Obama's national health records system will be costly, daunting

But an Electronic Health Records system could save the nation $300B a year
Lucas Mearian

January 20, 2009 (Computerworld) President-elect Barack Obama has said that a national electronic health records system will be a priority in his first term, not just for streamlining workflow at hospitals and physician offices but to cut costs and improve the quality of health care. And while he has pledged to invest $10 billion a year over the next five years on the effort, the price tag for such a system could be closer to $100 billion over the next 10 years, according to experts. They also note that sticking to his five-year time-table could prove to be daunting.

Money for the e-health records (EHRs) system would come out of the $825 billion economic stimulus package Obama hopes to push through Congress.

"The magnitude of what we're going to need to do on the Obama scale is just incredible to think about, when you consider linking all these medical records across all these different towns, cities, states," said Dr. Charles O. Frazier, a vice president of clinical innovation at Riverside Health System in Newport News, Va. "We have enough of a problem with that in our own health system."

In 2004, President George W. Bush called for establishing EHRs for most Americans by 2014. Bush created the Office of the National Coordinator (ONC) for Health Information Technology to lead the way. The ONC pushed several pilot projects and created standardized medical records. Even so, a survey of 2,700 U.S. doctors by the New England Journal of Medicine last July showed only 4% were using "fully functional" EHR systems; the rest are all still paper-based.

Currently, only 25% to 35% of the nation's 5,000 hospitals use -- or are in the process of rolling out -- computerized order entry and medical record systems, according to Dr. David Brailer, who served as President Bush's health information czar from 2004 to 2006. Full EHR systems include patient care order entry systems and networks to share patient data between hospitals, primary care physicians and insurance companies and fill pharmacy prescriptions.

"It's a multi-year implementation. Hospitals will have to make a sizable, potentially multi-hundred-million dollar budget commitments," Brailer said. "But the $100 billion is a one time cost over the course of a decade. That's in an industry that spends $2.2 trillion a year now and 10 years from now will spend $3.7 trillion per year. So it's a relatively small amount of money."

Brailer said the nation stands to save between $200 billion and $300 billion a year once an EHR system is in place by cutting down on duplications, reducing errors that generate expensive care later, avoiding fraudulent claims and better coordinating care between primary care doctors, hospitals and specialists. The idea is "just to create a more efficient workflow," he said.

Money an issue

To date, getting physicians and hospitals to spend money on EHR systems has been a sticking point.

Charlene Underwood, who chairs the private Healthcare Information and Management Systems Society, said the Bush administration did a good job of getting infrastructure in place, but "it didn't move the needle forward on adoption."

What's needed now is money for record-keeping technology that doctors and nurses often do not have as well as provide point-of-service technologies, such as notebook tablets for convenient data entry into those EHR systems. Underwood, director of Government and Industry Affairs for Siemens Medical Solutions, believes the bulk of money spent by the Obama administration should go towards creating a monitoring system to ensure hospitals and private practices are using EHR systems -- and they should receive money not only to prime the pumps but as a reward for using EHRs.

For example, if hospitals show they are using a physician order-entry work system or electronic prescription service, they would get funding to continue those services or upgrade them.

Underwood said U.S. health care providers also need to standardize on "evidence-based order systems" -- electronic templates that spell out how patients receive treatment that meets best practices for specific problems. For example, a patient who leaves a hospital after surgery for a heart attack would automatically be prescribed aspirin as part of the post-operative treatment.

"We're trying to put in place evidence-based standards to reduce variation in care," she said. "Vendors have built a lot of technology to ensure processes occur in a proper way."

Brailer, the former National Coordinator for Health Information Technology, agreed with Underwood, saying market forces alone will not ensure that private practices and small or rural hospitals move forward on EHRs. "There also has to be money that flows into the infrastructure, the tools and mechanisms that share data back and forth. The key thing here is that what we don't want is a computer on every doctor's desk but nothing that improves efficiency, and that comes from having the information shared."

Regional systems, or a national network?

To date, there are 66 Regional Health Information Organizations (RHIOs) in the U.S., many of which are are now planning EHRs and have yet to share electronic patient data. RHIOs bring together health care organizations in a defined area and control the exchange of information.

Massachusetts is one of 30 states that have introduced or passed legislation calling for the statewide adoption of standardized health IT systems. The commonwealth wants 14,000 private physicians' offices to adopt EHR systems by 2012, and its 63 hospitals, by 2014. According to Dr. Larry Garber, vice chairman of the Massachusetts e-Health Collaborative, putting EHRs in place will take at least two to three years and cost about $100,000 per physician.

With an eye toward the future, the Massachusetts e-Health Collaborative set up a beta RHIO in three different geographic locations. The central Massachusetts project is called SafeHealth, which stands for Secure Architecture for Exchanging Health Information, and was paid for in part by a $1.5 million state grant. The distributed database for SafeHealth resides in Fallon Clinic's Worcester, Mass. data center but for now contains no patient information. Instead, it holds simple routing information that enables the movement of data from one medical facility to another.

"It takes care of concerns of someone holding onto information about you," Garber said. "The only organizations holding information about you are ones you've given permission to hold it."

Dr. JudyAnn Bigby, Secretary of Health and Human Services for Massachusetts, said it will cost about $340 million to implement a state-wide EHR program. Some of that money -- about $25 million a year -- will come from higher tobacco sales taxes. But state officials also expect the private sector to chip in.
In addition to legislating EHRs, Bigby said the e-Health Initiative is now developing payment models that would reward physicians who show they are using the state's disease registries or other types of electronic medical support tools to care for patients.
Cutting costs

Fallon rolled out EHR systems at 23 of its facilities using e-health record management software from Epic Systems Corp. Not including the vendor search and contracts, the project took three years and completely changed the way doctors and nurses performed administrative duties, Garber said. For example, no longer are prescription pads necessary; all drugs are ordered through an electronic network. Fallon also rolled out Dragon voice recognition technology from Nuance Communications Inc.

Fallon saw immediate ROI. It was able to cut 70 positions dedicated to moving or filing paperwork. It also stopped sending physician voice notes to overseas transcriptionists, a system that cost $10,000 per doctor a year.

"Electronic medical records gut your organization and everything you do will be different after it," Garber said.

Although the Bush Administration awarded contracts to private corporations to develop a National Health Information Network, RHIOs are likely to remain at the community level to keep things simple, Garber said.

Bigby disagreed, however, saying Massachusetts plans to establish a statewide RHIO because that will be critical to tracking health trends statewide as well as identifying wasteful practices.

"While it is true that probably 85% or 90% of care happens within the community, there is a benefit to having a state-level heath information exchange," she said, noting that the state will look into using online services, like those offered by Google and Microsoft.

Microsoft launched its Healthvault beta program in 2007 and has now partnered with Kaiser Permanente and the American Heart Association, among others, to create a database accessible by patients and authorized care providers. Earlier this year Google launched its own health records beta, Google Health.

Another health care operation looking at those same online services is Riverside Health System, according to Frazier. Riverside includes five hospitals, three cancer treatment centers, two long-term care centers, private care practices and retirement communities, and relies on a myriad of medical record systems that do not mesh, including systems from General Electric and Siemens Medical Solutions.

One big frustration for the 300-plus physician group practice: the lack of advance notice from hospital emergency departments who had seen patients.

Riverside needed a way to automatically log patients out of its emergency department to provide caregivers accurate, up-to-date information. Previously, someone in the medical records department would spend eight hours a day updating the registration system to log out patients. That information would then be manually transferred to a primary care physician's office. "Using Boston WorkStation against our Siemens Invision system, we can now log these patients out in less than one hour. The script took us only three hours to write. The result is not only a more efficient registration process in the Emergency Department, but also [freed up] a full-time employee to use in a more substantial capacity," said Jim Foss, director of IS physician services.

Physicians can get updated patient information daily from the emergency department. That, in turn, improves the safety and quality of care for patients and provides medical staff immediate access to critical patient information. Ultimately, Boston WorkStation allows clinical information to flow easily throughout a patient's continuum of care.
Asif Ahmad, CIO for Duke University Health System in Durham, N.C., said he was able to roll out an EHR system, called HealthView Patient Portal, that was built on an open-standards and services-oriented architecture for $6 million -- far below the pricey estimates offered by Brailer and others. The five-year project, now in its second year, already gives students access to a wealth of personal health information.
Duke finds a way to be frugal

Duke was able to keep its existing software and hardware systems and employed IBM's Websphere Java-based software tools to create an online medical record site accessible by patients, who can then share the information with whomever they choose. In the first eight weeks it was up and running, more than 2,500 patients registered in healthview.dukehealth.org.

"Duke's Healthview portal is like your online banking or Expedia account, which pulls information from various sources and displays it to you. You can also pay your bills online, schedule appointments online," Ahmad said. The portal relies on a series of redundant Web servers to ensure uptime.

Soon, patients will be able to view clinical test results, renew prescriptions, change insurance information and get proxy access to their children's records. They will also be able to fill out medical forms online, review medical procedures or watch medical treatment videos.

"It took us three months to do it," Ahmad said. "That's it. You use the information by putting it into a common relational architecture. What we don't want in the country right now is hospitals getting into a [technology] replacement cycle."

Given that every hospital has IT systems already in place, he suggested they use existing systems and applications and pull patient information into a data warehouse that can be shared with physicians and patients. "Just fill in the gaps and only buy the applications you need," he said.

"That's the beauty of this.... We organized the information in a vendor-agnostic fashion," Ahmad said. "We're also looking at disease management. Someone who has diabetes or hypertension -- to be able to manage that on line so they don't come into emergency rooms like train wrecks -- [it allows] more focus on prevention and education through the portal."

Duke is also currently with Google and Microsoft to be able to share information beyond its campus with any hospital or private physician that is also a member of Google Health or Microsoft's Healthvault.

Regardless of whether the Obama plan leads to private or public online health record services, Brailer said records and systems will need to be regulated to ensure data security under the Health Insurance Portability and Accountability Act (HIPPA), the privacy rules that protect Americans health information.

"Ironically, HIPPA creates felony penalties if a doctor or hospital abuses the data, but there's absolutely no penalties for a Microsoft or a Google because they're not covered by the law," Brailer said. "It's nothing that they're doing wrong. It just shows you the state of mind of Congress when that rule was written 10 years ago, because they never ever envisioned there would be online services managing health information.

"I think that's a very high priority, because one consequence of the president-elect ramping up people's attention to this is that people will come back to a lot of their fundamental worries about the protection of their health information," Brailer said.

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