Posted on 02/22/2005 2:06:02 PM PST by Ernest_at_the_Beach
By STEVE LOHR
ALLAS, Feb. 17 - Dr. David J. Brailer, the federal official who is trying to prod the nation's health care system into the computer age, has delivered a warning to the health care industry: take steps soon to make it happen or the government will probably impose a solution.
Across the ideological spectrum, health care experts and politicians agree that the nation's hodgepodge of paper medical files needs to move into the digital era, so that eventually each person has an electronic health record that can travel across networks and be read by doctors, hospitals, insurers and the patients themselves. Doing so, the thinking goes, would reduce medical errors, improve health care and save money.
Congress has been doing its own prodding on the matter, with another bill introduced this week. Trying to pick up the pace, Dr. Brailer, in meetings with health care and technology executives here at their industry's big annual convention, has told them to come up with a single set of technical standards for electronic health records.
The approach, he said, must include a method to certify that the records can be opened and read by doctors and specialists, as authorized by the patient, even when different clinics and hospitals have different computer systems.
If the industry cannot agree upon such standards by this summer, "then government will probably do what government does best - put out a mandate," Dr. Brailer said in a talk to information technology companies here Wednesday. "Some people think that would be a train wreck, and some people think that would be a great idea."
Dr. Brailer's comments amount to goading with intent. A 45-year-old physician and economist, he explained over a late-night dinner here with a reporter that he regarded his job primarily as taking steps to repair a market failure in health care information technology. He is part policy maker, technologist, cheerleader and arm-twister, traveling much of his first 10 months on the job to meet with doctors, hospital administrators, technology executives and others.
At the Dallas convention, sponsored by the Healthcare Information and Management Systems Society and attended by more than 23,000 people, Dr. Brailer spent a typically adrenalin-charged day and a half. He arrived Tuesday night for a business dinner that ended at 11 p.m. His first appointment the next morning was shortly after 6 a.m., beginning a stream of meetings and talks that ended after 10 p.m., with groups that ranged in size from a few hundred people to a handful.
Thursday morning began with an early meeting, then off to an 8:30 a.m. speech to an audience of more than a thousand in the convention center's main arena. Next came a quick tour of the convention floor, before heading to the airport.
In the smaller gatherings, Dr. Brailer took notes and asked questions as much as he spoke. He is still wrestling with just how large and how direct a role the government should take in trying to accelerate the adoption of computerized health records. But it is clear that a common technical standard for those digital documents is a vital step.
In most markets, technical standards - from uniform railroad track sizes in the 19th century to software protocols for the Web in the 1990's - have enabled the growth of markets and industries that are built on those public standards.
Once a basic standard for electronic health records is in place, Dr. Brailer says, it will be less risky to invest in digital records for doctors or hospitals that may now worry that the software they purchase today, and struggle to learn to use, may become obsolete sometime later. "We've got to take the risk out of purchasing electronic health records," he told the group working on the standard.
The industry is poised for growth, judging from the turnout at the convention. It set an attendance record for the show, and more than 700 exhibitors displayed their wares on the trade floor. The booths were a corporate who's who of household names like I.B.M., Microsoft, Cisco Systems and General Electric, as well as health technology specialists like Cerner, McKesson, Epic and Allscripts.
Dr. Brailer, appointed last year by President Bush as the national health information technology coordinator, said that he would greatly prefer to see an industry consortium agree upon a technical standard, because it might be more flexible and open to future technical improvements than one determined by government edict, however well intentioned.
The industry group that is supposed to develop the electronic health record standard, the Certification Commission for Healthcare Information Technology, was formed last year, with members drawn from large medical centers, technology companies, insurers, physicians, nonprofit groups and consultants.
Speaking to a meeting organized by the commission, Dr. Brailer said their early efforts showed "great promise." Then, he added, "We're banking on this, until it is clear that you can't do it."
In small group meetings, Dr. Brailer urged the technology executives to set aside their narrow corporate interests, giving up some of their proprietary lock on customers, to open up a larger market opportunity for everyone. Each company cannot get all it wants, he said. Yet technical standards groups often bog down amid conflicting interests.
At one point, Dr. Brailer asked a group of technologists what they wanted from government. Wes Rishel, a veteran of health technology standards groups and a member of the certification commission for electronic health records, replied, "We need a tie-breaker - someone who is somewhere between a czar and a diplomat."
By now, the need to computerize a health care system that is choking on paper is beyond dispute. Health experts say that moving to electronic records, which would reduce paper handling and eliminate unnecessary or duplicative tests, could cut 10 percent or more from the nation's $1.7 trillion a year in health care spending. And a digital system should sharply reduce medical errors, which are estimated to be responsible for 45,000 to 98,000 deaths a year - more than breast cancer, AIDS or motor vehicle accidents, according to the Institute of Medicine of the National Academy of Sciences.
The electronic patient records could also open the door to a national health information network in which patient information, stripped of personal identification, could be used for national health research projects, impartial assessments of drugs' effectiveness and other data-mining possibilities.
Health care is already rich in high technology when it comes to diagnosis, surgery and treatment - from advanced body scanners to all manner of medical devices and drugs - in large part because those investments clearly generate revenue. But in information technology, health care lags well behind most other industries. In health care, the average investment in information technology computer hardware, software and services is only about $3,000 annually for each worker, compared with $7,000 a worker on average for private industry and nearly $15,000 a worker in banking.
Falling prices for personal computers and software, and the blossoming of the Internet in recent years, have brought down the cost of adopting electronic health records and made it easier to connect to specialists, hospitals and insurers.
But health care remains a fragmented industry, with much of the care still provided by physicians in small practices. An estimated 60 percent practice in offices with 10 physicians or fewer and 35 percent in offices with three physicians or fewer.
And for these physicians, who essentially are small- business people, information technology still represents a daunting cost: $30,000 a physician to adopt electronic health record technology, according to a recent study, which factored in the cost of hardware, software and time lost in terms of patients not seen while learning the system.
"The elephant in the living room in what we're trying to do is the small physician practices," Dr. Brailer said. "That's the hardest problem, and it will bring this effort to its knees if we fail."
Dr. Brailer is still studying what might be the right mix of incentives to encourage physicians to embrace digital health records. The incentives, he noted, could include federally backed loans, grants and extra reimbursement by Medicare and other insurers for using electronic health records.
Many large hospitals and medical centers already have electronic health records, accounting for most of the 10 to 15 percent of all physicians who have adopted computerized patient records. It will be essential for them, Dr. Brailer said, to make sure they conform to the new open standard, when it is developed by industry or mandated by government, so they can share information with other groups.
Once adoption reaches 45 percent or 50 percent, Dr. Brailer predicted, the benefits from digital records will be so apparent in terms of savings and quality of care that a tipping point will be reached. "That's when the network economics will take over," he said. "It will become a condition of being in business, like e-mail is in most businesses."
Dr. Brailer's challenge is to fashion the right policies to get there. "This is not about technology," he said. "It's really about transforming health care, fixing this market."
Computerization of medical records is a good thing.
The answer to this is a Grid-based solution. With self-describing Grid services, any PC that is registered on the Grid will suffice. I'm working on exactly this problem right now at i3ARCHIVE, Inc.
The biggest single problem is a set of standards, but IT is moving a blinding speeds. Here in Dallas big donors are paying out 20 million for IT work to get hospitals on the cutting edge. This train is leaving the station and it is a bullet train not a commuter.
I dont believe that grid services alone will solve the problem. Particularly when it comes to the security issues associated with records retention, records privacy, secure access, restricted access, encryption, etc.
In theory you can have both.
In the real world, you can't.
Privacy regulations are precisely what has kept the medical industry from storing all medical records in a centralized database.
I think the problem is the insurance companies don't want to make it easier to file claims.
It's the small doctor who gets hurt by non-standardization.
As someone who has had to see different specialists (sometimes in different cities), been subjected to changing medications and a whole host of tests, I am 110% for computerization of medical records.
Has anyone ever taken the time to look at their medical records file the that the physician brings the file into the examination room? What a 'frickin mess. In certain instances the file can be thicker than a NYC telephone book. I know, because I have PAID to have copies made for other physician vists... just so they would know results (such as blood work) that could impact treatment recommendations.
I would like to see a "medical card" that I could carry from physician to physician. I want my medical information stored where I can access it... where any physician can access it. I feel computerization, such as a "medical card", would help a physician when reviewing their own treatment and testing recommendations (e.g., blood work results).
The privacy regulations instituted by certain health providers, supposedly because of HIPPA, can be a HUGH problem.
Let me give you an example...
I'm a employer. As a employer, I pay the medical premiums for my employees. On more than one occasion there has been an instance where we have a billing question, such as adding or removing an employee from coverage.
More than once, BC/BS of NE PA has asked us to fax such requests. But... and here it comes... they turn the fax machines OFF at ~4pm and don't turn them back on until the next morning. Then, when youy do try during their so-called "business hours" the 'frickin fax is constantly BUSY! If you work late, TS. (4:01pm is late?? Not where I work.) If you work weekends, TS. BC/BS claims HIPPA forces them to do this. BS. We're talking billing, you maroons, not medical records.
yeah... I know all docs have Wed off.... like right after they get off at 0700 on Wednesday morning.... The computer in the office sounds great but it's just data entry... you and some of the others think it's great until you realize the complexity of something as easy as taking a history.. which varies from patient to patient even with the same problem....
an example for a pull down menu on the new software would be something as simple as chief complaint --nausea and vomiting ...easy huh.. presents 100 time in the ER over a 2 day period...
is this from hyperemesis gravidarum (pregnancy)
from bad sushi
from head injury
from medication reaction
from drinking alcohol
from drinking methanol
from meningitis... or
none of the above... cause he's got kidney stones that are killing him and are causing nausea and vomiting.... but wait if he presents with flank pain and hematuria... does he have
kidney stones
disecting aortic aneurysm
self inflicted trauma to the urethra to get pain meds
atypical presentation for bleeding disorder
coumadin toxicity.... and on and on.
That's just to get to the chief complaint.. figure in past med history,social history, surgical history, current medication and dosages, allergies, review of systems, vital signs, physical exam, labs, interpretations,assesment, treatment plan, referal and follow up instructions... as the disease or presentation change or symptoms wax and wane.. then you get an idea about how the doctor will spend about 20-30 minutes punching in questions to pull down menus... then punch in orders, then punch in vital signs, then punch in improvement, then punch in labs/ diagnostics/ then the results and interpretation of the results and how they vary.... all of this while juggling the other 10-15 critical, non critical and current patients at a time, that change every hour as the time in the ER goes along... then dealing with the ambulances that happen to pop in.... so if you have 10 patients that takes 20 minutes to document on.. say you see anywhere from 30-50 patients a shift on average.... you'll see that the old pen and paper or dictation is hard to beat... cause it's easy to multitask while you're yapping but hard to do it when you've got software glitches and different menu options...
It all sounds like it's just simple but I'd have you go down to a local ER that's busy (over 37-40,000) visits a year that uses certain computer programs..... you'll see a lovely sight. You'll see all the nurses and docs with their faces up against a monitor and a patient in the room puking or asking for help, while the ER tech runs around trying to do the "medical" part of medicine... which means the sitting at the bedside, looking you in the eye and bandaging, taking vital signs, assessing the treatment.... etc.
The reason the computerization of medicine is so important is for legal weenies and risk management geeks can have nice neat documents to run through management data bases for "numbers" to evaluate.
Medicine isn't ready for docs to be data entry techs... the software that could help would be a real time video/sound transcript of the medical visit. This could be archived and kept. It would beat dictation ... maybe. It would be hard to pin point data interpretation but would help the decision making process in that you could review what it was about a patient that made you order the CAT scan or lumbar puncture... sometimes it's just "they didn't look right".
I know many docs that have pulled patients away from the white light by just following their instincts. That's why medicine is part science and part art. I know that doesn't make a lot of people feel secure but it's the truth.
Yep. Makes it easier for whoever-wants-to to get ahold of your medical records.
On the contrary, those are exactly the areas where Grid services excel. One might even say that that's primarily what Grids are for.
And you think MD's practice defensive medicine NOW???
Wait until the lawyers get ahold of real-time VIDEO!!!
There are a lot of smaller insurance companies. If the doctor doesn't do enough business with a particular insurance company, it's probably time consuming or expensive to set up for electronic transmission to each company. There are intermediaries though.
I'm not sure how it is in Doctor's office, I worked in a different medical area, and we filed paper with everyone other than Medicare, because we didn't do enough business with any one insurance company to justify doing anything more.
In the real world, our company, i3ARCHIVE, Inc., has stored hundreds of thousands of real, clinical digital mammograms, over digital networks, from sites across the country. They are totally private; the entire system is fully HIPAA-compliant.
And for these physicians, who essentially are small- business people, information technology still represents a daunting cost: $30,000 a physician to adopt electronic health record technology, according to a recent study, which factored in the cost of hardware, software and time lost in terms of patients not seen while learning the system.
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Bet the big time HMOs all back this one to put the smaller docs out of business. It's how it always works. I think government is already in health care too much. A standardized system will probably evolve on its own faster if goverment doesn't mess around with it. It's government invovlement that is responsible for the stagnation of the health care system.
It is a very challenging problem.
There are companies, including one I've worked for briefly, who have the entire system ready, from card-making machines, to distributed secure computing and server farms, and entire training systems for doctor practices and hospitals, and everything else necessary. More secure than HIPAA, scalable up to over 120 million customers/patients(at present), complete integration of current medical coding and billing, room for expansion, etc. The problem, without government intervention, the hundreds of stakeholders in the currents system won't move toward a unified system such as what is already potentially available.
Other countries are going to be there soon, countries who you wouldn't think would have better health industry IT superstructures in place, will supersede America's IT structure within 5-10 years.
It's a disappointing situation, because the slimy politicians hands will foul the process when AARP or whomever creates the public outcry for reform and electronic medical records.
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