Important New Evidence on the Journey to HIT-Assisted Health Care

 On February 2, ONC had a major announcement related to the Direct Project.  Media were in the audience and on the phone.  One questioner in particular was picking on the value of EHR's, citing a recent Stanford review that suggested EHR's had questionable benefits.

Sitting in the front row of the audience, it was easy to gauge Dr. Blumenthal's heartfelt feelings, that this interviewer, and the referenced study, had it wrong. Now in a systematic and thorough literature review, Dr. Blumenthal, Melinda Buntin, Matthew Burke and Michael C. Hoaglin address these criticisms head-on and find consistently overall favorable affects of Health IT.

Check out this interview: Reaping the Benefits of Health IT: Q&A With ONC's Dr. David Blumenthal

And here's Dr. Blumenthal's response, from the ONC Blog:

Tuesday, March 8th, 2011 | Posted by: Dr. David Blumenthal

When Christopher Columbus set sail from Palos in the Gulf of Cadiz, he knew he had theory and experience on his side. The theoretical conception of the Earth as an orb was as solid as it could be. And Columbus had experience of the trade winds that could speed him both westward and eastward. Yet the final evidence was his to provide.

In deploying health information technology (HIT), including ubiquitous use of interoperable electronic health records (EHRs), we also are at the cusp that is faced by every pioneering enterprise: When all is said and done, the proof is in the pudding.

In 2009, building on a bipartisan foundation of many years’ making, Congress and the President authorized a very substantial national investment in transitioning from paper-based to HIT-assisted health care. We knew the benefits that should ensue, and we had important data from several large HIT “leader” providers, such as the Veterans Administration, Kaiser Health Plan, and others.

Yet, in truth, it is only as we approach the shore of adoption and meaningful use of EHRs that we will truly know the dimensions and consequences of our investment.

Today in the policy journal Health Affairs, an article by several ONC authors shows tantalizing hints at what may await us: Strong evidence regarding the benefits of HIT.

Using assessment methods that were employed by two previous independent reviews, the new study finds that 92 percent of recent peer-reviewed articles on HIT reached conclusions that showed overall positive effects. The study also finds increasing evidence of benefits for all health care providers, not just the larger HIT “leader” organizations that have provided much of the data regarding experience with HIT in the past.

This article brings us much more up-to-date, both in our confidence regarding evidence of the benefits of adoption and use of HIT, and also in our understanding of problem areas that still need to be addressed. This review is important because it helps us correct for the lag in evidence that occurs naturally in the literature, where research has trailed the now-accelerating implementation of HIT.

The review looks at articles published from July 2007 up to February 2010, following up on earlier reviews that had looked at articles from 1995 to 2004 and from 2004 to 2007. This update screened more than 4,000 articles, of which 154 were found qualified for the parameters of the study, a number similar to the previous efforts. It found positive results in 96 of the articles (62 percent), and mixed but predominantly positive results in 46 other articles (30 percent).

Negative findings in the study were most often found in studies of provider or staff satisfaction. According to the article, these findings “highlight the need for studies that document the challenging aspects of implementing HIT more specifically, and how these challenges might be addressed,” such as through strong leadership or staff participation when adopting and implementing HIT. There is also a pressing need to make EHRs more user friendly.

So even as our confidence grows that the nation has made a wise investment, we need to carefully monitor for course correction and continual improvement.

Today’s article adds significantly to strong, evidence-based confirmation that we are headed in the right direction. It likewise confirms what we know intuitively: There will be challenges, surprises, and bonuses throughout this journey to universal adoption and meaningful use of HIT.

Health IT - "Every provider, every patient will benefit"

National Coordinator for Health IT David Blumenthal has sent the strongest signal yet that requirements aren't likely to relax substantially from the proposed rule.  His latest post makes the case that providers and healthcare organizations have a principled obligation to adopt Health IT as contemplated by HITECH.  Blumenthal asserts that "while large hospital networks and smaller providers may be stretched to meet national health IT goals, it is not beyond their capacity for growth."

Adoption of Health IT
by Dr. David Blumenthal

Introducing change in health care is never easy. Historically, adopting our most fundamental medical technologies, from the stethoscope to the x-ray, were met with significant doubt and opposition. So it comes as no surprise that in the face of change as transformational as the adoption of health IT – even though it carries the promise of vastly improving the nation’s health care – some hospitals and providers push back. I resisted using EHRs while an internist in Boston, as I wrote in my blog, “Why Be a Meaningful User.” Over time, however, I found that working with health IT made me a better and safer physician. Most importantly, my patients received better, safer care and improved outcomes.

There are thousands of stories like mine across the nation. The question health care providers are facing today is whether we are pushing too hard, too fast to make this important change. I respectfully submit, no. In turn, I ask, “Can we make these changes expeditiously enough?”

Americans deserve better health care than they are currently receiving, and they need it delivered more efficiently. Every provider, every patient throughout our nation will benefit from the goals envisioned by the HITECH Act. Yes, this will be a challenge. While large hospital networks and smaller providers may be stretched to meet national health IT goals, it is not beyond their capacity for growth.

Doctors and hospitals will not have to go it alone. Programs, such as our 60 Regional Extension Centers located throughout the United States, are working hard to ensure that providers have all the necessary resources to meet the challenge. The incentive program will then provide reimbursement to providers who have achieved meaningful use.

This is the time to realize the promise of health IT. Information technology has improved every aspect of our lives, we need to channel information technology to improve our health and care. Providing patients with improved quality and safety, more efficient care and better outcomes is paramount. Physicians who adhere to the oath of Hippocrates believe we must act with all deliberate haste. More than two thousand years later, we can’t forestall health care quality improvements, not when so many patients entrust their providers for the best care they can possibly deliver. As the saying goes, “If not now, when?”

NIST Health IT Standards and Testing

The National Institute of Standards and Technology (NIST) has launched the Health IT Standards and Testing website with the first installments of a new health IT test method and related software.

Starting in 2011, the federal government will provide extra Medicare and Medicaid payments to physicians’ offices that implement health IT systems conforming to specific technical standards and put to “meaningful use”, performing specifically defined functions. Late last year, the U.S. Department of Health and Human Services (HHS) identified the required standards and provided a concrete definition of “meaningful use.” To help physicians’ offices evaluate possible health IT systems against these requirements, the HHS’s Office of the National Coordinator (ONC) has established a national health IT certification program.

As mandated by the American Recovery and Reinvestment Act (ARRA), NIST and HHS are working with health IT system vendors, standards organizations that include the American National Standards Institute (ANSI) Healthcare Information Technology Standards Panel, certification bodies and system implementers to develop a suite of software tools to support the health IT testing infrastructure. The tools are intended to help vendors test their health IT products and ensure basic functionality, such as the calculation of body mass index or proper formatting of common electronic health records in XML (eXtensible Markup Language).

The health IT testing infrastructure does not create any new standards, only the tools necessary to test for compliance with existing standards that HHS announced late last year. Testing laboratories will use these tools in the testing component of the certification programs established by ONC. ONC has stated its intention to use NIST’s National Voluntary Laboratory Accreditation Program (NVLAP) to perform the accreditation of testing laboratories.

A new Health IT Standards and Testing web site has been established to provide more information on the program and the testing infrastructure suite.

Conformance Test Method Rollout Schedule

Improving Care Coordination Through Health IT - Part II

Dr. Ann O'Malley and a research team from the Center for Studying Health System Change were profiled asking how care coordination could be improved through health IT. In Part II of this report, HTN sits down with Dr. O'Malley to ask about the study and its implications.

The study, published in The Journal of General Internal Medicine article, titled "Are Electronic Medical Records Helpful for Care Coordination? Experiences of Physician Practices," interviews physicians and staff with at least two years of experience with commercial ambulatory EMRs in place, along with CMO's from Health IT vendors and national thought leaders on health IT.

HTN: Why is coordination of care so difficult?

Ann O'Malley: First, it is not compensated. So coordination activities carried out by clinicians and their staff are done at the expense of other billable activities. Next, the average Medicare beneficiary sees 7 different physicians in a given year, that's a lot of people with whom that person's regular doctor may need to communicate. Third, systems are not in place to facilitate communication among clinicians caring for the same patient.

HTN: What are the primary policy and technical changes that could help?

Ann O'Malley: First, the creation of incentives for providers to coordinate care and to communicate with one another would be helpful. This includes not just financial incentives, but breaking down some of the existing systematic barriers to coordination that are present in the fee-for-service system. Next, improving the basic care processes around coordination and the infrastructure to support those processes, such as improved health information technology capabilities important to coordination tasks, could be quite helpful.

HTN: You identified many opportunities to take advantage of current technology. Which of these were likely to have the biggest impact on care coordination?

Ann O'Malley: Interoperability between EMRs is key so that clinicians in different offices or across inpatient and outpatient settings can exchange patient data in a secure way that promotes coordination.

HTN: You also identified areas for EMR improvement. Which of these were likely to have the biggest impact on care coordination?

Ann O'Malley: It's hard to say at this point in HIT development. But among the clinicians we spoke with, the exchange of medication lists, problem lists, and communication around referrals and consultations as well as shared care plans were quite important.

HTN: ONC has published the rules by which eligible professionals will be receive incentive payments to be meaningful users of a certified EHR. Where are these rules on the mark, and where do they fall short in terms of facilitating coordination of care?

Ann O'Malley: They are appropriately taking an incremental approach because there is such variation in terms of EMR implementation among U.S. practitioners.

HTN: You interviewed clinicians and leaders that are working every day with EMR technology. What's their general "temperature" related to the state of Health IT and EMR's?

Ann O'Malley: In general, most clinicians would not go back to paper. They felt EMRs were an improvement for care provided within their office. For those outside of integrated delivery systems however, EMRS were not felt to be helpful as they currently are designed and used for coordination of care across offices or settings.
_____________________________

Ann S. O'Malley MD, MPH is a senior health researcher with the Center for Studying Health System Change. She conducts quantitative and qualitative research on a wide range of topics related to quality and access. She is particularly interested in primary care delivery, its intersection with specialty care, and the coordination of care from both the patient and provider perspectives. O'Malley completed her pediatrics internship at Georgetown University Medical Center and a residency in preventive medicine at the University of Maryland Medical Center. She received her master's degree in public health from Johns Hopkins and then completed a National Research Service Award fellowship in primary care research. She is board certified in preventive medicine and is a fellow of the American College of Preventive Medicine.

Improving Care Coordination Through Health IT - Part I

Coordination of care is a significant problem in part due to the large number of specialists involved in patients’ care and a perverse payment system that rewards the most expensive care, doesn’t reimburse for proactive health management, and drives fragmentation of care delivery.

Into this web, steps Dr. Ann O’Malley and a research team from the Center for Studying Health System Change (HSC), asking how care coordination can be improved through health IT. Their findings are published in The Journal of General Internal Medicine, “Are Electronic Medical Records Helpful for Care Coordination? Experiences of Physician Practices”.  For their study, they interviewed physicians and staff with at least two years of experience with commercial ambulatory EMRs in place, along with CMO’s from Health IT vendors and national thought leaders on health IT.

'The study reports that a gap exists between policy makers' expectations that current commercial electronic medical records (EMRs) can improve coordination of patient care and clinicians' real-world experiences with EMRs.

Current commercial ambulatory care EMRs facilitate care coordination within a practice by making information available at the point of care but are less helpful for exchanging information across physician practices and care settings, according to the study supported by the Commonwealth Fund.

Clinicians identified many areas where both the design of EMRs might be altered, and office care processes modified, to improve EMRs' support for tasks involved in coordinating patient care.

Additionally, while current commercial EMR design is driven by clinical documentation needs, there is a heavy emphasis on documentation to support billing rather than patient and provider needs related to clinical management, the study found. And, current fee-for-service reimbursement encourages EMR use for documentation of billable events, office visits, procedures—and not for care coordination, which is not a billable activity.

"There's a real disconnect between policy makers' expectations that current commercial electronic medical records can improve care coordination and physicians' experiences with EMRs," said HSC Senior Researcher Ann S. O'Malley, M.D., M.P.H., coauthor of the study with HSC Senior Researcher Joy Grossman, Ph.D.; HSC Research Assistant Genna R. Cohen; former HSC Research Analyst Nicole M. Kemper, M.P.H., and HSC Senior Researcher Hoangmai H. Pham, M.D., M.P.H.

Excerpts from their findings that can be used to inform future EMR improvements include:

• EMRs may have unintended consequences for care coordination, such as creating information overload that complicates providers’ efforts to discern key clinical information. And, managing information overflow from EMRs is a challenge for clinicians.

• Clinicians believe current EMRs have limited ability to capture dynamic planning and the medical decision-making process in a way that supports future coordination needs—present EMRs focus on linear (moment-in-time) documentation while care coordination is dynamic and ongoing.

• Maximizing the potential of an EMR for coordination involves ongoing evolution of clinical care processes as well as clinician input on EMR design modifications and standards for data exchange to support those processes.

• Modifying reimbursement to encourage coordination of care by clinicians will likely drive clinicians to demand better EMR functioning to support coordination.

• Simply creating incentives to adopt EMRs as they currently exist, given the confines of the current payment system, may result in EMRs being designed for billing purposes primarily rather than for clinical relevance to patients and care coordination.'

The team identified EMR features that contribute to care coordination and areas for improvement.

In Part II of this article, HTN interviews principal investigator Ann O'Malley.

Best Links to HITECH

To understand the implications of the stimulus legislation on health IT in 3 clicks or less, here are the places to turn:

Health Care and the American Recovery and Reinvestment Act. New England Journal of Medicine. 2/17/2009.

Stimulus Bill dramatically modifies HIPAA rules. Wisconsin Technology Network. 2/18/2009

A Shared Vision and Roadmap for Health IT. By the chairs of the National eHealth Collaborative, HITSP and CCHIT. 2/10/2009.