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Why medicine must lead the way to electronic records

From the April ACP Observer, copyright 2004 by the American College of Physicians.

By Robert B. Doherty

For many years, a quiet effort has been underway by medical informatics experts, government officials, software developers and business leaders to lay the groundwork to create an electronic heath information infrastructure in the United States. Now that vision of computerizing medicine has suddenly been embraced at the highest levels of government.

In his State of the Union address in January, President Bush stated, "By computerizing health records, we can avoid dangerous medical mistakes, reduce costs and improve care." Presumptive Democratic presidential candidate Sen. John Kerry (D-Mass.) has proposed a "technology bonus" as an incentive to help health care providers and insurers switch to electronic records.

Creating a national information infrastructure means more than getting electronic health records into every doctor's office. It also means that each independent system must be "interoperable" with all other systems, including those used by other physicians, hospitals, pharmacies and laboratories.

And it means that each of those systems must allow users to immediately exchange clinical information, so information can be easily integrated into patient health records. Those records must then be maintained as electronic files, not paper documents.

Controlling costs, improving quality

Proponents of a national electronic infrastructure believe such a system can bring the same gains in efficiency and productivity to health care that technology has given to other sectors of the U.S. economy.

A study released last year by the General Accounting Office (GAO) looked at 20 different information technology initiatives undertaken by health care organizations. It concluded that information technology led to substantial savings and efficiency gains.

The GAO also found that heath care institutions that invested in health information technology reduced the number of administrative staff positions needed to handle patient records, ordered fewer portable chest X-rays and increased the number of claims processed without human intervention. Those savings occurred even though the surveyed practices were using stand-alone systems that weren't connected to a larger electronic system structure.

The Institute of Medicine (IOM) last year concluded that "a national infrastructure for standardized data collection and exchange is needed because patients often receive services from many different providers. Routine use of electronic health records would give health care providers and patients immediate access to complete patient information as well as tools to guide decision-making and help prevent errors". (For more on the IOM's call for information technology, see "The case for computerizing health care now, not later.")

Barriers to a national system

Despite these glowing endorsements, only a small percentage of physician practices, hospitals and health care facilities have installed electronic health records. Perhaps just as importantly, most of those systems do not communicate effectively with each other.

A new report by the IBM Center for Healthcare Management concluded that there are several key system-wide barriers to creating and adopting an electronic health information infrastructure. They include the following:

  • payment systems that fail to reward investments in any kind of health information technology;

  • a lack of standards and interoperability across systems;

  • clinicians' reluctance to adopt information technology because the technology isn't integrated into their workflow;

  • high investment costs; and

  • the failure of vendors to deliver systems that adequately meet the needs of providers and facilities.

A study published in the March-April 2004 issue of Health Affairs concluded that the uncertain payoffs of investing in electronic systems, as well as the high initial costs of both money and physician time, are slowing the acquisition of information technology.

The government's role

Overcoming those barriers requires renewed leadership and commitment. The private sector, not the government, should lead the effort to develop technologies, create necessary industry standards, and encourage dissemination to and acquisition of new systems by clinicians. But the federal government can do more to support such efforts.

The Medicare Prescription Drug Improvement and Modernization Act of 2003 established a voluntary electronic prescribing program. It also created financial incentives for acquiring information technology and authorized several demonstration projects on using information technology to improve quality.

The law also mandated the establishment of a new commission on system interoperability to develop a comprehensive strategy and timeline for adopting national standards.

But the IBM Center for Healthcare Management concluded that legislators have been unwilling to use the most powerful tools they have to drive broader change. No major changes, for instance, have been made to use the Medicare and Medicaid payment systems to promote technology adoption, and no major financial incentives exist system-wide to make adopting information technology a higher priority for clinicians.

Several prominent members of Congress are working on legislation to provide the required federal leadership and funding. Rep. Nancy Johnson (R-Conn.), chair of the Subcommittee on Health, which is part of the Ways and Means Committee, has introduced the National Health Information Infrastructure Act of 2003 (H.R. 2915) to support financing and implementation.

Sen. Judd Gregg (R-N.H.), chair of the Senate's Health, Education, Labor and Pensions Committee, has announced plans to move a bipartisan bill on information systems through his committee. Sen. Hillary Rodham Clinton (D-N.Y.) recently announced that she plans to introduce a comprehensive legislative proposal to promote quality improvement and the development of a national electronic health infrastructure.

And both the House and Senate have passed their own versions of patient safety legislation that include provisions to support information technology.

ACP's role

As the government moves toward defining its role in promoting information technology, it is essential that physicians be at the table.

The federal government can help physicians overcome the practical barriers to acquiring technology by providing financial assistance and facilitating the creation of voluntary standards on interoperability. But the federal government could also make that transition much more difficult, with heavy-handed and unfunded mandates or punitive measures to coerce physicians into acquiring information systems.

The College has developed preliminary policies on adopting information systems, and we hope to soon release a comprehensive position paper on creating an interoperable national infrastructure. Our policies emphasize the importance of providing resources and practical assistance so physicians can acquire and learn new technologies.

We are sending representatives and providing comments to various groups that are working to develop voluntary industry standards.The College's Medical Informatics Subcommittee and Medical Services Committee have recommended that ACP formally join the eHealth Initiative (EHI), a collaboration of more than 100 health care organizations from both the public and private sectors formed to promote the creation of a national infrastructure. And we have stepped up our advocacy on this issue with Congress and federal agencies.

Someone once said that war is too important to be left to the generals. The same can be said of creating a viable national system of information technology, given its potential to revolutionize the delivery and quality of medical care.

The College must be a participant in the policy decisions on creating the new information infrastructure. These policies are simply too important for organized medicine to leave to the government.

Robert B. Doherty is ACP's Senior Vice President for Governmental Affairs and Public Policy.

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