Health IT and the Care Continuum: Engaged Exchange of Health Information
In 2004, President George W. Bush set a goal that by 2014 every American should have an electronic health record (EHR).[i] October 1st 2010 marked the government’s foray into the 2011 Fiscal Year -- it is now T-3 years and counting. I have no doubt that every American will have an electronic health record by 2014. And if they don’t, well, they can have one of mine.
As a young person with a medical issue, I have upwards of 15 EHRs. Despite the prevalence of my EHRs, I doubt the quality of my care is significantly better. See, my EHRs don’t talk to each other. A few months ago I found myself trying to get care at a well-respected, technologically savvy, teaching hospital. Having not been there before, I attempted to have my medical records sent from another electronically enabled medical center. This task proved impossible and I had to have my friends bring me my hot-pink binder of medical records, which, unfortunately, did not reflect my most recent notes. See, in schlepping my medical records from hospital-to-physician-to-hospital, I had missed a visit. Indeed, it is a pain to ensure that the records are complete, even though many of them originated in EHRs.[ii] After all, a paper printout of an EHR is still just paper printout. The point of this anecdote is that if I, a Masters student in Health Systems Administration, cannot figure out the system, neither can your grandmother. This process is not safe or efficient and frustrates providers and patients alike.
2009 estimates show good progress toward President Bush’s goal: 46%[iii] of hospitals and 44%[iv] of ambulatory providers indicated that they have an EHR. Unfortunately, like my story showed, “adoption” is not indicative of meaningful adoption. When these rates are examined again, fully functional, communicating, EHR systems account for only 1.5%[v] of adoption in hospitals and 6%[vi] of adoption in ambulatory providers.
I don’t deny that full, meaningful, adoption is difficult -- startup costs are immense, workflow issues prohibitive, the Return on Investment questionable.[vii] Anyway the picture is painted, adopting a fully functional EHR is seemingly impossible for all but the largest medical centers.[viii] Fortunately, President Obama’s thrown a curve ball with the American Reinvestment and Recovery Act of 2009. Through the Title VII: Health Information Technology for Economic and Clinical Health Act, ARRA promotes the adoption of Electronic Health Records, promising upwards of 20 Billion dollars in incentive payments for the Meaningful Use of EHRs as defined by the Office of the National Coordinator (ONC).[ix] Furthermore, it allocates funds to provide assistance in vetting EHR software choices,[x] training workforces,[xi] and creating Health IT test-beds.[xii] But these programs are just tools. Indeed, the first step to creating a continuously learning high performing health IT system is to take advantage of these tools and incentives to lay a solid EHR foundation which exchange can be built from.
Second, it is time to spend energy not only on adopting EHRs but ensuring that we utilize them in patient centric ways. If patients aren’t engaged by their health information, what is the point? Sure, the physician has a complete record of care and is held responsible by mandatory quality reporting.[xiii] Sure, with clinical decision support tools and ePrescribing, drug safety increases.[xiv] But how does a patient know that these functionalities exist, let alone, that they are benefitting their health? If a provider cannot access an aggregated EHR at the point of care, again, what is the point?
Great strides have been made in integrating communities of care with electronic health information. Through the Patient Protection and Affordable Care Act, the Center for Medicare and Medicaid Innovation (CMI) has been tasked with defining and creating Accountable Care Organizations. These organizations will likely be based off of the Geisinger/Kaiser model and pay based on a capitated system.[xv] But what is more important than their payment structure and commitment to provide comprehensive care is their continual commitment to innovation.
This commitment to innovation is exhibited by CMI’s reception to mobile health technologies.[xvi] The ability of EHRs to interface with remote medical devices will be groundbreaking. Take, for instance, a diabetic. Currently, a diabetic takes a blood glucose reading and records it by hand. These logs are often illegible and physicians do not have the time to page through them to identify trends. Currently the technology exists to link glucose meter readings to patient records electronically. This link ensures that readings are recorded correctly and allows for physicians to passively monitor a patient’s blood glucose, enabling them to take immediate action when levels fall outside a predetermined range. Furthermore, the system can remind a patient to check their blood sugar and allows the patient to track their progress via an online portal. This application is a prime example of how technology enables effortless patient communication and provider accountability.[xvii] Pilot studies show that this kind of application is effective; indeed, it is correlated to a reduction of 5 points in blood glucose readings and a 1% reduction in HbA1c readings over a three-month period.[xviii]
But this level of innovation is not possible so long as we believe that EHRs are simply static repositories of information. Until there is an open flow of information between providers and patients, this level of innovation will remain but a dream. Indeed, patients and providers alike must demand this kind of functionality be reimbursed by payors by proving the tool’s value through consistent utilization and better outcomes. I believe that we can move beyond this dysfunctional Health IT system and into one that is truly patient centered. Have I been drinking the proverbial kool-aid? Probably. But if that’s what gets me to think outside of the “EHR as savior” box and vocalize the need for the engaged exchange of medical information across the continuum of care, pour me another glass. Cheers.
[ii]Medical Records Privacy Rights.
[iii] Beacon Partners. Healthcare Leaders Speak up on Where They are in the EHR Adoption Process.
[iv] NAMCS Data. Accessed May 2010. http://www.cdc.gov/nchs/data/hestat/emr_ehr/emr_ehr.pdf
[v] Jha et al., 2009, NEJM. Accessed May 2010.
[vi] NAMCS Data. Accessed May 2010. http://www.cdc.gov/nchs/data/hestat/emr_ehr/emr_ehr.pdf
[vii] Yu, Wil. Ambulatory Adoption. July 2010. Office of the National Coordinator for Health Information Technology.
[viii] Simon et. Al.” Correlates of Electronic Health Record Adoption in Office Practices: A Statewide Survey.” JAMA. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2215070/
[ix] Electronic Health Records and Meaningful Use.
[x] HIT Regional Extension Centers.
[xi] Community College Consortia to Educate Health Information Technology
Professionals in Health Care Program.
[xii] Beacon Community Program.
[xiii] Fact Sheet: Medicare Meaningful Use
[xiv] Hunt et al. JAMA. Effects of Computer-Based Clinical Decision Support Systems on Physician Performance and Patient Outcomes.
[xv] Lee et. Al. Creating Accountable Care Organizations. NEJM. http://www.nejm.org/doi/full/10.1056/NEJMp1009040
[xvi] $10B CMS Innovation Center to pilot eCare.
[xvii] Bluetooth Blood Glucose Meter Now
Interoperable With Nokia Phones.
[xviii] Watson et al. “Diabetes Connected Health: A Pilot Study of a Patient- and Provider-Shared Glucose Monitoring Web Application” Journal of Diabetes Science and Technology, March 2009, Volume 3, Issue 2: Page 345-352.