Electronic Health Records

Federal Government on the Fast Track to Implement Electronic Health Records

May 17, 2010

iHealthBeat.org - Last week, National Coordinator for Health IT David Blumenthal published an open letter touting the Nationwide Health Information Network as a model to help health care providers meet the "meaningful use" requirements of the 2009 federal economic stimulus package, Modern Healthcare reports.

Under the stimulus package, health care providers who demonstrate meaningful use of electronic health records will qualify for Medicare and Medicaid incentive payments (Conn, Modern Healthcare, 5/17).

Blumenthal wrote that NHIN is "not a network per se, but rather a set of standards, services, and policies that enable the Internet to be used for the secure exchange of health information to improve health and health care."

He also acknowledged that some health care providers "may have simpler needs for information exchange, or perhaps less technically sophisticated capabilities." He said such health care providers could benefit from NHIN Direct, which still is under development (Blumenthal letter, 5/14).

NHIN Direct is a basic version of NHIN that offers health care providers open-source software to develop a network for the electronic transmission of health information (Modern Healthcare, 5/17).

Blumenthal wrote that NHIN Direct "is meant to enhance, not replace, the capabilities offered by other means of exchange." He added that the model could "complement existing NHIN exchange capabilities and strengthen our efforts toward comprehensive interoperability across the nation" (Blumenthal letter, 5/14).

In addition, Blumenthal wrote that ONC is "on an aggressive timeline" to develop standards for NHIN Direct so health care providers can use the framework to qualify for incentive payments.

He also called for greater public participation in the NHIN Direct project through blogs and a community wiki, which are available on the project's website (Modern Healthcare, 5/17).

In Search of ... Health Information Exchange

May 17, 2010

iHealthBeat.org - Californians think big -- as the seventh largest economy in the world we have to. And as one might expect we boast some of the biggest health IT successes and failures.

Kaiser Permanente recently completed a $4 billion-plus electronic health record initiative -- considered the largest completed civilian health IT project in the country.

... California received almost $38.8 million for HIE under the American Recovery & Reinvestment Act. While this may sound adequate, our estimates suggest that at least $1 billion is needed in California to meet National Coordinator for Health IT David Blumenthal’s vision:

"… the goal is to have information flow seamlessly and effortlessly to every nook and cranny of our health system, when and where it is needed, just like the blood within our arteries and veins meets our bodies' vital needs."

So it was with much excitement that I first read the language in the HIE funding announcement where his office stated the following:

"Medicare and Medicaid meaningful use incentives are anticipated to create demand for products and services that enable HIE among eligible providers. ... The resulting demand for health information exchange will likely be met by an increased supply of marketed products and services to enable HIE, resulting in a competitive marketplace for HIE services."

The expected $20 billion to $40 billion in incentives gave me hope, perhaps for the first time, that we finally had what we needed: a policy-driven government financed market for HIE services to sustain an elusive HIE market.

The Market Failure

Alas, as the first federal rule-making process overseen by CMS establishing "meaningful use" (MU) requirements and payments comes to a close, it does not appear that these government-driven "market forces" will optimally favor state HIE programs, or efficient and reusable HIE services for that matter. Here's where the market forces doctrine falls down in the current proposed MU framework:

A Medicare "eligible provider" (EP) qualifying for MU payments during the program's first two years may receive up to $44,000, with $30,000 of those payments coming in the first two years. If she does not qualify until after 2013, her incentive payments drop dramatically, to only $24,000. The market incentive therefore strongly encourages physicians to qualify for meaningful use in the first two years, discouraging later adoption.

However, the initial HIE requirements in those two years are expected to be minimal. It is likely that she will need to electronically prescribe and electronically receive lab results. It is expected -- though not yet known for certain -- that she won't need to electronically submit claims or eligibility inquiries, and other functions such as exchanging clinical information with other providers and patients will either require a solitary test, or will not require HIE at all. In fact, as currently written, all the MU requirements that propose exchange of information are totally silent on how this exchange is to be carried out.

In this case, silence is deadly rather than golden. The reason is that the rule does absolutely nothing to change current business practice, which is to develop costly and proprietary point-to-point interfaces. The rule also does nothing to encourage the use of reusable infrastructure and services, and it is completely silent on the use of any HIE services being supported by states through ARRA.

Another sad irony is the requirement that CMS forgot, or simply ignored. Doctors will be required to receive lab results electronically to be eligible for incentive payments, but hospitals that provide lab services are not required to send the results electronically to ordering physicians.

Meanwhile, the very same hospitals can meet their own MU requirements and receive at least $2 million in incentives without having to send electronic lab results to their customers. The oversight is staggering; hospital labs make up a large percentage of the outpatient lab business in California and nationally -- between one-fourth and one-third by volume. These hospital labs in some regions (especially rural areas) are the only game in town. This oversight will leave many physicians twisting in the wind with no choice but to forgo their own incentive payments.

Aligning Market Forces

CMS should do two things. First it should require hospitals with outpatient labs to deliver standardized electronic lab results to ordering physicians as part of the hospitals MU requirements. Second, CMS should align market and policy forces by allowing an "alternative pathway" where EPs and EHs could meet their HIE-MU requirements by connecting to a "state-certified" health information exchange organization (HIO).

This would not necessarily have to be an HIO operated by a state, and there could be multiple HIOs within a state, but they would all have to meet some minimal set of state and federal requirements. States could then ensure that local and state regulatory and statutory requirements -- for privacy and security for example -- are adequately incorporated into the policies of each certified HIO. This solution would help align market forces by channeling customers and resources to these fledgling entities.

eHealth and Health Reform

Health reform represents another massive opportunity to use policy and market forces to drive health IT adoption. While there is a sprinkling of language in the health reform bill suggesting that EHR and HIE (together "eHealth") services should be supported, one gets the feeling that our lawmakers didn't have enough confidence in HITECH or eHealth for that matter, to make it a central theme of health reform requirements.

While I'm thankful for the token nod to supporting EHR adoption for long-term care providers, I was expecting stronger policy levers to institutionalize eHealth services broadly in a reformed health care system. These levers are inadequately represented in the legislation. Accountable Care Organizations and Primary Care Extension Center programs may be encouraged but are not required in the legislation to use state HIE services, or be meaningful users of EHRs.

While the language is mostly suggestive, there remains a glimmer of hope that eHealth could be a larger piece of health reform. If we as policy makers, providers and consumers care enough about it, we must demand good policy choices to CMS during the current and forthcoming rule-making processes and make eHealth an intractable component of the health reform landscape. Bruce Fried in an April iHealthBeat Perspective pointed out one incredibly important issue that merits action in the determination of medical-loss ratios. Others will emerge in the months ahead.

As health reform policy and regulation is developed, we could go one of two ways. We could simply encourage our institutions to use these eHealth tools to demonstrate better care, or we could require it. The question for us all is whether we're confident enough about the benefits of eHealth.

I bank online, my groceries are bar coded, I make restaurant reservations using Open Table, I even file my taxes electronically. It is time for us to "think big" about the role of eHealth in our society and commit to doing what we all should have done long ago.