical records–specifically, psychotherapist’s notes allegedly documentating travel and work-related activity that conflicted with her claim. 

According to the article, neither state nor federal law currently safeguards the privacy of confidential information in electronic medical records. ”[Health Insurance Portability and Accoutability Act] HIPAA’s principal goal was to ensure that people could change jobs without losing insurance coverage for pre-existing medical conditions. When employers and insurers complained about the added cost, the federal government pledged to make it easier for medical providers, insurers and others to swap medical information electronically, potentially saving as much as $30 billion over a decade. To assuage concerns of privacy advocates, Congress authorized the Department of Health and Human Services to draft privacy regulations. The final rules allow health insurers and medical providers — including doctors, pharmacies and hospitals — to disclose medical information for “treatment, payment and healthcare operations,” among other situations, without specific patient permission. But they aren’t supposed to send any more records than necessary for nontreatment purposes.”

The article goes on to describe other examples of unexpected disclosures: how one hospital’s collection agency had detailed information from the medical records of an uninsured patient; how patients diagnosed with borderline diabetes received unsolicited marketing materials from their medical providers. “The federal rules allow patients to ask doctors, other medical providers and insurers not to share records with certain people, groups or companies. But medical professionals and insurers can ignore such requests” if, for example, it is technically unfeasible or if the request would incur addtional costs.  

However one feels about the examples provided in this article, the assurance of confidentiality is at the heart of patient care. From the Health Care Renewel blog, see Another Electronic Medical Records Horror Story by Scot Silverstein, MD, director of Drexel University’s Institute for Healthcare Informatics. All three letter responses to the article as printed by the WSJ are available on the nonprofit organization Patient Privacy Rights Web site.

December 14, 2006

It doesn’t hurt to ask…

Filed under: — mlazoff

Two recent surveys released earlier this month provide contradictory data regarding patients’ enthusiasm for electronic health records (EHRs). First, a PriceWaterhouseCoopers study, The Top Seven Health Industry Trends of ‘07 (free registration) found that only 34% of the 1,000 Americans surveyed last October are convinced that EHRs will improve the quality of healthcare. Then, several days later, the Markle Foundation released their survey of 1,000 (presumably different) Americans surveyed last November, 88% of whom believe online EHRs would be important in at least one component of quality care: reducing unnecessary and redundant tests.  EHR adoption has been slow in the US, and some predicted that patient interest would help spur growth in healthcare information technology.   

December 2, 2006

Wal-Mart Rollbacks EMR

Filed under: — mlazoff

A November 29th Wall Street Journal article (available to WSJ subscribers) reports on a plan by Wal-Mart, Intel and British Petroleum, among others, to develop a joint employee-owned digital medical records system that will link physicians, hospitals, and pharmacies. ”Their goal: to cut costs by having consumers coordinate their own health care among doctors and hospitals.” 

The initiative was suggested to Wal-Mart by the Centers for Disease Control and Prevention, who is active in several government HIT efforts. A 2005 CDC study posted on their site found less than 10% of office-based physicians use EMRs containing a minumum set of required features.

According to the WSJ, “At the heart of the Intel-Wal-Mart approach is the belief that if price and quality measures apply market pressures, technology can duplicate the integration that government-run health-care systems…achieve…The government posts pricing information using the fees charged to Medicaid. Groups including Hospital Quality Alliance, Ambulatory Quality Alliance and the Wisconsin Collaborative for Healthcare Quality rate hospitals and doctor groups on quality. ‘The evidence is beginning to show that what gets measured and reported publicly gets improved faster,’ says Christopher Queram, president of Wisconsin Collaborative for Healthcare Quality, which began rating southeast Wisconsin hospitals and doctors in 2003.”

Employee participation will be voluntary, but participants’ physicians must use electronic records and e-prescribing. As the nation’s largest employer, Wal-Mart has promoted its employee health plan as consumer-empowering, but others have criticized it as ”miserly.” Wal-Mart’s successful (if not profit-generating) $4 generic drug plan and their more controversial walk-in health clinics may be more marketing tools. 

Freely available commentaries on the article are available from the media company Red Herring, Intel, Wal-mart Plan Health Net, and in a post by Scot Silverstein, MD, from the thought-provoking Health Care Renewal, headed by Brown University’s Roy Poses, MD. [Added Dec 4: For background information, see Health-IT World News Intel, Wal-Mart Call For Employer Activism in Demanding Health IT. The reporter, Neil Versel, has posted a podcast of his interview with these companies’ executives.]

November 3, 2006

CCHIT interchat static

Filed under: — mlazoff

On October 27th, HHS designated the Certification Commission for Healthcare IT (CCHIT) the first recognized certification body to ensure the functionality, interoperability and security of health IT products such as electronic health records (EHRs). (see N&V’s CCHIT Chat) Yet according to an October 30th article in Modern, interoperability is not yet operable. “CCHIT is still waiting for standard-setting bodies to finish their tasks so, for 2006, the only interoperability requirement needed for certification was the ability to receive laboratory-test results electronically. Starting in May 2007, EHRs will need to be able to electronically transmit prescriptions in order to be certified. And, in 2007, [CCHIT Chairman] Leavitt said they will need to be able to electronically transfer medical-record summaries…’We’re going to get more interoperability criteria every year,’ he said…” 

CCHIT Chairman Mark Leavitt noted the HHS’s recognition will ”serve to promote more interoperability between EHRs because it opened the door for more hospitals, health systems and health plans to donate EHR hardware and software to their affiliated physicians.” (see N&V’s Kicking Back Anti-Kickbacks) A conditions of the new exceptions is that the donated EHR be certified within 12 months prior to the donation by a certification body recognized by the Secretary of the HHS—and right now, that’s only CCHIT. 

October 19, 2006

AHIC’s Mini-Me

Filed under: — mlazoff

From an article posted on GovernmentHealthIT: “Through a [$2 million dollar, 1 year] contract with the National Governors Association (NGA), the Office of the National Coordinator for Health Information Technology will sponsor formation of a State E-Health Alliance in 2007…Under the agreement, NGA’s Center for Best Practices will form a high-level steering committee that includes governors and state legislators to tackle barriers to the formation of health information networks…Interim National Coordinator Robert Kolodner described the states’ project as mirroring at the state level the American Health Information Community, which is the Department of Health and Human Services’ advisory committee consisting of federal, health and corporate leaders.”

October 13, 2006

EHR Mega-meta-analyses

Filed under: — mlazoff

The answer to the title of Wednesday’s Health Affairs article, How Common are Electronic Health Records in the United States? A Summary of the Evidence, is no surprise: “…when available information is limited to studies of high or medium quality…[t]hrough 2005, approximately 23.9 percent of physicians used EHRs in the ambulatory setting, while 5 percent of hospitals used computerized physician order entry.”  Between 1994-2005, ten ambulatory studies of sufficient quality were identified, although the statistics for ambulatory EHR use cited above come from only one: the CDC’s 2005 National Ambulatory Medical Care Survey (see News&Views The Times They Are A’Changin…A Little, Take Two), an annual survey whose methodology the article supports in general, while offering suggestions for improvement. All ambulatory studies found that solo practitioners were less likely to use EHRs than were physicians who worked in larger practices. According to the article, there is no accurate national statistics on the use of inpatient EHRs, although a single high quality survey found 59% of hospitals have at least patient demographics in electronic format.

In summary, the authors, “…found distinct shortcomings in the literature including varying EHR definitions, varying quality of survey methodology, and almost no information about the use of EHRs by safety-net providers.” The article was authored by faculty from Harvard’s School of Public Health and Institute of Health Policy, and George Washington University’s Department of Health Policy, and was supported by The Office of the National Coordinator for Health Information Technology.

Medpundit links to the Washington Post article describing this study, and comments from her perspective as a solo practitioner “why EMRs have been so slow to catch on?” In addition to expense and regional trends, “…hospitals are emerging as the dominant forces in selection of electronic records systems. They’re seeking to have integrated networks in which everyone in the community (or hospital community anyway) uses the same hospital-based electronic record. That means that each doctor’s medical records are housed on the hospital’s servers and that everyone in the hospital (or at least every doctor in the hospital and probably lots of administrators) has access to them. Some doctors embrace this idea, but others are leary of having their patient records owned and controlled by someone else. Many are waiting to see how this shakes out. No one wants to invest tens of thousands of dollars in a system only to have it prove to be useless when community standard becomes a hospital-approved and sponsored record. Nor do they want to jump into a hospital partnership that could go south in a couple of years if it proves too much of a financial burden for the hospital.” See News&Views Kicking Back Anti-Kickbacks on how the federal government is now supporting hospitals and others who wish to donate HIT programs to physicians, for better or for worse.

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