The case for computerizing health care now, not later
From the April ACP Observer, copyright © 2004 by the American College of Physicians.
By Deborah Gesensway
America's physicians will never be able to meet their promise to keep sick patients safe if they continue to operate without integrated computer systems using standardized data.
That was the conclusion reached by a much-heralded report released last fall by the Institute of Medicine (IOM). The report argued that technological innovations such as electronic health record (EHR) systems, computerized decision-support tools and data collection programs are all essential for better quality and more cost-effective care.
Even more important, the IOM report claimed that information technology is the key ingredient in safeguarding public health. Without widespread adoption of information technologies, the report concluded, health care professionals will never be able to substantially reduce the number of medical mistakes that occur each year.
The chair of the committee that produced the IOM's "Patient Safety: Achieving a New Standard for Care" report is Paul C. Tang, FACP, chief medical information officer at California's Palo Alto Medical Foundation and one of the leading internists working in the field of medical informatics.
Dr. Tang explained that while the report stressed the need for physicians, hospitals and health systems to invest in information systems, the government also has a key role to play.
For one, the IOM report concluded that the federal government should provide financial incentives to prompt the private sector to develop and adopt electronic health record systems. The report also called on the government to take the lead in accelerating the development of standards for clinical "vocabulary" and for mechanisms that will allow clinical information to be exchanged and shared among different provider systems.
The report even urged the government to take a harder line with providers, requiring them to adopt national data standards in their EHR systems as a condition for their continued participation in Medicare and other government health care programs. (The report is online.)
Dr. Tang recently spoke with ACP Observer about the report and the nation's slow progress computerizing health care.
Q: No other industry in the 21st century would consider operating without the aid of computers. What is different about health care, and why did this report have to be written?
A: There are a lot of legitimate reasons why health care has been slow to adopt information technology, but now the tipping point has been reached. With the amount of information and knowledge required to practice medicine today, it is no longer safe to practice without the same pervasive information support that exists in other industries, such as the airline industry.
It is not feasible to monitor and guide air traffic without an extensive computer infrastructure supporting the air traffic controllers and pilots. The health care industry must step up to the challenge of revamping the infrastructure that underlies health care delivery. The IOM report outlines some of what needs to be done to accelerate that adoption of information technology. It will take bold action by all the health care players—the government, payers, providers and even patients.
Q: When you talk about needing better information systems to promote patient safety, are you just talking about a standardized adverse event and near-miss reporting system?
A: No. When most people think of patient safety, they think of reporting all the bad things that happened. We are saying, 'Let's turn it around and prevent these bad things from happening.' We want to reduce the chance of making an error in the first place, and the best way to prevent errors from happening is by implementing electronic health record systems.
We redefined safety as the prevention of errors of commission and errors of omission. That equates patient safety with quality of care.
What most people talk about are errors of commission, such as a medication error. But the bigger opportunities are preventing errors of omission: not following our own best evidence or not treating a condition optimally. For example, even for common conditions such as hypertension, we often don't achieve our desired treatment goals. A busy internist is hard-pressed to achieve those goals relying on a paper record system.
Q: What needs to be part of a national electronic health information system to improve patient safety?
A: Ultimately, we would like to collect patient information once and give secure access to the data to everyone who has a professional need for those data. That includes other members of the health care team, patient safety organizations, accrediting organizations and the patient.
To do this, the computers that store, transmit and retrieve data must have a common way of understanding the data, as well as common policies to protect data confidentiality.
These are two critical components of a national health information infrastructure. By having common data standards, we will not only be able to share patient data among physicians for providing care. We should also be able to reduce the administrative burden of complying with various reporting requirements because reports should become a byproduct of care, not a separate activity.
Q: How significant is last year's government agreement with the College of American Pathologists to license its Systemized Nomenclature of Medicine-Clinical Terms (SNOMED-CT)?
A: HHS Secretary [Tommy G.] Thompson's announcement that the federal government has purchased a five-year license for SNOMED-CT on behalf of all U.S. health care organizations is a major step toward developing a complete set of vocabulary standards.
While this step won't have an immediate impact on practicing physicians, it allows EHR system developers to work on standardizing the underlying vocabularies so that different vendors' solutions will eventually be able to share data among various systems.
Q: What are other barriers to more widespread investment?
A: One is leadership. We believe that the federal government—as the guardian of public health and the largest payer for health care services—has a vested interest in promoting standards that support patient safety. We are not advocating for a government takeover, but the federal government needs to take a leadership role to stimulate or accelerate the actual work that will be done by the private sector.
Another barrier is money. It's very expensive. Here again, the committee believes the federal government should take a leadership role in creating financial incentives to increase the investment in information technology that enhances patient safety.
Q: Did the committee recommend any type of financial incentives or funding mechanisms?
A: The committee didn't recommend any specifics because that was beyond the scope of its charge. I think CMS [the Centers for Medicare and Medicaid Services] is exploring several options and demonstration pilots, and I would encourage ACP and its members to participate in discussions with HHS to help shape possible incentives.
Q: Is the government getting more involved in information technology in other ways?
A: Yes. The Medicare bill [passed last year] calls for some demonstration projects. The president mentioned computerized medical record standards in the State of the Union. The Agency for Healthcare Research and Quality (AHRQ) is funding $50 million of research and evaluation of information technology support of patient safety. There is tremendous support and activity in this area within the administration and Congress.
Q: If EHR adoption is required to participate in Medicare, will some small or rural providers be cut out of the program?
A: Clearly, the health care information infrastructure can't leave anyone behind. In fact, AHRQ has earmarked half of the $50 million research grant program to address the needs of small or rural providers. The information infrastructure needs to cover everyone.
Q: Given the current lack of standards, what should doctors do? Aren't they setting themselves up for hassle and expense if they invest in a system that might be out of date in a few years?
'Patients will be asking 'Got EHR?' waiting is not an option because the status quo is unacceptable
A: That's exactly the logjam we're trying to break. In a sense, the private sector is waiting for something to make everybody go at the same time. The federal government needs to pull the trigger to start the race.
But we are saying that you can't wait for standards. It's too bad that we don't have them, but waiting is not an option. Adopting electronic health record systems in practices is being identified as virtually the only way you can practice high quality, safe medicine. Patients will begin asking, 'Got EHR?' Waiting is not an option because the status quo is unacceptable.
It's the old question of 'Why should I buy a computer today when it's going to be faster and cheaper tomorrow?' In that case, you still wouldn't own one.
Deborah Gesensway is a freelance health care writer who lives in Glenside, Pa.
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