Some of the Top Health IT Stories from 2008 are discussed.
In the past 12 months, we have seen the rise of social networking sites for physicians, growing enthusiasm for the concept of patient-centered medical homes, the roll-out of PHRs by major players like Google and Microsoft, a shift from medical search engines to general search engines, and the first wave of retail DNA tests. One thing we didn’t see in 2008 was major progress in physicians’ adoption of HIT. We tackle these topics and more in this review of some of the top health IT stories from 2008.
1. Let's Speed IT Up
Despite a number of efforts to promote HIT adoption, including studies showing the cost-savings that could accompany widespread HIT adoption; local efforts, such as Vermont’s Health IT Trust Fund and New York City Mayor Michael Bloomberg’s charitable foundation that provided $27 million for EHR adoption; continuous efforts by HHS to increase transparency and adoption; and financial incentives offered by Medicare for e-prescribing, the fact is that IT adoption in healthcare is proceeding at a snail’s pace. Let’s review some lowlights from 2008:
Jan. 18: A report from the California HealthCare Foundation said efforts to create a Nationwide Health Information Network are “impractical and cannot be implemented,” and added that “none of the [health IT] leaders interviewed for this report could point to substantial, real advances in the adoption and utilization of [health IT] since the president launched his initiative.”
Jan. 24: Only 4% of respondents to a physician EHR adoption survey reported using a “functional EHR;” only 14% used a “minimally functional EHR.” Adoption rates were 35% in practices of 10 or more and 6% for solo practices.
March 2: The Baltimore Sun reported that 90% of US physicians and more than two-thirds of hospitals still use paper records, putting healthcare in the country “at least a generation behind the rest of society in terms of technology,” according to David Merritt, project director at the Center for Health Transformation.
July 18: A Commonwealth Fund report found that it will take more than 30 years at the current HIT adoption rate to expand clinical support tools to all US physicians.
Aug. 31: An American Hospital Association survey found that although 68% of US hospitals have implemented some type of EHR, most are only used in parts of the facility.
Oct. 30: According to a Healthcare Information and Management Systems Society survey, roughly 30% of physician group practice administrators said they have functional components of an EHR in place in their organization, up just 4% from 2006.
Nov. 11: A survey presented at the American Health Information Community meeting showed that between 2% and 12% of US hospitals use EHRs, depending on how the term is defined.
2. MDs Are Going Ga-Ga over Google
It is becoming increasingly difficult to stump medical students on clinical rounds nowadays; they always seem to come up with the correct diagnosis, in part because they are particularly adept at finding the right information as quickly as possible using the Internet.
Search engines are extremely useful, because they can take a query, find the words that match, and put them together into an outcome that makes sense. Unlike medical search engines that rely on keywords, from the author and the researcher, the Internet looks at all of the words entered and makes no judgments as to their value. Your words are just as important as the authors’, though there is some contextual awareness.
Google makes no judgments unless you misspell a word, and it will then suggest a correction. It allows you to search the way you think, not how the author was thinking. Occasionally, you will type in a query, find the article, and get blocked because the publisher wants you to pay to view the content. To solve this problem, simply take the article citation and search through secondary sources at a university, hospital, or office library to do the PubMed or Ovid search.
I am preparing to take my recertification in geriatrics, and during the individual self-evaluation medical knowledge modules, Google and Google Scholar were my best friends. When there was a question I needed help with, these search engines gave me the easiest way to find the right answer. If a keyword is obvious, and you search Ovid, PubMed, or Up-To- Date, you might narrow your query but still might be unable to find the quote. With Google, you type in the quote, and the article pops right up.
—By MDNG editorial board member Eric G. Tangalos, MD
3. The Patient-Centered Medical Home
The patient-centered medical home concept continues to gain steam as more and more physicians and organizations— including the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Physicians, and American Osteopathic Association—endorse the idea. In fact, these organizations have collaborated to produce the Joint Principles of the Patient Centered Medical Home. Other organizations are now emerging to do their part to encourage the evolution of the medical home, including Bridges to Excellence, a not-for-profit organization that rewards healthcare providers who “demonstrate that they have implemented comprehensive solutions,” which has developed different levels of medical home designations. Physicians who are able to attain these designations can receive an annual bonus payment of $125 for each patient covered by a participating employer, with a suggested maximum yearly incentive of $100,000. To read more about the program, visit [here]. As support grows for this patient-centered approach to providing comprehensive primary care, the big question becomes, “What role will healthcare IT play?” Technology systems are already in place to help healthcare providers maintain records, electronically prescribe medications, and exchange all types of medical information. In order for the medical home concept to thrive, physicians will have to use information technology for care management and quality improvement, as well as to provide an adequate payment method and to communicate with patients. As is the case with many ideas intended to improve healthcare delivery, the technology is there, but the major stakeholders need to iron out interoperability issues, manage costs, and continue to produce standards that will truly make the medical home revolutionary.
“In spite of continued talk about expanding health information technology, I am not aware of much tangible delivery.” —G. Stephen Nace, MD, MDNG editorial board member, and Associate Professor of Clinical Medicine, University of Illinois College of Medicine at Peoria Creating a single network for processing almost all US electronic prescriptions promises many benefits, including lower costs for providers and patients and an expedited and simplified medication ordering and dispensing process.
4. Uncle Sam Wants You… to Get Paid for E-prescribing!
On October 30, CMS announced “a new initiative for physicians to trade in their prescription pads and improve efficiency and safety when ordering drugs for patients with Medicare.” The final step in a years-long legislative and policy effort, this announcement finally put into place a concrete (albeit modest) financial incentive for physicians who treat Medicare patients to take the leap into the brave new world of electronic prescribing. In addition to the well-known potential benefits for patients from e-prescribing (virtual elimination of drug errors due to illegible or misread handwritten prescriptions, reduced out-of- pocket costs, etc), now physicians, too, can derive tangible benefits. Physicians who adopt e-prescribing technology in 2009 and 2010 will get a 2% bonus in their Medicare payments. In 2011 and 2012, they will get a 1% bonus. Docs who wait until 2013 will get only a 0.5% bonus. However, starting in 2012, CMS will also assess a 1% penalty on physicians who refuse to adopt e-prescribing; the payment cuts will escalate to 1.5% in 2013 and 2% in 2014 ().
If the combination of fewer medication errors and a little bump in reimbursement is appealing, but you are still unsure of how exactly you should go about trading in your trusty prescription pad, download The Clinician’s Guide to Electronic Prescribing. Issued by The eHealth Initiative in collaboration with the AMA, the AAFP, the ACP, the MGMA, and the Center for Improving Medication Management, the guide was created to be a “how-to” guide to “help clinicians make informed decisions about how and when to transition from paper to electronic prescribing systems.” For more on the various caveats, adjustments, and concerns some practitioners have raised, read Dr. Robert Jasmer’s detailed rundown.
5. This Is Big. Really Big.
“In the single most significant advance to the accuracy, efficiency and quality of information associated with the four billion prescriptions written annually in the United States, the nation’s retail pharmacies and leading pharmacy benefit managers (PBMs) today announced an unprecedented collaboration to unite the country’s two leading health information networks.” Thus was the merger of SureScripts and RxHub announced with typical understated corporate PR-speak. Seriously, though, this was a major development. Creating a single network for processing almost all US electronic prescriptions promises many benefits, including lower costs for providers and patients and an expedited and simplified medication ordering and dispensing process. Plus, the combined network’s sheer size and ubiquity enable it to set standards for the whole industry, which has its good and bad points (good in that it simplifies things for technology vendors, while also requiring them to create products with valuable features like medication histories and eligibility checks; bad in that there are always concerns whenever one player in an industry is in a position to wield so much infl uence; privacy advocates have also expressed worries about having so much patient data in the hands of one company). Go read more about the company and the details of the merger.
6. Was Time Magazine Just Spittin’ in the Wind When it Comes to Personal Genomic Testing?
In 2007, Time magazine was spot on when it named Apple’s iPhone as the invention of the year. However, they may have blown it this year by bestowing the title on 23andMe’s retail DNA test. The test predicts disease risk and ancestral history by relying on a technology developed last century that has been applied to research this century. If direct-to-consumer genetic testing continues, physicians could have patients who have had a single-nucleotide polymorphism (SNP) scan. With the cost of sequencing genomes decreasing rapidly (now $30,000), what does this mean for you?
Every cell in the human body carries an individual’s genetic information, and microarrays—which probe hundreds of thousands of gene markers simultaneously—can measure whether certain genes are “faulty.” Affymetrix, the first company to offer high-density arrays (>500,000 markers), combined its efforts with results from the Human Genome Project/HapMap to enable whole genome investigation. Pacific Biosciences developed rapid genome scanning, which could allow for the $100 genome within two years. Its technology relies on Mother Nature’s ability to rapidly copy a genome and merely eavesdrops on it to produce a clearer picture than a microarray scan. The real trick lies in interpreting this information and deriving clinical utility from it. The Genome Wide Association Scan was one of the first to utilize this technology and was recently used to identify novel molecular pathways in a cadre of diseases. This approach has the advantage of being an unbiased, comprehensive search across the genome for susceptibility alleles and has been successfully applied for many single-gene disorders.
For common complex diseases, the message is not so clear. Even with positive links, using SNP for common disease testing may not be useful for clinical application. An article in the New England Journal of Medicine recently reported on the lack of significant benefit in diabetes risk prediction using chips similar to the one 23andMe off ers. Using microarray analysis may be interesting, but it has not been validated as a way to obtain risk estimates for disease. Despite this lake of granularity, Time has decided to name 23andMe—a company which sells this technology with little, if any, clinical validity directly to the public—as the invention of the year. Hopefully, they don’t end up with spit on their face.
—By Steven A. R. Murphy, MD, founder/ president of Helix Health PLLC/LLC.
7. The Case for Aggregating Health Data around Patients
In 2004, President Bush promoted the idea of an electronic health record for most Americans by 2014. This set in motion a wide variety of initiatives and projects. The Office of the National Coordinator for Health Information Technology was established. A certification process was set up for ambulatory and hospital EMR vendors to ensure a certain level of interoperability between systems. There was a lot of talk about developing a National Health Information Network (NHIN) through the funding of Regional Health Information Organizations (RHIOs). Although a few RHIOs have become operational, many have failed, and the long-term business model for those that remain is illusive.
As I’ve traveled the world, I’ve yet to see a fully developed digital health information exchange in any country I’ve visited, yet alone one that could scale to the kind of system we would need for all Americans. I’ve come to believe that developing a digital network providing for the free, bidirectional fl ow of health information between every physician, hospital, clinic, pharmacy, laboratory, imaging center, insurance plan, and everything else in the ecosystem just isn’t feasible at scale. Even if the technology existed to do this, the money certainly does not, and furthermore, there’s no business model to support the exchange of information between competing physicians, hospitals, and clinics.
Fortunately, there is an answer to this dilemma, and I believe most pundits are coming to the same conclusion. Why not put patients at the center and aggregate a copy of their health data around them? Even among organizations that compete, few have a problem with sharing most, if not, all of the patient’s health record with the patient. Global technology companies have come forward with solutions like Microsoft HealthVault, Google Health, and medical record banking initiatives that make it possible for patients to securely store a copy of their personal heath information electronically on the Internet and to receive electronic copies of heath information from their providers. In the case of HealthVault, patients have complete control over who they share this information with (family member, care provider, or anyone else who needs to know), and when. It is also possible to connect a myriad of devices—like blood pressure cuff s, glucometers, weight scales, spirometers, and heart rate monitors— that collect health data and store this information where others who need to know can see it. Imagine a day when each of us has a PHR and an EHR in the “cloud” that is always available, whenever and wherever we might be. RHIOs and other health information exchanges could then focus on an achievable goal—unifying critical patient information for care providers in a region.
I do believe that local and regional information exchanges make sense. First and foremost, we’ll never get where we need to be so long as health information exists on paper or is locked up electronically in silos. But I also believe that aggregating health data around the person to whom it belongs is not only a solution that scales, but is perhaps the only way we can attain the vision of a truly transportable, always available EHR for most, if not all, Americans.
—By MDNG Healthcare It Advisory Board member Bill Crounse, MD, senior director of Worldwide Health for Microsoft Corporation
8. Health 2.0, Health 3.0, and beyond …
The healthcare world has embraced the principles of Web 2.0, even taking the liberty to rename it in its own image, Health 2.0. The idea is catching on, and conferences such as Health 2.0 are enjoying a record number of attendees. At one time, people argued that these 2.0 technologies were not sustainable for lack of a viable business model and source of financial revenue. Setting those fears aside, it looks like these user-generated platforms are here to stay with Health 3.0, and even some rumblings of Health 4.0 in the distance. What do all these fancy names mean?
1. Health 1.0 = content
2. Health 2.0 = content + community 3. Health 3.0 = content + community + consumer-centric commerce
4. Health 4.0 = content + community + working commerce models + coherence (connectors)
The Health 3.0 concept, which incorporates a source of financial benefit into its models, is stepping out of the theoretical imagination and into the real world. Hello Health/Myca incorporates text messaging and AIM into its physician practice model. JustAnswer.com provides qualified health professionals who answer online submitted questions for fees ranging from $9-15. LivePerson.com offers live chat with health professionals, charging by the minute. Other Health 3.0 approaches include American Well and Organized Wisdom.
9. Social Networking Is Just What the Doctor Ordered
Would it bother you to know that your physician smokes cigars? That your gynecologist was a member of a group called “I Hate Medical School”? Should physicians share this kind of personal information on social networking sites like Facebook and MySpace, where patients could potentially see it? Many doctors are turning to physician-only networks to get away from the prying eyes of patients. After all, we are all human and need to relax, socialize, and talk about our children, work, frustrations, and hopes without being paranoid it is going to come back and haunt us. Three of my favorites are:
iMedExchange is only open to practicing physicians. Chief Executive Tobin Arthur says that the company hopes to create a virtual version of the doctor’s lounge at a hospital. iMedExchange may not have the catchiest name, but it is one of my favorite sites. iMedExchange verified my identity with a phone call, checking that I was a physician and that I registered. They were the only site to do this. They also have a very impressive live chat with customer service. In development for more than a year, iMedExchange studied how sites such as LinkedIn, Facebook, and Craigslist could be applied to physicians, and it shows!
The Student Doctor Network is an independent community of students, advisors, educators, and practicing doctors. The membership extends from college students to practicing doctors in every healthcare specialty. It is a wonderful resource for college students from hoping to get into medical school on through residency.
On Sermo, physicians come together to talk about observations from their daily practice. Physicians can tap into the collective knowledge to achieve better outcomes for their patients. Physicians can benefit, too; I’ve seen burned out physicians get invaluable support on Sermo, which is now partnered with the American Medical Association. A visitor must verify that he or she is a physician before participating in the discussions.
—By MDNG editorial board member Nancy Tice, MD
10. Mobile Phones Will Revolutionize Your Practice
Smartphones and other mobile technologies will become major tools for physicians for improving quality of care and communicating better with patients and colleagues. Indeed, mobile phones are rapidly morphing from forbidden gadgets in healthcare to the most prized clinical assistants, facilitating improved communication and mobile computing in medicine.
Mobile phone-based solutions can be helpful to physicians and patients alike. For example, appointment management software allows physicians to automatically contact patients, reminding them of their appointments in advance and requiring them to confirm that they are on their way. This software has the potential to decrease “no shows” and excessive wait times.
The ability to use a cell phone to access relevant patient data when in the exam room or during hospital rounds can dramatically increase efficiency. Using this technology, physicians can have inexpensive and effective mobile e-prescribing systems; access to key data, such as previous medications and possible interactions, which can reduce medical errors; and immediate access to important guidelines and protocols that can enhance care and reduce costs. Also supported are real-time charge capture systems and point-of-care documentation.
Today, we see the beginning of a new range of disease management modules based on mobile phone communication. Successful programs have been demonstrated for diabetes, asthma, smoking cessation, and other conditions, with increased two-way communication greatly influencing results. Vitals and other data can be readily and automatically collected and transmitted for quick collection and processing.
Patients want better communication than is possible in the few minutes available during a typical visit. In the near future, many patients will carry a copy of their personal health information on their mobile phone. Expect that patients will send their eligibility and health history data to your office before they arrive. There will be no cumbersome on-site collection of insurance information, demographic data, etc. Even more importantly, patients will start sending their “agenda”—the list of symptoms and problems they want you to address during the visit—in advance. This will change the workflow of your encounter. A patient may tell you about specific information she found on the Web, and your mobile phone will help you to check that data on the spot and respond accordingly in a timelier manner. Today’s software systems also allow any practice to set up preferred patient groups who, for an extra fee, are reminded to take their medications and have the option of dialing their doctor’s office directly with a simple code. This is just the tip of the iceberg.
—By C. Peter Waegemann, CEO of the Medical Records Institute, which sponsors the annual TEPR+ conference (Toward an Electronic Patient Record) and recently established the Center for Cell Phone Applications in Healthcare (C-PAHC). Mobile phones are rapidly morphing from forbidden gadgets in healthcare to the most prized clinical assistants, facilitating improved communication and mobile computing in medicine.