AAMC Reporter: April 2009

No Easy Path for Health IT

Medical leaders lauded the federal government's inclusion of major funding for health IT projects in the recent economic stimulus package, but acknowledged serious challenges in quickly implementing health IT systems that can improve the delivery of care.

"The funding from the stimulus will be a major boon for health IT," said Morgan Passiment, AAMC director of information resources outreach. "Now the real question is, if you're going to set up electronic medical records, how are you preparing your institution for this? Who will be affected? It is a very different way of working. Will the system actually allow you to improve health care quality? It's about deciding what's right for your institution."

Health IT systems are far from a one-size-fits-all proposition. Accreditation and advisory groups such as the Certification Commission for Healthcare Information Technology and the Healthcare Information Technology Standards Panel provide guidelines, but no definitive set of standards or objectives exists.

The inconsistency in the services an electronic medical records system provides, and how it provides them, is at the heart of the health IT challenge. In January, the Institute of Medicine revealed that, in a study of eight medical centers with some form of health IT, widespread obstacles exist in sharing and integrating data among different systems, deploying new technologies, and managing data.

The American Reinvestment and Recovery Act stipulates that physicians and health systems must begin using health IT systems by 2015 or face a 1 percent reduction in Medicare fees that year; in 2017, that cut rises to 3 percent. On the other hand, health professionals who use IT will be eligible for sizable incentive payments through 2016. Medicare-participating physicians who by 2011 or 2012 adopt health IT in a way that is considered "meaningful"—a term yet to be defined—could receive up to $44,000 for up to five years. Physicians whose caseloads include at least 30 percent Medicaid patients are eligible for nearly $64,000 for up to five years.

The stimulus package set aside approximately $17 billion for anticipated reimbursements related to the Medicare and Medicaid health IT incentives. In addition, a $2 billion designation was made for the costs of training a health IT workforce and health professionals, and includes matching grants for demonstration projects that develop educational curricula involving health IT. According to Charles P. Friedman, Ph.D., deputy national coordinator for health information technology in the U.S. Department of Health and Human Services' Office of the National Coordinator for Health Information Technology, which will help coordinate much of the health IT funding distributions, no specific details are yet available on how or when funds will be made available. Friedman did acknowledge health IT training as a major priority.

"There is an emphasis on educating a health IT workforce and training health professionals," he said.

Office of the National Coordinator officials also acknowledged that defining the word "meaningful" was key to their efforts, and speculated that the government would probably be "willing to listen to input from stakeholders" on the definition, probably through one or more proposed regulations, which are subject to a public commenting period.

In the meantime, health systems are struggling with several key questions. One top question is that of interoperability, or the ability of health IT systems to communicate with one another. For the University of Virginia Health System (UVA), increasing interoperability meant combining a 20-year-old collection of health IT systems, plus its paper record-keeping infrastructure, into one system covering the entire network.

"As it stands, there is enormous variability in the way we document information on things such as allergies," said Marshall Ruffin Jr., M.D., UVA's chief technology and health information officer. "Our new system will result in better patient safety and throughput. They'll share the same system of alerts and reminders, they will share the same logic, and they will have a common look and feel. No matter where you are, you're going to know where to go for a certain piece of information."

Developing and implementing such a system takes a mammoth commitment of time and money. When converting to the new system, paper documents will need to be scanned and thousands of staff will need to be trained, Ruffin said. Ruffin estimated the cost at roughly $100 million over 10 years for software, hardware, training costs, and various services from the more than 30 vendors involved in the project.

Many institutions will not be able to implement health IT without some stimulus funding. That can mean creating a proposal quickly, and if funds are received, spending them quickly. According to Arthur J. Krumrey, chief information officer for Loyola Health System, who oversaw Loyola's development of a health IT system covering inpatient, outpatient, and pharmaceutical operations, readymade packages and expert consultants are increasingly available from private firms.

The technology itself is important, but securing staff support may be an even greater task, Krumrey said.

"The biggest challenge was dealing with a physician who spent the last 20 years optimizing his or her workflow in a paper world," Krumrey said. "With health IT, you change the workflow tremendously. We sought physicians' input from the beginning. The technology has to work, of course, but they have to be able to use it."

Krumrey made certain the system contained features that made care delivery more, not less, convenient.

"You have to be flexible," Krumrey said. "We rearranged the exam room layout so that the computer is a partner, and not a preoccupation. We put the computer on a pivoting screen so you can easily share information or not as appropriate."

Another key task is identifying decision makers before the process begins.

"As you put together all the policies and procedures and rules and templates, you need approval," said Kari Cassel, University of Arkansas for Medical Sciences' (UAMS) chief information officer. "You need the involvement of medical boards, IT teams, and others. A lot of people underestimate that end of it."

Cassel said that UAMS will soon begin requiring residents and doctors be trained to use the university's health IT systems.

"We're working to put electronic medical records training in all of our [health professions] colleges," she said. "With the residency class that begins July 1, we will have competency-based training for everyone, including physicians."

—By Scott Harris