The potential for HIT to influence the outcome of health reform
By Peg Scheible
July 15, 2010
Dream with me... You enter into the physician’s office confident in the care and your
ability to afford it. Your practitioner is confident, as well. Unlike the first days of his practice;
today, he has immediate access to your personal health information, clinical support and
laboratory data. While he must inform you of a serious illness, he was able to review current lab
reports along with medical documentation on treatment options, find a possible medication, and
then compare it to your DNA to see if you’re able to respond positively to it. You then leave the
physician and drive to the pharmacy to have the prescription waiting for you.
It isn’t all fantasy because most of the above is very possible. It is a dramatic
transformation from where health care is currently and the pivotal difference is the widespread
use of health information technology.
Using the Donobedian model with cost, access and quality as the key aspects to
healthcare, we can look at the present conditions. Cost: The current estimates are
approximately 17% of the US GDP is spent on health care amounting to $2.5 trillion dollars.
Access: The system is not working because the US has 47 million people uninsured and 20
million under-insured. Quality: Possibly most unfortunately is the US spending does not
translate to exceptional healthcare outcomes. When compared to other countries, the US
spending is one third higher for comparable outcomes. What this means is the US has too many
people without the ability to afford care or get the proper care at the proper time to have health
maintained. These three factors open the window of opportunity to find a way to reduce costs
while maintaining the same level of outcome.
What in our current system could be changed to make a difference? The healthcare
reform bill, American Reinvestment and Recovery Act (ARRA), signed into law in early 2009 is
complex and can not really be explained in a single paragraph. However, for our purpose, we
can look at the broad topics covered by the bill to see the connection to the three legs of
healthcare. Title I (cost and access): Addresses private insurability by making it possible for
almost everyone to have insurance coverage. By removing barriers such as life time limits and
pre-existing conditions to insurability, guarantees availability and renewability of coverage. This
title outlines a Health Insurance Exchange to be created. Title II (cost and access): Addresses
the public health insurance by expanding coverage provided by various programs such as
Medicaid while simplifying qualification/enrollment processes via the Health Insurance
Exchange. Title III (cost and quality): Addresses the delivery of healthcare via linking
payment to quality outcomes for Medicare. Quality reporting for physicians and various
facilities, encouraging different models for patient care, and many methods of payment for
services are also addressed. Title IV (cost and quality): Addresses chronic health problems and
prevention in an effort to encourage a healthier population. Incentives are laid out to prevent
chronic disease and health and wellness is encouraged in communities.
The US government is the largest payer of health care costs through the Medicare and
Medicaid programs, and all Americans assist in the financial backing of these programs via
taxes. While not a panacea; HIT is going to take great strides towards reducing overall costs,
increasing access and quality by creating a necessary infrastructure to reform our current system.
Health Insurance Exchange: The simplest way to think of a Health Insurance
Exchange is an online shopping location for both public and private health care plans allowing
people to compare benefits and prices, and choose the plan that's best for them. Each plan
should have one basic, affordable benefits package which includes prevention and protection
against catastrophic costs. The intended purpose of this HIT initiative is to provide affordable
health care to all, even if it is federal or state sponsored. The expectation is more people with
insurance will reduce the overall healthcare costs by stimulating appropriate preventive or acute
care (i.e. – reduce emergency room visits by those who wait too long to receive care or don’t
have insurance coverage).
Electronic Health Records (EHR): The heart and soul of HIT for positively
influencing the outcome of the reform is the EHR; an electronic version of the patient chart, but
with a significant amount of additional capabilities. Paraphrasing the HIMSS definition, the
EHR will contain patient demographics, medications, problem lists, past history, track labs and
radiology reports along with containing physician progress notes. If a physician practice or
hospital accepts Medicare patients, then they are eligible for an incentive program to encourage
EHR adoption by providing up to $44,000 per physician over a five year period beginning in
2011 with increasing requirements likely as time progresses, along with penalties imposed if not
adopted. There are restrictions on who may receive incentive payments, but it’s not the intention
of this paper to list all requirements.
EHR systems eligible for payment must demonstrate ‘Meaningful Use,’ which is the
vehicle the government is incorporating to increase the quality of care provided. One aspect of
meaningful use, is in regards to electronic prescribing of medications. This is a quality initiative
because the use of electronic transfer of a prescription from physician directly to pharmacy will
reduce the number of transcription errors. A second, but closely related criterion is clinical
decision support. While this has many forms (alerts, reminders, and access to evidence based
medicine); one, is in checking to see if a patient has a known drug allergy or has a current
medication that interacts adversely with the medication being ordered by the physician. Yet
another aspect of Meaningful Use, is in tracking preventative steps being taken by the physician
for ordering mammography, colon screening, or smoking cessation. With respect to chronic care
diseases such as diabetes or hypertension, decision support located within the EHR guides best
practices. The above examples of meaningful use all relate to increasing patient safety,
providing a higher quality of care, and reducing costs.
The over arching feature of Meaningful Use is the ability to report electronically to
Centers of Medicare and Medicaid Services (CMS) adding to the reduction in paper based record
keeping. Quite possibly, CMS will in the future, use the information being collected to change
the payment structure to physicians and hospitals from pay for services to pay for performance,
rewarding those physicians that have adopted an EHR and have quality performance as
demonstrated by data.
Health Information Exchange (HIE): The health information exchange is a state
sponsored public and private business partnership. Using the EHR as the building block;
continued improvement of patient safety and quality of care includes the free exchange of
information between providers of acute and well care. The ability of providers to access patient
information will give all providers a current picture of the patient’s health including medication
lists, labs or tests results. With respect to chronic diseases, the HIE will assist in the coordination
of care for the patient. This information will reduce duplication of services, elevate patient
safety and reduce costs associated with the care.
While the infrastructure of health reform revolves around the adoption of an EHR system,
it’s not a panacea, unfortunately, because most HIT projects in the past have either failed or been
scaled down. The incentive package is intended to address the number one physician adoption
barrier - cost. Realistically, successful implementation of an EHR system will involve process
and culture changes in the practice environment, and this shouldn’t be overlooked especially in
light of the physician revenue reduction during implementation. Hopefully, hospitals and
physicians will see the benefits of EHR adoption as a means of demonstrating their personal
performance quality, along with the advantages of interoperability between providers, and
patient safety advancements such as the prescribing of medications.
A transformed health care system, with increases in access and quality of care, and best
of all, a reduction of overall cost, is achievable. The infusion of HIT into the US system will
assist in this transformation, setting the foundation for future advancement. The first few baby
steps are being taken with the passing of ARRA, making our dream possible.