In rush to digital medical records, progress comes slowly
The day before Mac Greene died, he visited a wound doctor. Greene had some bursitis on his elbow—a fluid-filled sac underneath his skin. But without access to Greene’s medical records, the specialist couldn’t treat Greene. He especially couldn’t see that Greene needed medication to stop the fluid from spreading to other body parts.
Instead, the wound doctor sent Greene back to his oncologist. After all, Greene was suffering from colorectal cancer, and didn’t oncologists deal with cancer patients?
But Greene landed in the hospital before he even saw another medical professional. Forty-eight hours later, he was dead.
Only later when the hospitals doctors obtained Greene’s health files, did they learn that fluid in his chest put pressure on his heart, causing it to stop. The hospital didn’t know this information because they didn’t have Greene’s records either. His primary-care physician failed to mail Greene’s paper files to other medical offices in time to save the patient’s life.
“The chain of information and the specialists in the health care system— if these aren’t connected, people can die,” said Kenyon Crowley, Greene’s stepson. “It causes pain, it causes loss, it causes inefficiencies, and it causes costs.”
Of all people, Crowley understands the magnitude of this problem. That’s because he works as the assistant director of the Smith School’s Center for Health Information and Decision Systems at the University of Maryland. If only Greene’s file could have been more easily transmitted—even e-mailed—between doctor’s offices, he said, someone could have prevented his stepfather’s death.
As part of his 2009 stimulus package, President Barack Obama offered $27 billion to encourage all physicians to computerize health records by 2015. “Health IT” mainly refers to the digitization of paper patient files, but it also includes how professionals manage the exchange of information between doctors, patients, insurance providers and the government using software.
In the health care debate, hot topics such as premiums, preexisting conditions, and individual mandates have dominated the headlines. But some lobbyists and Congressmen are beginning to say that electronic health programs —and the growing business empire that surrounds it—could be a noncontroversial solution to improving our health.
“We administer the largest, most complex, and arguably the most important sector of our economy with manila envelopes—even though our lives and well-being are at stake,” wrote Newt Gingrich and Tom Daschle in their book, Paper Kills 2.0. “Updated, accurate and comprehensive patient information will prevent medical errors.”
But medical centers have faced roadblocks as they’ve tried to implement Obama’s recommended programs. Few hospitals and practices have made progress towards electronic medical records in 2011, blaming costly installations. And in light of the proposed budget cuts led by Republicans, health care professionals wonder: what do facilities need to do to meet the law’s goals by 2015? And more importantly, will meeting them make us healthier?
21st-CENTURY SYSTEMS FOR 21st-CENTURY HEALTH CARE
Starting this year, doctors who comply with the stimulus law and use electronic medical records in a “meaningful” way begin to receive incentives in the form of Medicare reimbursements up to $65,000—almost four times more than it costs to treat a Medicare patient annually, according to a Dartmouth report. The government has yet to define the term, “meaningful,” but many doctors agree that a “minimally functional” system can view lab results and clinical records, as well as order tests and prescriptions online.
Meaningful health systems “have to be able to talk to each other,” said Vincent Frakes, the national policy project manager at the nonpartisan Center for Health Transformation. Frakes compares the ideal accessibility with that of ATMs—just like Americans can access their bank records at an ATM in India, health professionals should be able to view files from any location.
“If you put records in their hands, more people will have a more proactive, interactive relation with doctor,” Frakes said. “If we’re moving towards saving lives, it’s a natural way of getting to that goal.”
The physicians who fail to install digital health records by 2015 will face a one percent reduction in Medicare reimbursements every year until implementation.
Tim Huerta, assistant professor of Health Organization Management at Texas Tech University in Lubbock, Texas, says health facilities cannot possibly meet nationwide standards by 2015.
“You can’t legislate innovation. It’s impossible to make any advancements because we have no idea how changes in the system affect the quality of care,” Huerta said. “You have some hospitals who don’t even know how much it costs them to do a specific procedure.”
In 2008 only four percent of physicians used electronic medical records that could be described as “meaningful,” according to a national survey in the New England Journal of Medicine. And according to a study published in Health Affairs in 2010, only two percent of U.S. hospitals reported having electronic medical records that meet the government’s criteria.
Huerta said doctors may resist adopting the technology because it consumes a facility’s manpower, time and money. Doctors may have to pay to train employees how to operate the system, or spend the time or money to learn themselves. Meantime, the digitization of hundreds of thousands of paper medical records could take years. That switch could take up to 10 years for hospitals with high volumes of patient files, said Kim Bussie, the Director of Health Information Management at Howard University Hospital.
That’s why professionals need to adopt a business model, Huerta said. If medical institutions invest in health software, physicians will “increase revenue and reduce staff.” By transferring paper records to a computer, records would never be lost. Electronic files eliminate sloppy handwriting, and the human errors it causes. It only takes one mismatched document to wrongly administer a patient Ambien instead of Allegra. An online network would remind nurses to administer vaccinations and make switching doctors easier; rather than faxing a patient’s entire medical history to a new office, the receptionist could download a single file (complete with x-rays and charts) from a secure site.
Organizations such as the Electronic Privacy Information Center have long publicized the security concerns associated with Internet connections. In nature, electronic medical records are prey to hackers looking for personal information.
While Internet sites are always susceptible to fraud, electronic records are less vulnerable than paper files, Frakes said. The Center for Health Transformation estimates the current level of fraud at American Express—now largely paperless—below one-tenth of one percent.
Frakes said software developers such as GE and Siemens should aim to design secure systems, especially when paper errors in Medicare near $100 billion annually, according to a study conducted by the Center for Health Transformation.
“There is ample evidence that [electronic health records] do improve care,” said David Blumenthal, a former doctor and now the National Coordinator for Health Information Technology at the Department of Health and Human Services. “I avoided giving patients a drug they were allergic to or exposure to radiation they didn’t need because it was a duplicate procedure.”
After reviewing more than 4,000 cases in the past five years, HHS made a starting discovery: in two-thirds of these incidents, an electronic reminder stopped a professional from giving a patient the wrong service or drug.
“Professional competency will be unattained without the best ways to collect information,” Blumenthal said.
Other data contradicts the findings. A team at Stanford University found that “electronic health records do little to improve quality [of care].” Between 2005 and 2007, researchers made more than 250,000 visits to outpatient locations. They concluded that even when professionals had “decision support” software that advised them how best to treat individual patients, almost no correlation existed between IT and patient health.
“Putting a valuable tool in the hands of a doctor doesn’t mean they’re going to do anything with it. It requires a new mantra of thinking of how they’ll use this tool,” said Donald Wilson, the medical director at Quality Insights of Pennsylvania, a nonprofit organization dedicated to improving patients’ health. “You can’t expect health information technology to do it itself.”
KICKING IT OLD SCHOOL
Some professionals agree that computerized records alone won’t make us healthier, and that its costs can outweigh its benefits. Dr. Kevin Lanphear runs a family practice in Newburyport, Mass. While his staff has started to use electronic programs, Lanphear said the technology has only increased his daily work flow.
Lanphear currently owns a computer with a 32-bit processor. But to use the latest version of electronic medical records, he needs to upgrade to a 64-bit processor—an investment Lanphear says he can’t afford right now.
“I’m a fan of the technology, not just the mandates and the regulations that interfere with our ability to deal with patients,” Lanphear said. “I still have to do my day job.”
Denise Schwartzberg, a medical biller at plastic surgeon Dr. Carolle Lessene’s office in New York City, said between training staff and purchasing software, switching from paper to electronic “doesn’t come cheap.”
“Make the switch and it could cost $40, 000,” Schwartzberg said.
MAN VS. MACHINE
People across party and professional lines agree on one thing: the success and future of health technology depends on the people who operate it.
“I can have a great computer program, but if I don’t have people caring about the data, then the data will be poor,” Huerta said. “We need people who understand the meaning of coding. Most of them just have high school diplomas. They need a least an associate’s degree.”
As part of the Health Organization Management program at Texas Tech, Huerta teaches students, who can be certified in electronic health records, how to run hospitals and clinics. The market for this training is “growing faster than we’re capable of handling,” which means doctors will spend less money teaching employees the technology, he said.
Schwartzberg said she wanted to enter the health administration field because it looked “easy to pick up.” But she said electronic medical records could make her job even “easier.” Some of Schwartzberg’s responsibilities include processing insurance authorization for patients’ medical procedures.
“Sometimes patients have serious issues and needs to be approved for surgery,” Schwartzberg said. “If everything was done electronically, it would be a click of a button.”
The facility has yet to see stimulus money from the government. Currently, the reconstructive surgery office only uses a simple system that can log doctor’s patient’s notes, Schwartzberg said.
But in Schwartzberg’s ideal world, she’d be able to view every single patient’s medical history for the past 30 years on the computer. She could even look at x-rays and photographs—email them to insurance providers if her heart so desired.
She herself admits this fantasy isn’t too far off, that she’d be willing to do her part to integrate the new software into her office.
“I’m always happy to learn,” Schwartzberg said. “It can’t be that difficult.”
A glossary of terms
HIT (Health Information Technology): How professionals manage exchange of information between doctors, patients, insurance providers and the government
AS (Administrative Simplification): Health Insurance Portability and Accountability Act provision that mandates establishment of national standards for electronic health care transactions
EHR (Electronic Health Records): Digitized patient medical files
Interoperability: Ability of computers to work with each other
CCR (Continuity of Care Record): Example of interoperability; snapshot of a patient’s health history that can be uploaded to a thumb drive; includes history of present illness, current health conditions, medications, allergies
CDS (Clinical Decision Support): “Evidence-based” recommendations for treatment based on patient history
RLS (Record Locator Support): Index that shows where patient information is stored on computer or in locations (i.e. storage unit, file cabinet)
HIE (Health Information Exchange): Allows doctors to send/receive patient information between offices
DICOM (Digital Imaging and Communication): Form for viewing and sending radiology images and reporting
HL7 (Health Level 7): “Standard” message format for communication between different record management systems