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Can US medicine achieve President George W. Bush's goal to have interoperable electronic health records (EHRs) in widespread use by 2014? The technical, practical, and financial hurdles look awfully high.
But the president's health technology czar, David Brailer, MD, PhD, predicts that we'll meet that goal—with time to spare. Still, he said, there's plenty of work to be done, and it's important for specialists, such as clinical oncologists, to help shape that information technology to come.
Brailer has led the Office of the National Coordinator for Health Information Technology (ONCHIT) for a year now. That year was devoted to assessing the challenges of implementing health information technology by looking at the needs and problems of physicians, hospitals, health plans, government agencies, and the public. The reason he is so optimistic, he told the Journal of Oncology Practice, is he saw that “this issue has had very deep resonance, and a very strong sense of can-do has come from physicians, hospitals, and many others. It's something that we really never expected when the plan was laid out originally.”
Now, ONCHIT is about to launch its action plan. On the plan's short list, he said, are getting a certification process for EHRs into the marketplace, getting standards in place, building the data-sharing capacity required to move the information around, and improving and expanding security and privacy protections. The office is now working out the specifics that should make patients' information truly portable and EHRs adoptable by physicians, he said.
So far, the market-based solution the administration seeks to support has meant that early adopters have been large health systems that can reap the financial benefits of efficiency, even after very large investments. Smaller practices have a much more difficult time taking on what is still a large financial risk without direct monetary benefits.
Whether practices are large or small, the risk of implementing EHRs is still high—unacceptably so, said Brailer. Although the federal government won't be offering financial help to offset the risk, it is looking for ways to lower it.
Certification (that is, identifying “better-bet” products) can go a long way toward lowering risk, Brailer believes. To that end, health technology trade associations came together to form the Certification Commission for Healthcare Information Technology (CCHIT). It's a private-sector commission that Mark Leavitt, MD, PhD, the commission's chair, likened to Underwriters Laboratories. “Basically,” he told the JOP, “we're trying to put stickers on EHR products that gives extra assurance that they're going to do what physician consumers want, that they're going to be secure and protect patient information, and that they'll be able to communicate with other systems and be compatible.”
Today, Leavitt explained, the stakeholders in health care are deadlocked when it comes to implementing EHRs. Providers are reluctant to buy EHR products because the risks and costs are high and the incentives to buy are few. Payers and purchasers won't offer incentives to providers unless the benefits of EHRs are clear and their interoperability is assured. Vendors can't bring down their prices until adoption by providers accelerates.
Certification, he said, can break that deadlock by assuring providers that an EHR product can work for them, removing some of the risk, which will accelerate adoption. With increased volume, vendors can improve their products and lower prices. And when payers are assured that EHRs can deliver what they want—cost effectiveness and better compliance with guidelines—they will offer incentives for adoption. And certification is on its way. CCHIT's pilot program will be in place this summer.
Certainly, certification isn't the only barrier to adoption of EHRs, but it can have tremendous power to break them down, believes Leavitt. He pointed to wireless fidelity (Wi-Fi) certification as an example. Just a few years ago, it cost at least $1,000 to add wireless capability to a computer, and setting up a network to accommodate it took high-cost custom engineering. But the industry came to agree on standards and the Wi-Fi Alliance stepped in to certify that products met them and were interoperable. Prices plummeted as a result. Leavitt recently bought an adapter for about $20, and he can connect to a wireless network almost anywhere he goes—airports, hotels, even Starbucks.
Another barrier, Brailer pointed out, is that today, “we pay for volume, not for quality.” And that needs to change. Pay for performance, which is emerging with Medicare and other third-party payers, will “really start changing the landscape of what is valuable to a doctor and what isn't.” That will make the advantages of EHRs, such as error reduction, following practice guidelines, or using the most up-to-date treatments, financially worthwhile.
Standards for EHRs, too, are still in development, although computer science–based standards, such as those for data format and exchange and data protection and security, have come a long way already. The standards that need development the most, said Brailer, are clinical standards—the medical evidence guidelines that can be incorporated into EHRs.
The challenge for oncology, he said, is to figure out “how do we take all these great ideas and this evidence and science and boil it down to the things that physicians ought to do routinely when they see patients and how do we get that into computer-readable form? There's nobody who really owns that right now. It's open territory. I think that's where ASCO needs to take a look,” Brailer said.
Leavitt sees a need for ASCO and specialty societies to shape, not just clinical standards, but also how EHRs will incorporate them. “The worst case is having every oncology office inventing their own concept of what their EHR should do and customizing it. That's the way to have no impact on the market.” The best tack is to ensure that general purpose EHR products can add the layer of customization that oncologists need, much like tailoring an off-the-rack suit. And the society can take on the task of making sure that the protocols, guidelines, forms and more that could be imported into the EHR are up to date.
Oncology as a specialty also needs to ensure that EHR systems are reliable enough to handle the numerous and critical checks oncologists must make and robust enough to manage a lot of data, such as protocols and guidelines, drug interactions, or cumulative lifetime doses, he said.
When the specialty as a whole can come to a consensus on what it needs, that can have a powerful effect on the market, said Leavitt. Letting CCHIT know the specialty's needs is one way to do that, as the new Physicians Electronic Health Record Coalition, which includes 15 societies, is doing. CCHIT has had one public comment period and is scheduling more for July and beyond.
A society can also exert its power on the EHR marketplace by reviewing products, helping their members implement them correctly, and even acting as group purchaser, said Brailer. He pointed to the American Academy of Family Practice's Center for Health Information Technology, which has driven group purchasing agreements with vendors to help bring down prices and help practices choose products.
“It's the new dawn of a very automated, decision-support driven environment for physicians,” said Brailer, who singled out oncology as a specialty that could reap enormous benefits from EHRs because of the protocol-driven nature of treatment and oncologists as physicians who have the aptitude to determine how information technology can improve their practice.