Tuesday, April 6, 2010

Health Affairs and Their Issue on Health Information Technology: Your DMCB Helps You Take A Tour

If you're mystified by the continuing folderol over electronic health records (EHRs), you may want to head over to your closest medical library and take a look at the latest April 2010 issue of Health Affairs. It has a good spectrum of informative articles on the Feds' efforts to promote adoption of EHRs, the debate on meaningful use, some of the usual pro-EHR fluff, what's going on in physician practices nationwide and - and kudos to the HA Editors on this - some warnings about where this technology falls short. You can read more about the issue at the Health Affairs blog.

Alternatively, since you are one of the thousands of savvy Disease Management Care Blog readers, all you really need to do is get a cup of an appropriately caffeinated beverage, adjust your monitor, sit back and quickly scan this encapsulated summary. THEN you can decide which articles warrant use of your precious time for closer inspection:

In her opening article, Editor in Chief Susan Dentzer points out that only 6% of hospitals and 2% of physicians rely on EHRs and that the Feds are banking on a combination of sticks and carrots to encourage them to adopt "meaningful use" EHRs. She notes the taxpayer's $29 billion investment in the HITECH legislation hinges on getting the definition of meaningful use right.

There's a Health IT Gold Rush Underway, says Nancy Ferris, thanks to HITECH's $750 million in grants and contracts going to 40 States and 30 non-profit organizations that, in turn, are supposed to facilitate health information exchanges and technical assistance. There'a another $225 million going to train people in information technology, courtesy of the Department of Labor. That's just for starters, and a pittance compared to the more than $14 billion that will go to physicians (as in $18,000 per doc per year) and hospitals. You can also get her summary of the five key goals of HITECH and wonder if it will be enough to prod physicians into spending an estimated $30,000 apiece for a functional EHR.

Want a screen shot of what the docs at Kaiser Permanente see when they're taking care of patients? It lists chronic conditions, immunizations, vital signs (including obesity), care suggestions ("flu shot due, Active tobacco use, advise quitting"), recent lab tests and a list of medications.

What happens when you put an ex-national coordinator for health information technology with the current coordinator for health information technology in the same room? After reading this exercise in mutual admiration and closed circular reasoning, the DMCB asks who really cares?

John Halamka is the blogging CIO Beth Israel and Deaconess and likes what he sees in the emerging definitions of meaningful use, but has some suggestions about increased governmental guidance without stifling innovation. Those suggestions include content specificity, creating better vocabulary subsets, better approaches to data transmission, and heightened secruity and quality reporting. This article - by someone well versed on how to use the written word - gives some insight as to why getting into the weeds of health information technology is not easy.

Sean Hogan and Stephanie Kissam of RTI International suveyed 4,484 physicians with a 2,758 responses (an impressive 62% rate). They found that 18% have at least a basic EHR and, depending on the which part you ask about, about 75-85% meet the various individual meaningful use criteria. The DMCB asks how many physicians met ALL criteria simultaneously, a number that was apparently not mentioned in the report. The DMCB also wonders if the other 82% of physicians, after reading this paper, might think they made a smart move by waiting.

James Ralson and other colleagues from Group Health report on that organization's experience with the system-wide implementation of an EHR, a patient centered medical home model of care and a web portal through which patients could view their test results, request medication refills and email their physicians. Before you take the time to read this, the DMCB warns there doesn't seem to be any new insights on how to pull this off outside of integrated delivery systems.

David Bates and Asaf Bitton of Brigham and Women's have some thoughts on how health information technology can be configured to better support the patient centered medical home. While they think the two are inseparable, they have some specific suggestions on how to achieve better clinical decision support, registries, communication capabilities that enable teaming, tracking of hospital discharges, patient friendly personal health records, enabling of remote monitoring and support of quality reporting. The DMCB agrees wholeheartedly, because much of this is already being used to great success in commerical disease management programs.

"Warning!" says Rushika Fernandopulle and Neil Patel, who describe How The Electronic Record Did Not Measure Up To The Demands Of Our Medical Home Practice. With great expecations, AtlantiCare started up a PCMH in New Jersey and found they were stymied by computer slow-downs, e-prescribing security glitches, inabilities to import lab data, clinical alert fatigue, increased physician busy work, too much effort reconciling medication lists, having to rely on an outside vendor, lack of a registry and inflexible on-screen templates unsuitable for non-physicians and group visits. They eventually turned to other software solutions to operate in parallel fashion.

Using "Analtyica 4.1 modeling software", Colene Byrne and colleagues from the "Center for It Leadership" performed a cost-benefit analysis of the Veteran Administration's $7.16 billion VistA EHR. Thanks to projected reductions in adverse drug events, diminished duplicate lab testing, reduced work, decreased operating expenses and more freed space, the cumulative yield in benefits net of costs was $3.09 billion. Before you take the time to read this, the DMCB again warns there doesn't seem to be any insights on how to pull this off outside of the VA, even if you accept the black box analysis.

Catherine DesRoaches and other colleagues from Mass General, George Washington University and Harvard find a poor correlation between hospital adoption of electronic health records and measures of quality. In a companion piece, Jeffrey McCullough and colleagues from the University of Minnesota found a better correlation in hospital quality but many of the outcomes failed to reach statistical or even impressive clinical significance. After reading this, the DMCB wonders if the other 94% of hospitals waiting on the sidelines are thinking they are doing the right thing.

But the debate about hospital-based computerized physician order entry (CPOE) is over, right? Well, maybe not exactly. While previous studies have shown CPOE without a full fledged EHR can reduce medication errors and save lives, Jane Metzger et al show the systems aren't perfect. Using a simulation tool in a sample of hospitals that volunteered to go through this, only 53 percent of the medication orders that would have resulted in fatalities and 10–82 percent of the test orders that would have caused serious adverse drug events were detected. Uh oh.

Oh, never mind says Susan DeVore and Keither Figlioli of Premier health care alliance. They surveyed their hospital members and found the road to EHR installation is lined with gradual implementation to account for objections and work-flow hiccups, clinical champions, lots of staff training, meaningful quality-based decision support and reporting, high security, clear policies and budgets that can handle the unexpected and pay the clinical champions.

Phyllis Torda, Easther Han and Sara Hudson Scholle of the NCQA interviewed 'knowledgeable people" about the implementation of EHRs and found no problem cannot be solved by assistance, consultants, trust, engagement, expertise, sophistication, realism, operational excellence, program redesign, selection of the right software and hardware and sustainability. See... it's that easy! Check out the list of insider knowledgeable people and you'll see why.

Alan Hinman and David Ross go back to the fundamentals and review the building blocks of EHRs, health information exchanges and immunization registries, suggesting the latter may be a good way to tie everything together. The DMCB thinks there may be something to this learn to walk before you run approach.

Good grief you made it to the end of this summary. If you are that interested in the topic, the DMCB suggests you head on over to Vince Kuraitis' e-CareManagement Blog where he has inaugurated a series of very informative posts on HITECH.

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