Tag Archives: electronic health records

Ashish Jha on Digitization of Health Records in the US

Ashish Jha, Assistant Professor of Health Policy & Management at the Harvard School of Public Health and practicing physician at the VA, discussed the digitization of health records on NPR’s OnPoint on Wednesday, April 22. You can hear the entire episode here at OnPoint Radio’s site: http://www.onpointradio.org/2009/04/tracking-electronic-medical-records. My favorite quote, in response to why automate a broken system rather than fix the fundamental problem:

“We can’t fix the healthcare system without IT, but IT alone can’t fix it.”

Dr. Ashish Jha also recently published an excellent article entitled Use of Electronic Health Records in U.S. Hospitals in the New England Journal of Medicine. Dr. Jha and colleagues found that only 1.5% of hospitals have comprehensive electronic medical record (EMR) systems and an additional 7.6% have basic EMR systems. Hospitals cited capital costs and high maintenance costs as primary obstacles to adoption. President Obama’s plan for every American to have an electronic health record by 2014 appears even more ambitious in light of these numbers.

Dr. Ashish Jha will be speaking at the Public Health & Technology Conference on Friday, May 1 at the Harvard School of Public Health. Details of the conference and free registration are available here: www.hsph.harvard.edu/phat.

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How Kaiser Permanente Went Paperless

A great article in Business Week from April 7, 2009: How Kaiser Permanente Went Paperless. Describes Kaiser’s $2 billion electronic health record implementation and the resulting benefits. The major conclusions:

  • Return on investment is a wash at best, although quality improves in some areas
  • Implementation isn’t transferrable to small providers

Can Health IT Save Health Care?

Adding health IT to our current system and claiming that will solve our health care problem is like taking a 1971 Ford Pinto and giving it a new paint job and sound system. It looks cool. It sounds cool. But you’re missing the point.

Health IT can be and should be a piece of the health reform puzzle. And it’s one of the few- and perhaps the only puzzle piece that holds bipartisan support. Even accounting for the initial upfront costs, health IT is touted to save billions of dollars. (And recent new argument: It’ll create jobs.)

This CBO report lists how health IT can:
• Eliminate the use of medical transcription and allow a physician to enter notes about a patient’s condition and care directly into a computerized record;
• Eliminate or substantially reduce the need to physically pull medical charts from office files for patients’ visits;
• Prompt providers to prescribe generic medicines instead of more costly brand-name drugs; and
• Reduce the duplication of diagnostic tests.

In addition to the above mechanisms to cut wasteful care given, there is very little doubt that health IT can improve the quality of care given. From that same CBO report, health IT can:
• Remind physicians about appropriate preventive care;
• Identify harmful drug interactions or possible allergic reactions to prescribed medicines, and
• Help physicians manage patients with complex chronic conditions.
• All problems cost money to fix, so preventing these problems from occurring does save money.

In public circles, the common rhetoric is that this higher quality of care results in lower costs. And this is where I take issue.

Yes, healthy people cost less. If you don’t need a doctor, you don’t cost much (duh). But healthy people don’t undergo high quality care; they don’t undergo any care!

On the other hand, by definition, those with chronic conditions are in constant need of care. High quality care to this population means doing more tests and providing more care more often.

That’s because only 56% of those with chronic conditions receive the recommended level of care. So higher quality care means more care. And in our system built on a la carte financing, more care means more money. Now this a real problem!

Those with one or more chronic condition currently make up 75% of our health care costs. And that number will only rise. (Explaining why is a whole other post)

Health IT can help providers know what care needs to be provided in order to adhere to these standards. Many EMRs in place today force providers to go through check-lists while caring for a patient to ensure that everything that is ‘supposed to be done’ is in fact done. EMRs also allow providers to be proactive and give patients appointment reminders to increase quality (and quantity) of care.

Does this mean we should forgo implementation of health IT? Of course not! Health IT can help us reduce needless spending for needless care and increase needed spending for needed care. It’s just that in weighing these two, spending may prevail.

Health IT is a powerful tool. But we have to recognize its place among other tools on the tool belt.

A sustainable business model for health information exchange

Personal Health Records (PHRs) have received a lot of attention lately with the release of Google Health and Microsoft HealthVault. PHRs allow individuals to securely organize their own health information and to control who has access. PHRs allow users to import data from many large repositories, including insurers, pharmacies, and laboratories, but mostly do not connect to care providers, excepting a few integrated delivery networks such as Kaiser and Beth Israel in Boston.

RHIOs are less well known but have been around much longer. RHIOs exist at the community level to facilitate the exchange of health information between care providers (e.g. doctor notes), though some also aggregate data from insurers, pharmacies, and labs. The primary audience here is care providers, rather than consumers. In theory, a network of RHIOs could form together to create a National Health Information Network (NHIN), but this is unlikely to occur without significant federal funding. More than 140 RHIOs exist today, but only a handful are considered sustainable (look at the Regenstrief Institute and MA-SHARE). Interoperability between EHR systems is complex and expensive, and though it will improve quality of care, there will be a negative return on investment until a significant proportion of providers is sharing data in a standardized way. Read The State Of Regional Health Information Organizations: Current Activities And Financing by Julia Adler-Milstein, et al for a better understanding of the current RHIO landscape.

Given the similar goals of PHRs and RHIOs, I have speculated that these ideas may eventually end up merging. John Halamka, CIO of Harvard Medical School, commented on Google Health’s new sharing and auditing features in his Cool Technology of the Week update:

I’ve already invited my primary care doctor, my family, and a few of my clinical systems colleagues who built the BIDMC-Google interface. Thus, in one morning I’ve become my own regional health information organization, sharing medical records across multiple organizations with perfect privacy controls.

However, Dr. John Glaser, CIO of Partners Healthcare, estimates that only 1 out of 10 American’s with access to an electronic health record will access it, meaning that consumers are unlikely to drive the healthcare industry’s to adoption of EHR and HIE (see Glaser’s interview with Information Weekly).

Though PHRs do not have a huge chunk of the health consumer market, 6 million users (10% of the estimated 60 million American’s with electronic health records) is large enough to give Google, Microsoft, Dossia and Revolution Health some leverage with data furnishers. PHRs also capture a monetizable audience (consumers) whether through advertising or sales of health applications. RHIOs, on the other hand, make participating providers pay to use their service, but are not large enough to offer providers significant incentives for involvement. Most rely on government funding to stay afloat. I am of the opinion that unless government steps in to fund a largescale network, PHRs have settled on a more sustainable business model and could more easily extend their data aggregation efforts into doctors notes and other administrative data handled by RHIOs. In this case, both providers and consumers would be the primary audience of the platform. By using the PHR for both consumer and clinical needs, the record becomes immensely more useful, assuming that audit trails, quality control, and security measures are in place.

health, crowds, and data mining

Google released Google Flu Trends yesterday, which analyzes search terms for indicators of flu activity. With the onset of flu season, people start searching for keywords such as “flu vaccine” which Google detects and charts. The example below reveals that we are just a couple weeks away from a time of year that has experienced a large outbreak:

Google Flu Trends Sample

The true genius behind this system is that Google is not directly involved in data collection. Data is collected passively as searches are submitted by users. Incredibly, Google Flu Trends reliably performs flu surveillance up to 2 weeks faster than the CDC (US Center for Disease Control)! For details on Google’s tracking method, check out their blog post Tracking Flu Trends.

In a similar fashion, David Bates of Harvard Medical School is creating an epidemic surveillance system that analyzes electronic health records of several Boston-area medical centers every night. When an outbreak is in the works, not all the sick people go to one hospital. 2 might show up at one hospital and 3 at another. The next day several more go. By the time authorities are aware of an outbreak, it is weeks too late. Performing surveillance on data from several hospitals simultaneously greatly expands quantity of information available and can potentially prevent outbreaks from occurring.

Data mining in health that transcends a single unit (like a hospital) has only just begun. Personal health record systems like Google Health and Microsoft HealthVault optionally aggregate health data from a variety of sources (e.g. hospitals, clinics, insurers, pharmacies). Determining health trends is one of Google’s primary goals with this system:

Google will use aggregate data to publish trend statistics and associations. (http://www.google.com/intl/en-US/health/privacy.html)

Once again, while Google and Microsoft are both investing heavily in platform development and partner recruitment, the data is entered, imported, and managed by the consumer. For an interesting post on the positive and negative ramifications of Google Health, check out Tree of Knowledge.