Health IT

HEALTH REFORM: The Great Digital Divide

Allison Levy — Wed, 28 Oct 2009 20:38:00 -0400

"In a health-care debate characterized by partisan bickering," Alexi Mostrous of the Washington Post writes, "most lawmakers agree on one thing: American medicine needs to go digital." But how how we make sure it goes digital -- evenly? In other words, how can we use technology to eliminate health disparities -- not enlarge them?

As we have written before, there is significant evidence that the widespread (and smart) adoption of health information technology will help improve the safety, efficiency and effectiveness of the U.S. health care system. It can also eventually save money or "bend the cost curve." As such, Obama's American Recovery and Reinvestment Act of 2009 (the stimulus bill) made a roughly $30 billion net investment toward Health IT adoption by physicians and hospitals.

But the administration also wants to make sure that health IT reduces -- not deepens -- health disparities. That means making sure the health IT funds benefit the rural, uninsured and underserved populations.

A study released this week by Health Affairs, Evidence of An Emerging Digital Divide Among Hospitals That Care For The Poor, funded by the Office of the National Coordinator for Health Information Technology and the Robert Wood Johnson Foundation, examines the adoption of electronic health records in hospitals nationally. They surveyed 3,747 acute care non-federal hospitals and received responses from 2,368 -- a response rate of 63.1 percent.

While the study is only an early indicator of EHR use in U.S. hospitals, it has some interesting conclusions:

EHR adoption rates are low overall; hospitals with higher rates of poor patients have lower adoption rates of electronic decision support tools, electronic medication lists and electronic discharge summaries
Hospitals that serve high numbers of poor patients more often cite money as a major barrier to adoption
There are modest differences in the quality of care provided at hospitals disproportionately caring for the poor versus hospitals that are not

Hospitals with high numbers of poor patients (Disproportionate Share Hospitals) rely on Medicaid funds significantly more than other hospitals. As states that have "cash strapped" Medicaid programs may choose not to contribute to health IT initiatives, these hospitals will have less money available to launch EHR systems.

The researchers are concerned that a "digital divide" is emerging between hospitals treating high numbers of poor patients -- and those that are not. They worry that as hospitals adopt electronic health records, hospitals that serve a disproportionate number of poor patients will fall even further behind in their ability to provide quality care. So despite the great potential of health IT, the impending "digital divide" and insufficient financial capital may well continue to exacerbate, not end, health disparities throughout the country.

"Our study shows that EHRs have the potential for eliminating disparities between hospitals that care for greater numbers of poor patients and those that don’t," explains Dr. Ashish Jha, the lead researcher.

For example, the research reveals that there is no disparity between the care provided by hospitals caring for more poor patients than those that do not -- but this is among hospitals with EHR systems. "Without HIT," Dr. Jha continues, "it will be much harder for hospitals that primarily serve the poor to catch up. HIT is woefully inadequate throughout the health care system, but institutions that treat the most vulnerable patients have much less of it and this leads to worse care." (To learn about one safety net hospital that has used Health IT extensively and effectively, read about Denver Health here.)

Another study conducted by Esther Hing and Catherine Burty illustrates that uninsured Black and Hispanic or Latino patients, as well as Hispanic or Latino Medicaid patients, are less likely to have primary care physicians that use EHRs than privately-insured white patients.

As policymakers decide what measures they will take to make lasting improvements in the U.S. health care system, it is critical that they address the "digital divide" and ensure that hospitals are given equal opportunity to adopt EHRs. "This is not an isolated issue," Dr Jha explains, "We are talking about one in every four hospitals -- and they treat millions of patients. These hospitals will need a concerted effort from both national and state policymakers to avert a serious digital divide from emerging."

HEALTH IT: Statewide Networks Ready for Launch

Meredith Hughes — Thu, 24 Sep 2009 18:14:00 -0400

Remember that funding for health information technology in the stimulus package? We know, it's been a little while, and when it comes to health reform, we've had a lot on our minds lately. But states haven't forgotten about health IT and the American Recovery and Reinvestment Act of 2009 boosted both their motivation and resources to get health IT programs up and running in two to six years. That states are interested in establishing electronic health information exchanges isn't exactly breaking news, but the recent progress in investment, implementation, and infrastructure is pretty exciting.

The stimulus package included the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH Act), which lays the groundwork for advances in health care quality. Late in August, the Obama administration announced $1.2 billion of the stimulus funds would be released in the form of health IT grants, reports American Medical News.

The goal is to create a network of health IT centers, both regional and state-based, to help and support physicians and hospitals transitioning into electronic health record systems, says AMNews.

The initiative has two specific grant programs. The first makes available $600 million to set up approximately 70 regional health IT centers. According to AMNews, these centers would offer "technical assistance, guidance and information" to physicians and hospitals that want to become meaningful health IT users, with a special focus on helping primary care physicians and small group practices adopt EHRs. The second offers a total of $560 million -- plus technical and legal assistance -- to states that want to start their own state-wide health IT information exchange. HHS wants to make sure systems are both secure (just like electronic banking, health information should be private) and interoperable within states and across state lines (meaning information can go from your doctor's office to another's, or to a local hospital -- or a hospital hundreds of miles away).

Among others, Maine, California, New Hampshire, West Virginia, Texas, Vermont, Washington, Wisconsin, Rhode Island, Tennessee, Utah, and New York all are working on statewide systems. Here are some highlights:

Maine

In late July, Maine announced HealthInfoNet, a statewide health information exchange. According to Eastern Maine Healthcare Systems, the exchange represents collaboration between government and public health officials, physicians, insurers, consumers, employers, and non-profits. According to EMHS:

In addition to regulatory oversight and internal security, HealthInfoNet has established Consumer Advisory Committee comprised of healthcare and computer experts, a number of consumer advocacy groups with strong interests in patient privacy, as well as educators.

New Hampshire

This summer, the New Hampshire legislature passed a set of guiding principles for a statewide exchange. New Hampshire hopes to use stimulus funds to further statewide use of health IT, and prioritizes information privacy. In a press release, state representative Cindy Rosenwald wrote:

This spring the New Hampshire legislature took a major step forward in advancing the adoption of Health Information Exchange among providers. House Bill 542 sets out the strategic framework, starting with principles developed by the Citizen's Health Initiative, to bring about the successful exchange of health information among an individual's doctors, no matter where they are located. The American Recovery and Reinvestment Act includes $20 billion to promote health information technology and exchange. When Governor Lynch signs HB 542 into law, New Hampshire will be poised to benefit from our share of the incentive.

New York

At a State Alliance for e-Health conference in August, NY State Department of Health Deputy Commissioner Rachel Block discussed New York's health IT strategy. Like Maine, New York's strategy requires cooperation between health care stakeholders and state government. This collaboration created the New York eHealth Collaborative (NYeC). According to its website, the NYeC represents a "public-private partnership that will serve as a focal point for health care stakeholders to build consensus on state health IT policy priorities, and collaborate on state and regional health IT implementation efforts." The goals of a statewide health IT infrastructure in New York are to:

Support clinicians and consumers with information at point of care
Advance care coordination
Strengthen public health surveillance and response
Enhance quality and outcome measures

Tennessee

According the Tennessee Office of e-Health Initiatives, Tennessee already established an e-Health Network, a secure health information sharing network in 95 counties. Additionally, the state has two Regional Health Information Organizations (RHIOs), CareSpark in the Tri-cities region of East Tennessee, and the MidSouth eHealth Alliance, Memphis in West Tennessee. Tennessee's goal is to align all health care stakeholders in a public-private partnership, to further improve their utilization of health IT and improve public health, quality of care, access to care, and lower costs.

Vermont

Vermont is a leader in health reform on a state level. While bringing down costs and covering more Vermonters over the past several years, the state also implemented health IT. In 2005, Vermont authorized the creation of the Vermont Information Technology Leaders (VITL), a non-profit, public-private partnership that laid down guidelines and goals for a statewide health information exchange. Vermont is renewing its push for meaningful, organized health IT use in a landscape improved by the economic stimulus package. The Blueprint for Health goals include making health information exchanges bi-directional, to share info between doctors, hospitals, labs, and public health registries. Vermont hopes this improved flow of information will improve quality, lower costs, and support care coordination, as it will speed up processes such as receiving medical lab test results.

When utilized properly, health information technology can improve quality of care, lower costs, and increase efficiency. States realize the value of health IT -- many were already working on implementing health IT before stimulus funds were available. The provisions in the American Recovery and Reinvestment Act are a great step forward, as they encourage and aid states that want to improve the quality and efficiency of health care through electronic information technology. For more information on regional and statewide health IT initiatives, click here, here and here.

HEALTH CARE: What Grand Junction Colorado Can Teach the Rest of Us (Part 2)

Joanne Kenen — Fri, 14 Aug 2009 13:29:00 -0400

Grand Junction, CO, is the high-quality, low-cost flip side of McAllen, Texas in Atul Gawande's recent New Yorker article. New America's health policy team just published a case study on how Grand Junction's health care system evolved (full paper here, summary here), and what the rest of our country can learn from it. We gave you an overview on our blog Thursday. Now we're going to look at how the community uses health IT to create quality and value.

We all know that health IT in and of itself isn't a cure-all. But it's hard to fix health care without smart use of health IT across the community.

One of the unusual features about the Colorado community is that the main health plan (Rocky Mountain Health Plans) pays a "blended rate" to physicians. That means it's a similar rate for private insurance, Medicare, and Medicaid. Doctors thus don't have any incentive to cherry-pick better paying privately insured patients, and shun the poor. Everybody gets care. The community benefits.

Rocky ended up in a lawsuit with the state Medicaid program a few years ago and got a $21 million judgment for underpayment in the 1990s. Rocky divvied up most of the money among physicians it contracted with, but a dispute arose over $2.5 million. The solution? Spend the money on something that would benefit the community as a whole. Rocky was already helping physicians install electronic medical records in their offices. Now they would go a step further and create a community-wide system. The Quality Health Network went live in 2005, and is now nationally recognized.

Today, the network serves western Colorado and eastern Utah. It is a community-wide effort, with a board of directors and several subcommittees of leaders from all areas of the health care community. About three-fourths of its funding comes from the community's two hospitals, Rocky, and the Independent Physicians Association of Mesa County. (Our case study explains more about the unusual degree of cooperation between these key health care players).

The health IT network's roots actually go back about 15 years, when Rocky and the IPA doctors wanted to have one place to access information about patients who see both specialists and primary care providers. But it was early in the information age, and the first attempts failed. About three years ago, they tried again. Now network users include physicians and hospitals, clinics, hospice, long-term care facilities, mental health providers, home care agencies, physical therapy, occupational therapy, schedulers, labs, transcriptionists, case managers, and insurers. As of February 2009, there were 1,569 licensed users from 84 different organizations, including the public health department. In just the first two months of 2009, there were more than three million requests of the server. In June 2009, western Colorado was granted $4 million to install a QHN system that would connect outlying areas with an Internet database for physicians to access patients’ medical histories.

Health IT is a big boon to Grand Junction's providers. They get to see a complete picture of their patient. The cardiologist, for instance, knows what the pulmonologist prescribed, what tests were done. The hospital knows what the outpatient community-based care providers did and vice versa. There's less risk of harmful drug interactions if all the doctors can see the complete records. Less duplication of expensive tests and imaging. Better coordination of care. Fewer unnecessary hospitalizations. Higher quality. Lower cost.

Grand Junction's use of health IT shows us what we should all be striving for.

IN THE STATES: Vermont Pushes for Lower Cost, Quality Care

Meredith Hughes — Wed, 29 Jul 2009 16:56:00 -0400

Long before the federal government began its big push to reform the U.S. health care system, states were feeling the strain of rising health care costs and increasing numbers of uninsured. Many states decided to take a crack at health reform in their own way. We've heard a lot about reforms in Massachusetts, but other states have also made progress.

One such state is Vermont. USA Today highlights some of the quality innovations in Vermont that have helped the state save money and improve efficiency. Rather than start with the goal of universal coverage like Massachusetts, Vermont started working towards two other aspects of health reform: lowering cost and improving quality of care. (It already had a -- relatively -- low rate of uninsured residents, and including when Howard Dean was governor, the state had taken steps to cover most children and pregnant women, and as we'll see in a moment, it is also working on covering more adults.)

Among other cost saving measures, Vermont has made good use of health information technology and programs that encourage disease prevention and management. For example, using health IT, doctors can see (if patients consent, of course) whether or not patients filled their prescriptions on time. Helping patients adhere to treatment recommendations such as taking their medications correctly and consistently improves health outcomes and in the long run lowers costs, because patients don't seek as much emergency treatment for serious conditions, relapses and complications.

The state's Blueprint for Health helps patients manage costly chronic conditions such as diabetes through a team-based approach to care, reports USA Today. Primary care doctors work with community health specialists such as nutritionists and social workers to coordinate care for each patient. The pilot program includes approximately 60,000 people.

Vermont even offers a plan for low income residents to acquire health insurance, Catamount Health. The program is priced on a sliding scale and contains all the benefits mandated by the state, including hospitalization and drug coverage, doctor visits for primary and specialty care, and mental health and substance abuse treatment. Vermont set the goal of near universal coverage by 2010. They're not there yet, but they've managed to reduce their uninsured population from 9.8 to 7.6 percent over the past couple of years.

Financing for the Vermont reforms comes from contributions by hospitals and insurers, an 80 cent tax on cigarettes and a penalty of $365 for each employee for businesses that do not offer health insurance, says USA Today. The federal government also allowed Vermont a little more flexibility in Medicaid spending.

Though the program is too new to have data on definite cost savings, reformers are optimistic. According to USA Today, Vermont has already seen a 30 percent drop in emergency room utilization. Savings from increasing the quality and efficiency of care aren't immediate (and sometimes they are difficult to score), but they are there -- and they're vital to creating an affordable, sustainable health system in the long run.

Higher quality care and lower costs are part of the goal for health reform, but they don't complete the package. When we have truly meaningful health reform, we will have coverage for all Americans, better care, and lower costs in a stable, sustainable health system.

HC4HR: How a Safety Net Hospital Unleashed the Power of Health IT

Paul Testa — Wed, 15 Jul 2009 12:38:00 -0400

The story we are about to tell you is probably not what automatically comes to mind when you hear "safety-net hospital."

On Monday, we continued our series of posts on the Health CEOs for Health Reform by looking at how more integrated models of care can deliver higher quality at lower costs.

Today, we'll see how Denver Health -- an urban safety net institution for Denver and the Rocky Mountain Region -- has established a highly integrated system that consistently delivers high-value care to vulnerable population. Health IT and electronic medical records are key to their success, as Patricia Gabow, MD, Denver Health's CEO explains in the video below:

Denver Health is a complex system providing a whole host of services. Just to name a few, there's the 911 ambulance and trauma system; a Disproportionate Share Hospital (the busiest hospital in Colorado); eight federally qualified health centers; the county public health department; 12 school-based clinics; as well as an HMO which serves Medicaid, SCHIP, Medicare and commercial patients. And, as Dr. Gabow will tell you, what makes all these moving parts work together for Denver Health is the commitment to health IT. Their imaged, electronic medical record ties it all together. It lets doctors communicate with doctors -- for example, a doctor in the ER can easily bring up a list of all the medications an unconscious patient's primary care physician has prescribed. It helps doctors communicate with patients, developing treatment plans and following up on adherence.

Health IT has helped Denver Health manage complex chronic diseases, like diabetes or asthma. As Dr. Gabow noted, 61 percent of their hypertensive patients have their blood pressure under control compared to a national average of 34 percent. Denver Health has 92 percent of its one-year-old patients fully immunized. Furthermore, consistent and constructive use of health IT has enabled Denver Health to eliminate ethnic disparities in areas like cancer screenings and diabetes management.

What makes this all the more impressive, is that Denver Health is a true safety-net institution. It serves 150,000 patients annually, of which 78 percent are minorities, 50 percent are uninsured, and 85 percent are below 185 percent of the Federal Poverty Level. Since 1991, it has provided $3.4 billion in uncompensated care for the uninsured -- with $360 million in uncompensated care projected this year. Yet each year they manage to stay profitable, by providing high-value care in an integrated system. If Denver Health can do it, so can we.

HEALTH IT: Appointments Online

Joanne Kenen — Wed, 08 Jul 2009 19:54:00 -0400

I keep reading and hearing and sometimes even writing about doctors who let patients make appointments online or request prescription refills online. As a full time working mom, I am a big fan of online convenience, online shopping, online communication, anything that keeps me off of "hold."

None of my family's doctors yet offer such a service. But I just had what you could call a hybrid online experience. I pulled up the website (rather than hunt through my old personal phonebook...which I confess is still on paper) for a radiology center. Alongside the phone number was a place to make a request for an appointment online. It wasn't a completely computerized experience, but I filled out a form on the website, saying what test I needed, what days and times were convenient for me, which of their seven locations I preferred, and what time they could call me. They promised to get back to me the next business day. They called at the specified time, and offered me a choice of three appointments that met my criteria.

It took a minute (not counting the 45 seconds it took for me to pull over and grab a pen, as she called when I was in the car). In past years, this took multiple phone calls and time on "hold." I suspect this saves the clinic money; it's a more efficient use of their schedulers' time. And it's definitely good for my mental health.

COST: Fixing the "Invisible Wiring"

Alex Mazerov — Thu, 02 Jul 2009 16:14:00 -0400

The nation’s largest health insurer says we can save well over $300 billion in the health care system over the next decade by streamlining administrative procedures and making better use of technology.

In a report released yesterday, UnitedHealth Group proposed twelve broad reforms to the administrative and transactional aspects of the U.S. health care system that it estimates can save $332 billion over 10 years.

Through twelve building blocks we identify administrative savings opportunities of $332 billion in national health expenditure over the next decade. These savings would be likely to benefit families and employers through lower health care costs. As importantly, they would simplify the lives of patients, and eliminate much frustration on the part of doctors and hospitals.

The proposed changes include more widespread use of automated swipe cards to validate patient benefits, elimination of paper checks and remittance advice (to be replaced with electronic systems), and creation of a national payment accuracy clearinghouse. The report, “Health Care Cost Containment—How Technology Can Cut Red Tape and Simplify Health Care Administration” also recommends using predictive modeling to pre-score insurance claims.

Simon Stevens, UnitedHealth’s executive vice president, said that these changes must be applied across the entire health care sector for maximum effect. From BNA:

Stevens said the administration of health represents the “invisible wiring” of the system and must be addressed as part of comprehensive reform. “Getting it right offers huge opportunities to simplify the experience that patients have every day when they interact with the system and to reduce a lot of the frustration that doctors, hospitals, and health plans all experience,” he said.

"Other sectors of the economy have mastered it long ago, and it's time for healthcare to catch up," Stevens told Reuters.

HEALTH IT: The Inter-Operetta

Joanne Kenen — Mon, 08 Jun 2009 22:05:00 -0400

The Wall Street Journal's health blog brings us the story of a Health IT guru who made a little musical ode to Health IT and put it up on YouTube... We aren't even going to try to summarize it, see for yourself...

COST: Industry Groups Outline Cost-Savings Initiatives

Joanne Kenen — Mon, 01 Jun 2009 22:23:00 -0400

The industry groups that gathered at the White House last month and pledged to bring down health costs by $2 trillion in the next decade followed up with a 28-page document to the White House Monday. The letter addresses things like better management of chronic diseases, more administrative simplicity, appropriate utilization of medical services, quality improvement and medical error reduction, expansion of health information technology. In other words, the industry gave a real world vote of approval to what a lot of what academic researchers and health policy experts have been saying about the ways to bring down the costs and improve care.

However, the document (from the American Medical Association, PhRMA, the American Hospital Association, the SIEU, America's Health Insurance Plans, and AdvaMed, which is the main medical device trade group) was a vague on whether there were any teeth in the pledges to do this, that and the other thing, or on what would happen if these initiatives fall short (or fall apart).

Individually and together, our organizations have developed initiatives that will help move the nation toward achieving the Administration's goal and we intend to keep working. Our organizations will now pursue these initiatives which, together,will help transform the U.S. health care system.

So while this is certainly a step in the right direction, giving more oomph to the cost-down, quality-up message, it remains to be seen exactly who is committed to doing what when, and what legislative steps, regulation, timetables or mandates the industry will or will not embrace. Guess we'll find out later this month when the rubber starts to hit the legislative road...

HEALTH IT: Redrawing the Cancer War Battle Plan

Joanne Kenen — Thu, 21 May 2009 16:07:00 -0400

Hundreds of thousands of patients undergo cancer treatment each year, using all sorts of combinations of drugs and treatments and therapies. Not all are in clinical trials—but many of them have something to teach us. We linked to Gooznews touching on this topic a few months ago. Now Merrill Goozner has a longer analysis at Science Progress of how, in part because of advances in health IT, we could tap this untapped pool of knowledge:

A redrawn battle plan—one that focuses on turning the treatment system into a research and learning system that can teach oncologists the best use of the weapons they already have—is long overdue...

…Many of the nation’s 30,000 oncologists are engaged in what could be described as an unobserved and uncontrolled science experiment, especially when it comes to treating the 560,000 Americans who die each year from the more than 100 forms of the disease. As these patients’ cancers advance, their physicians try regimens they read about in journals or hear about from colleagues. The outcomes are never gathered. The data is never analyzed. And the findings are never disseminated.’

The economic stimulus package should help us expand our use of HIT. Goozner says we also have to encourage doctors and scientists to be more accepting of retrospective analysis of treatment data, not just the proverbial gold standard of double-blind clinical trials. But we should be able to harvest some of that knowledge and disseminate findings much more quickly than we do today. The National Cancer Institute has already begun creating that learning system through the Cancer Biomedical Informatics Grid, known as caBIG. The goal: not just broad findings about this drug or that, but fine analysis of which subgroups of dozens of kinds of cancers respond best to which specific treatments or combination of treatments. And rather than limiting and impersonalizing choices, this could move us toward “personalized” medicine.