Electronic Health Records
Hospital of the Future: Achievement of Patient-Centered Care
There are many critical issues facing hospitals today. Among these are an increased demand for emergency care, an increased elderly population, more people suffering from chronic conditions, increased costs, and an increased need for access to care. In 2006, a roundtable of healthcare experts joined together to discuss these issues, make recommendations on these findings and trends, and to describe the hospital of the future.
The roundtable’s goal was to examine current healthcare issues such as socioeconomic trends, the physical care environment, technology, patient-centered care values, staffing challenges, and how those issues impact the hospital of the future. Following is a summary of the discussion and conclusion on the topic of achieving of patient-centered care:
It’s About the Patient
As a result of patient safety revelations, there is a a current emphasis and acceptance that the patient is the center of care. Since the patient has the greatest stake in the outcome of treatment and care, that patient should be respected as an equal partner. Family members are also influential in making healthcare decisions, thus becoming the third partner.
These partnerships have significant implications for the safety and quality of patient care. One large study showed that adult patients with chronic or serious conditions who were engaged in a collaborative care model had better control of their blood glucose levels, blood pressure, and serum cholesterol than patients who felt less confident of their doctors or in their own ability to care for themselves.
To further demonstrate the value of patient-centered care, in 2003, the MCG Health System in Augusta, Georgia redesigned its neuroscience intensive care unit to allow patients’ families to stay with them at all times. As a result of the increased insights and observations offered by family members and improved communication, medication errors decreased by 62%, the length of stay was reduced by 50%, and the staff vacancy rate fell from 7.5% to zero.
The Joint Commission’s National Patient Safety Goal 13 has a specific requirement for healthcare providers to encourage patients’ active involvement as a patient-safety strategy. It also requires healthcare staff to identify ways that a patient or family can report safety concerns and encourage them to do so. The foundation for the goal is the idea that when a patient knows what to expect, there is a greater awareness of possible errors and choices. When all aspects of care, treatment, and services are communicated, the patient can be an important source of information about adverse events and hazardous conditions to further engender a culture of safety.
Patients and families are driving momentum for the notion of “nothing about me, without me” with patient advocacy organizations such as Partnership for Patient Safety and PULSE. It is also likely to increase as a result of consumer-directed health plans and health savings accounts that increase consumer responsibility for value-based health care purchasing decisions.
The technology of personal health records (PHRs) that offers patients access to their own health records and increases communication with their healthcare providers will further drive momentum to patient-centered care. A higher level of home care increases the role of “partner” to a 24/7 responsibility.
Barriers to Patient-Centered Care
One of the barriers to patient-centered care is the need for increased patient education even when healthcare providers apparently have less time to spend with them, as in the 10-minute office visit. Health literacy is also an issue, with an estimate that almost half of the U.S. population lacks the skills required to make appropriate health decisions.
Hospital risk managers can be uneasy with the focus on transparency. However, several studies have shown that a collaborative relationship with open disclosure nurtures, rather than harms, the patient/caregiver relationship.
Half of all hospitalized patients today suffer from one or more chronic conditions and the prevalence of chronic conditions is expected to rise. More than 75% of adults over age 65 have at least one chronic condition such as diabetes, heart disease, or asthma, and many have multiple conditions. Those with multiple conditions often receive care from multiple providers and take numerous medications. Care is often fragmented, ineffective, and costly due to duplicative services and testing, avoidable hospitalization, and adverse drug events.
Patient-Centered Transformation
The hospital of the future will better meet the needs of all patients–including the underserved, the chronically ill, and the aged who will be filling its beds in greater numbers–with patient-centered care. Process improvement tools such as Six Sigma and Lean can be utilized by hospitals to increase the reliability of delivering patient-centered care.
An example of this transformation can be seen the ThedaCare hospitals of southern Wisconsin. The application of the patient-centered care methods to general medical units has resulted in a reduction of medication errors, a reduced average amount of time patients are hospitalized, and a reduction in fees for certain procedures. Other hospitals such as Virginia Mason Medical Center in Seattle and New York Presbyterian Hospital have used these tools to similar benefit.
Modernizing the Healthcare System is Crucial to Reform
In an August 20, 2009 roundtable discussion led by Vice President Joe Biden at the Mount Sinai Health System in Chicago, healthcare reform and health information technology were the two primary topics of discussion. The panel also included Kathleen Sebelius, Secretary of Health and Human Services (HHS), David Blumenthal, HHS National Coordinator for Health Information Technology, and six Chicago-area healthcare workers: three physicians, a nurse, a public health research program director, and a hospital chief information officer. The attendees of the roundtable discussion included about 50 nurses, physicians, other healthcare workers, and a few Illinois public officials.
In an introductory address before the panel convened, Biden spoke of the “moral imperative” in improving the U.S. healthcare system, including the need to get healthcare costs under control. Biden emphasized that they were not there to debate the controversial public option, but rather to discuss cost containment priorities. “Let’s agree on what we can agree on,” he said. “We’ve got to modernize this system.” One part of that is adopting information technology (IT).
Converting Paper to Computerized Records
Biden explained that storing patient data electronically improves efficiency and prevents medical errors. He added that he’s tired of filling out paper forms every time he goes to a doctor.
“If I get handed one more clipboard I feel like clanging somebody on the head,” he joked, prompting laughter from the audience. “How many times do I have to fill out, yeah, I had asthma, yeah, I had two craniotomies?”
Biden lauded the recent allocation of nearly $1.2 billion for health IT funding out of the $2 billion appropriated in the American Recovery and Reinvestment Act of 2009. $598 million has been earmarked to institute regional health IT extension centers to assist clinics and hospitals in the technical implementation of electronic health record systems (EHR). Another $564 million will help develop health information exchanges to assist hospitals in sharing patient information. An additional $34 million will be administered by Medicare and Medicaid in direct subsidies for the implementation of e-prescription systems.
The Need for Interoperability
Chere Hamilton, a Mount Sinai Hospital emergency department nurse, addressed the committee. She described a typical ER patient, explaining that these patients come to the ER as a last resort, usually with no money for medication and likely without a primary -care physician. Often, these patients have visited several hospitals in the area, seeing three or four physicians whose names they can’t remember.
“We need information,” she said. “We need it right away. We need to make decisions.” Hamilton explained that healthcare IT interoperability would provide ED clinicians with the quickly accessible and accurate information they require from within the systems of other hospitals.
The Mount Sinai Health System uses the Meditech Magic healthcare information system, with plans to upgrade in January 2010. For instance, 85% of all orders are processed by the computerized physician order entry (CPOE) system in the 102-bed Schwab Rehabilitation Hospital. It has also been installed in the surgical intensive care and psychiatric units within the 291-bed main hospital.
After the meeting, Mount Sinai Chief Information Office Peter Ingram indicated that he is optimistic that the Mount Sinai Health System EHR will meet the “meaningful use” requirements set forth under the stimulus law in order to qualify for the EHR Medicare subsidy payments beginning in 2011. Though most of the IT focus of the new law has concerned clinical application, Ingram feels that the financial side also requires government and private sector attention. He pointed out the need for insurance industry performance improvement, specifically the need for a scanable standard insurance identity card to simplify payments to physicians.
Ingram said that the stimulus grants are good news for the hospital, saying, “We need all the help we can get in implementation,” in completing the transfer to computerized records. He predicts that the greatest benefit from the mandated regional IT extension services will be to small, primary care practices. He also sees those centers as becoming “test beds” for IT interoperability between providers within their regions.
Preventing Anticoagulant Errors
There has been significant public attention paid recently to the issue of accidental deaths and overdosing resulting from the improper use of anticoagulant drugs. In the U.S., anticoagulants have been identified as one of the top five drug types associated with patient safety incidents. According to the United States Pharmacopeia MEDMARX database, there were 59,316 medication errors related to anticoagulants from 2001 to 2006, which do not include errors involving heparin lock flush. Almost 60% of those errors reached the patients, with almost 3% of those resulting in harm or death. Administration error is the most frequent cause.
According to MEDMARX and a hospital study, the anticoagulants most frequently cited in error reports are unfractionated heparin, warfarin, and enoxaparin. They are also the most commonly used anticoagulants. In 2005, enoxaparin errors resulted in four patient deaths and two instances of permanent harm. The concurrent use of heparin and enoxaparin, and also argatroban and lepirudin, are associated with additional errors.
Careful screening for drug interactions and contraindications is required for patients under consideration for anticoagulant drugs. While being administered the drugs, patients must be closely monitored to prevent side effects or overdosing. There is a high potential for complications with the use of heparin and warfarin in particular, since they have narrow therapeutic ranges and are a greater risk of harm to a patient.
Confusion can be created when there is a lack of standardization in the naming, labeling, and packaging of anticoagulants. Heparin flush syringes have been confused with low molecular weight (LMW) heparin syringes. Lesser know anticoagulants, such as enoxaparin, dalteparin, and tinzaparin that are less commonly used, may result in duplicate medication orders and errors in dosing.
It can be a challenge for providers to keep current with varying dosing regimens for different patient populations, expanding lists of drug interactions, newer assay methods, and potential reversal strategies. This is especially problematic for those who infrequently administer or prescribe anticoagulants. Other issues result from the problems in treating neonates and pediatric patients due to medications being formulated and packaged primarily for adult patients.
Lack of documentation and communication during transfers and hand-offs can result in medication errors. It is imperative to document specific instructions and monitoring information such as dose adjustments, lab values, and changing patient conditions that are part of the prescribing and administration of anticoagulants.
Specific risk reduction strategies can prevent anticoagulant-related errors in healthcare organizations. These risk strategies should be implemented by all staff who manage the drugs, including pharmacists, physicians, nurses, dietitians, and case managers. Specific guidelines have been developed by the U.K. National Patient Safe Agency, the Institute for Safe Medication Practices, and the Institute for Healthcare Improvement regarding anticoagulant management. They stress improved staff communication and information access, close pharmacy oversight and involvement, and increased patient education. It has been shown in studies that there is a significant reduction of adverse effects and injury among patients who manage their own anticoagulation therapy in comparison to those who rely solely on their doctor for treatment monitoring.
The implementation of pharmacist-managed anticoagulation services can assist discharged patients receiving warfarin treatment. It also assists staff in caring for patients with all types of anticoagulant therapies and helps prevent medication errors.
Computerized provider order entry (CPOE) and/or bar coding technology can be implemented to aid in the interdisciplinary documentation and communication necessary to prevent duplicate medication or erroneous dosing. Bar coding can be used by the pharmacy to replenish anticoagulant medication stock and automated dispensing cabinets.
The Changing Role of the Hospital Pharmacist
Recruiting has long been a challenge for hospital pharmacies. With considerable competition for pharmacists in the retail industry, where compensation is often higher and more regular hours are offered, i.e., no on-call requirements, hospitals have had a more difficult time attracting and keeping quality personnel. The hospital pharmacist must also be better trained with a broader knowledge base than the retail pharmacist due to the expanded inventory of drugs in use for inpatient care.
New developments in biologics, genomics, robotic preparation, and pharmacy automation require a superior level of technological expertise in the hospital pharmacist. For this reason, the entry-level degree for a pharmacist has been raised to a doctorate (Pharm.D). Completing residency training is also required of many hospital pharmacists. This higher standard is to be lauded, though it has had the side effect of increasing vacancy rates for hospital pharmacists by creating additional educational requirements for the entry of new pharmacy students.
The role of the hospital pharmacist has been changing with greater involvement in direct patient care. In order to combat the high volume of medication errors that occur in hospitals, the role of the pharmacist will become increasingly visible in patient-centered care delivery. With this enhanced patient involvement, hospital pharmacists need additional training and experiential education in hospital settings, with a greater reliance on trained and certified pharmacy technicians for the preparation and delivery of medications.
The physical environment of the pharmacy is facing change as well. With pharmacists increasingly counseling patients on drugs and therapeutic regimens, private space needs to be incorporated to accommodate confidential discussions with patients and families.
With the Joint Commission standards requirement that hospitals must provide pharmacy after-hour services, further stress has been placed on smaller hospitals to maintain pharmacists around the clock. For some, it is not economically feasible to keep a high-salaried pharmacist onsite for only a few requested orders during night-time hours. This issue is being addressed by contracting offsite pharmacists connected to the hospital system who have the ability to approve orders and authorize nursing staff to dispense the medication.
With increased requirements for educational and technological expertise, as well as increased direct patient involvement, the hospital pharmacist is playing an even greater role now as an active member of the healthcare team. The patient-centered model of care is becoming a core philosophy for forward-looking hospitals in which the pharmacist plays an increasingly important part. It is therefore necessary to recruit and retain the best and the brightest for the hospital pharmacy to insure patient safety and quality care around the clock.
Phoenix Children’s Hospital Achieves 99 Percent CPOE Adoption
Phoenix Children’s Hospital, born in 1983, is one of the ten largest children’s hospitals in the U.S. It serves Arizona and the other Southwestern states, offering world-class specialty and sub-specialty inpatient, outpatient, emergency, and trauma care. With care in 40 sub-specialty fields of pediatric medicine, it has most recently focused the development of its medical programs on neonatology, neurosciences, hematology/oncology, cardiac services, orthopedics, and Level 1 trauma.
The metropolitan Phoenix area expects an explosive growth in population over the next decade. To address this anticipated growth, Phoenix Children’s Hospital recently announced a $588 million expansion plan that includes major facility upgrades, staff additions, and branching out into high-growth areas of the valley.
The Phoenix Children’s Hospital is also a leader in the completion of its hospital-wide activation of a computerized physician order entry (CPOE) system. As announced by Eclipsys in a news release on August 24, 2009, Phoenix Children’s has successfully achieved a 99 percent adoption rate of their Sunrise Acute Care™ solution. Physicians and other clinical staff at Phoenix Children’s now place 99 percent of their orders electronically. It is the latest milestone in the multi-phase effort to expand the CPOE technologies throughout the hospital system.
The success of the hospital-wide CPOE launch is attributed to its “hybrid rollout methodology,” according to the release. Each department was enabled to implement the system as it was ready to, with each department being embedded with information technology (IT) staff support and advanced training. There was a common deadline among departments to ensure that systems goals were met.
The goals were, in fact, exceeded with a 95 percent adoption rate upon implementation of the new hospital-wide system. Physicians have been pleased with the system and the capability to sign orders electronically, reporting significant time savings.
Previous to the hospital-wide launch, Phoenix Children’s employed Eclipsys’ CPOE systems in only two units. Knowledge-Based Charting™ from Eclipsys was activated last fall to convert records into an electronic format.
About Eclipsys’ CPOE Systems
Eclipsys’ CPOE systems automatically interpret and recalculate new order protocols based on patient condition updates. Working in real time, the high speed and adoption rates are based on complex, embedded algorithms, transcending fundamental order entry. The intuitive solution is easy to implement to provide complex clinical decision support capabilities tailored to how physicians practice medicine. Complex order sets and medication ordering are fully automated, including complicated treatment plans, long-range medication ordering, and exacting protocols often required in pediatric and oncology care environments.
“Meaningful Use” and the American Recovery and Reinvestment Act
Jay Deady, executive VP of Eclipsys’ Client Solutions, states in the news release that the success of the CPOE project at Phoenix Children’s Hospital supports the company’s position on the “meaningful use” of an EHR’s definition under the American Recovery and Reinvestment Act (ARRA). With the success of the Phoenix Children’s Hospital electronic conversion, it is demonstrated that CPOE adoption as required for incentive payments authorized by ARRA is not too onerous for institutions to meet by the deadlines set.
Eclipsys believes it to be critical to the improvement of patient care quality and safety, as well as for cost containment in the U.S. healthcare system, that a specific timetable be established to place clinical decision support tools in the hands of practitioners at the point of care. Eclipsys encourages the adoption of CPOE within the ARRA “meaningful use” definition beyond the current 10 percent rate that they believe is easy to achieve. By meeting only this very limited goal, 90 percent of an institution’s care will remain uncoordinated until higher rates of implementation are achieved.
Addressing Medication Errors
Medication errors result in consequences ranging from minor injury to death for thousands of people every year. These errors frequently occur when multiple medications are taken at the same time. They may result from incompatible medications, duplicative therapies, or taking more medications than needed. To prevent such errors, the Joint Commission’s National Patient Safety Goal 8 requires accurate and completely reconciled medications inclusive of all care a patient receives.
The use of multiple medications by a single patient is called polypharmacy, which carries the increased risk of adverse drug events. Patients suffering from several medical conditions, such as diabetes and heart failure, will often require several medications to control the conditions, perhaps eight or nine medications simultaneously. In addition, these patients are often seeing several physicians, further increasing the likelihood of unintended side effects and dangerous consequences.
Clinical pharmacists and the organizations they represent are working to proactively address the adverse consequences of polypharmacy and establish plans, programs, and processes to prevent medication errors. The role of the clinical pharmacist has expanded from dispensing medications and checking for adverse drug interactions to directly addressing a patient’s medication list to identify and resolve potential issues. Technological advances such as computerized physician order entry and automated medication records assist pharmacists, physicians, and nurses to be able to quickly identify and resolve potential drug problems.
In 2007, the Jewish Health Care Foundation created a fellowship designed to assist pharmacists in testing approaches to eliminate the adverse effects of polypharmacy and develop evidence-based interventions across entire institutions. Following are examples of three Pennsylvania-based organizations that are participating in the fellowship program and how they are working to address polypharmacy issues:
University of Pittsburgh School of Pharmacy
At the University of Pittsburgh School of Pharmacy, patients are offered a comprehensive review of their medications in the outpatient clinic. During a 30-60 minute interview with a pharmacist in a private counseling area, the pharmacist reviews the patient’s prescription medications, over-the-counter medications, and herbal supplements. The pharmacist determines if the patient understands why the medications are being taken and how they should be taken. The pharmacist also looks for potential drug interactions, duplicative therapies, and unnecessary medications. The patients identified as requiring additional counseling services, such as nutritional counseling, insulin instruction, or lipid management, are referred for additional comprehensive counseling elsewhere in the hospital.
Patients targeted in this program are patients at high risk for medication errors. These include patients over the age of 65 with more than three chronic conditions and taking more than five medications. The service is available to anyone interested in it, including patients who do not get their prescriptions filled at the facility. They are referred by their physicians, or find the service through advertising or word-of-mouth.
The University of Pittsburgh School of Pharmacy is currently implementing the program within one of its pulmonary clinics to help ensure that the medication reconciliation process within the clinic is effective. It ultimately hopes to provide these counseling services throughout the hospital.
Western Pennsylvania Hospital
The Western Pennsylvania Hospital is a 512-bed tertiary care hospital serving the Pittsburgh area. Their pharmacy department is working on a project to create a pharmacy-assessment tool that will examine a patient’s multiple medications and identify potential issues. The organization will monitor outcome results, such as patient falls, length of stay, the number of medications, and patient costs, to measure the effectiveness of the tool and the review process.
The initiative is being implemented on a small scale in the inpatient rehabilitation unit of the hospital where patients come from different areas of the hospital, such as the orthopedic unit. The relatively long length of stay in the unit offers an increased opportunity to analyze the potential effectiveness of the assessment tool. Since the patients have come from other areas of the hospital, the medication lists more closely mimic those of patients that have been discharged from the hospital. The ultimate goal is to identify potential medication problems and improve patient outcomes throughout the organization.
Allegheny General Hospital
Allegheny General Hospital is a 724-bed academic medical center focusing on improving its discharge medication process. Too often, a patient leaves the hospital with a list of medications that are not understood by the patient and can be problematic if the list contains potential medication interactions or duplicate medications. Retail pharmacists often question the medication list, but the patient doesn’t know which medications should be taken.
To address this problem, a specific unit in the hospital is working with an affiliated physician group to oversee released patients’ medications. Upon discharge, the patient’s summary medication list is reviewed by the clinical pharmacist and compared to the medication list in the outpatient chart of the physicians’ office. The goal is to improve the discharge process and identify and address potential breakdowns in the process. By starting small within a specific patient population, a series of small changes can be implemented that can impact outcomes and later be introduced to a wider population of patients.
Though these programs are in the early stages, each organization is utilizing the expanding role of the clinical pharmacist in the participation of patient care in order to improve patient outcomes. The programs can have a long-term impact on patient safety within the hospital environment and improve the quality of care provided.
Pyxis: What It Is and How the Automated Medication and Supply Management Systems Are Beneficial
The Pyxis Profile System and MedStation is a cutting-edge way for hospitals to streamline and manage the distribution of medication. The system effectively turns medication distribution points into advanced and very secure vending machines called MedStations. These MedStations, when provided with a proper code and the patient’s attending nurse’s fingerprint, allow for only that nurse to directly retrieve the appropriate dosage from the machine as pre-programmed by the pharmacist who filled the prescription.
By each MedStation carrying a wide variety of common medications, the pharmacist needs only to enter the prescription into the machine’s database and the medication then becomes instantly available. This process bypasses the otherwise lengthy distribution choke point between prescriptions being written and the distribution of the physical medication, as well as cutting back on the travel time between the pharmacy area and the actual patient. Aside from expediting distribution, this also saves the hospital money by requiring fewer pharmacists on staff at any given time as well as decreasing the likelihood of an improper amount of medication from being distributed by the pharmacists themselves.
The Pyxis MedStation is also valuable in emergency situations, as the dispensary functionality can be overridden with a separate code to provide emergency medications when the need arises. The machines carefully monitor internal stocks as well to ensure that the correct amount is retrieved and that controlled substances are secure. This process increases hospital efficiency as well by partially automating medication stock amounts while simultaneously calculating the proper billing amount per patient for the medication they received.
Furthermore, the Pyxis system can be implemented in other ways, such as bedside terminals that check medication bar codes versus the patient’s medical records to ensure that each specific medication makes it to the correct patient. By having the Pyxis system involved on multiple levels, the likelihood of hospital error drastically decreases (by as much as 80%), thereby increasing patient health and improving turnover rate.
http://www.stlukes-sf.sutterhealth.org/news/enews/0206_pharmtech.html
Hospital of the Future: Technology for the Provision of Care
A growing population of elderly, an increase in the number of people suffering from chronic conditions, and an increasing demand for emergency care are among the many critical issues facing hospitals today. Hospitals are seeing an increasing need for access to care and efficiency in healthcare delivery due to continually rising costs and decreasing federal reimbursement. A roundtable of healthcare experts joined together in 2006 to address these current and future needs and create a picture of the hospital of the future.
The roundtable’s goal was to examine current healthcare issues such as socioeconomic trends, the physical care environment, technology, patient-centered care values, staffing challenges, and how those issues impact the hospital of the future. Following is a summary of the discussion and conclusion on the topic of technology for the provision of care:
The Cutting Edge of Digital Technology
Digital technology is allowing for care that has historically fallen under the umbrella of the hospital to be served outside of the hospital’s walls. The U.S. Department of Veterans’ Affairs (VA) is on the cutting edge of using this technology to better meet the needs of their patients. Their use of the national Care Coordination Home Telehealth (CCHT) Program, implemented in 2004, is allowing a transition from institutionally-based care to patients’ homes, when appropriate, to enhance and extend care.
Especially beneficial for patients living in remote areas, the CCHT Program emphasis is on patient self-management with a program of care. Remote monitoring technologies enable data, such as the blood glucose levels of a diabetic patient, to be uploaded to their Electronic Health Record (EHR) daily. Care coordinators are able to determine from this data those who require active care management. The CCHT allows each coordinator to support caseloads of 120 to 150 patients.
CCHT helps to reduce disease complications with its emphasis on disease management and vital sign monitoring, since it allows for quicker recognition of signs that may require hospital admission or a doctor’s visit. As of 2006, the CCHT Program supported the care of 33,883 patients in their homes. Data from 17,025 patients demonstrated a 20% reduction in hospital admissions and 25% reduction in hospital bed days of care.
Since 1995, the VA system has decreased its hospital beds from 50,000 to 18,000, while adding more than 1,000 sites that provide primary and ambulatory care in local communities. It has become dramatically more efficient with only a small increase in staffing while serving a doubled patient population from 2.5 million to 5 million. Veteran patients receiving CCHT show a mean satisfaction score of 86%, indicating that the quality of patient care has not diminished.
Innovation and standardization is perhaps more achievable in the VA system due to its integrated, single-payer system. New models of care such as CCHT require changes in clinical practice, technology infrastructure, and business processes that are more difficult for providers operating in fragmented environments. However, with an increasing number of patients suffering chronic diseases, remote patient monitoring could have the same evolutionary impact to hospitals outside of the VA.
Health Information Technology
A comprehensive electronic health record system is at the core of the VA’s Care Coordination Program. Outside of the VA, only about 11% of non-federal hospitals and 12% of physician practices have implemented such programs. The U.S. is a dozen years behind other industrialized nations in adopting health information technology (HIT). Successful implementation of the HIT programs, resulting in reduced costs and improved quality, is credited to the simpler payer structures in those countries, making it easier to standardize nomenclature and create an interoperable platform.
Attempts to implement computerized physician order entry (CPOE) systems in the U.S. has resulted in only about 5% of hospital utilization. This is attributed to the cost of implementation and resistance by physicians. In 2005, the Department of Health and Human Services (HHS) created the American Health Information Community (AHIC). This advisory committee, made up of representatives from both the public and private sectors, was formed to provide recommendations on making health records digital and interoperable, while protecting patient privacy.
To provide financial incentives for healthcare providers to use HIT, the HHS has launched demonstration projects such as allowing the Centers for Medicare and Medicaid Services (CMS) to make bonus payments to small physician practices. Strong evidence supports claims that HIT systems result in significant benefits for safety and quality care, but the level of initial investment is such that hospitals need further incentive.
In addition to implementation costs, many are concerned about work flow disruptions that can come about from full-scale HIT implementation. Key to its success is the involvement of clinical staff using the technology, such as office, pharmacy, and lab personnel. New technologies must be labor-saving in order to maximize already stretched professional resources.
Current issues of interoperability between HIT systems, still unresolved, are resulting in a “wait and see” attitude among many providers before investing in the technology available. Concerns of data privacy as well as system obsolescence add further to delays.
New technologies are being created daily by the well-funded biotechnology industry desiring to create new markets and needs, but making it more difficult for healthcare providers. Some of these new technologies will increase costs and waste in the system as well as disrupt work flow and increase inefficiencies. Little value results from technologies that do not integrate with other technologies.
With such cutting edge information and costly technology-purchasing decisions to be made, an objective authority to help guide these investments is important in making value-based decisions. Until 1995, one such authority existed, the Congressional Office of Technology Assessment (OTA), which offered such objective analysis. Their reports were authoritative and well-respected but unpopular when their findings negatively affected the interests of those industries. ThOTA ceased to be funded in 1995 and has not been re-authorized.
Federal Stimulus and the “Meaningful Use” of Electronic Medical Records
Beginning in 2011, $17 billion will be allocated to doctors and hospitals that employ “meaningful use” of electronic medical records as part of the stimulus act signed by President Barack Obama. Health care providers may face financial penalties if such processes are not implemented by 2015.
One of the key components of Obama’s plan to reform health care in the U.S. is electronic recordkeeping. Electronic health care records will help reduce the chance for errors by allowing critical care information to follow patients throughout the medical system. To qualify for the stimulus incentives, hospitals must act soon to purchase the systems and implement the processes, though the qualifying criteria has yet to be defined.
The challenge to small and rural hospitals is great, due both to the cost of purchasing and implementing the systems as well as not knowing what the federal government’s ultimate definition of “meaningful use” of electronic records will be. The National Rural Health Association, representing more than 2,000 hospitals and clinics, claims that the current draft definition could be difficult for rural hospitals to implement by 2011.
Rural hospitals that have trouble raising revenue are taking significant risks by converting to expensive electronic systems in time to qualify for the stimulus money. These hospitals also have a shortage of staff with the technical expertise needed to implement the conversion from paper to digital. They have to hope that they will be able to meet the criteria in order to get some of the stimulus money in the future to help offset the ill-afforded costs now.
The plan to convert recordkeeping from paper to digital is acknowledged to be a positive one, with the number one barrier being the high cost of the systems. There are also issues of the costs of additional personnel with the expertise required, staff training in the use of the new systems, and disruption of facility processes during the conversion.
The imperfections inherent in paper recordkeeping include a significant number of medication errors, often due to the renowned illegibility of physicians’ handwriting. Replacing paper charts with computerized records will help eliminate many of these errors to improve patient safety and quality of care. Computer systems can flag unusual test results, potential drug interactions, duplicative therapies, and potential allergic reactions to medications. Additional safeguards include tagging patients with bar codes that must match coding on the practitioner’s electronic orders before medications are administered to ensure that the right patient is receiving the right medication.
Other negative issues involved with paper records are the inefficiencies of having to duplicate paper entries on varying forms between hospital units, something that electronic record keeping eliminates. Digitizing speeds the process significantly and makes hospital staff time more productive and devoted to direct patient care. The physical storage of paper records exceeds capacity at many facilities, requiring expensive offsite storage and slowing the retrieval of needed records.
Few dispute the enhancement to medical care and patient safety with the implementation and “meaningful use” of electronic records. It’s getting there that presents the problems.
Electronic Health Records Cut Healthcare Costs
The business side of healthcare views the electronic patient chart as long overdue. In fact, the medical industry is one of the last major industries to adopt across-the-board computerization to streamline business, improve efficiency and productivity, and maintain long-term accurate records. One of the blocks to health information technology (IT) expansion is the high cost of implementing the new systems.
Assistance to clinics and hospitals to pay for new interoperable IT systems is promised from nearly $54 billion in federal stimulus funds, signed into law by President Barack Obama in February 2009. This includes about $34 billion from the temporary Medicare and Medicaid reimbursement program. These bonuses are scheduled to begin in 2011 for providers who provide “meaningful use” of health IT. They will total as much as $11 million in bonuses per hospital and $64,000 per physician.
Additional stimulus funds have been allocated for health IT, including $598 million in grants to assist hospitals and clinics in implementing EHR (electronic health records) through regional health IT extension centers. An additional $564 million has been earmarked to develop health information exchanges to enable hospitals to share patient information, i.e., making the systems interoperable.
It is hoped that these incentives, (and eventual penalties for those not incorporating them in a timely manner), will make interoperable EHR systems standard by the year 2014. Reform advocates anticipate that EHRs will lead to significant cost savings in the near future, with huge returns in future healthcare savings.
The Advantages of Interoperable EHRs
There are many ways in which EHRs improve the safety and quality of care for patients as well as cut costs for healthcare providers. Some of them include:
- Medication data stored in EHRs can prevent potentially dangerous drug interactions, duplicative therapies, allergic reactions to medications, and medication errors.
- E-prescribing prevents errors resulting from illegible handwriting and follows the prescribed drugs to allow patients taking recalled drugs to be quickly identified and alerted.
- Systems requiring computerized physician order entry (CPOE) include embedded protocols and alerts that enable providers to make the best care decisions, minimizing complications, lengths of stay, and re-admissions.
- Costs associated with “defensive medicine” may be reduced by EHR systems by providing proof that physicians have followed evidence-based protocols, offering grounds for avoiding or minimizing malpractice claims.
- With government and private payers increasingly employing various quality metrics to justify differentials in payments to providers, EHR systems will allow providers to provide outcome data to show that they have met the quality measures.
- Patients with chronic conditions, such as diabetes, can be tracked electronically, allowing for notification of recommended tests or procedures to prevent complications and increased cost procedures such as amputations.
- Duplicate testing can be avoided by following patients through multiple points of care, preventing one provider from ordering a test recently administered by another.
- EHRs eliminate the need for transcribing physicians’ notes and the storage of paper documents.
- The widespread use of EHRs will produce massive outcome data that will be mined by researchers to lead to more refined evidence-based protocols, improving outcomes and reducing costs.
- The current fee-for-service payment system provides incentives for additional visits and procedures that could be shifted to a system with added incentives for more efficient care–such as e-visits, preventative care, and patient education–for higher quality outcomes and improved data collection.
- Easy access to medical records enables patients to be more engaged in their health, widely believed to improve wellness and lower costs.
Though the financial costs for purchasing and implementing EHR systems are significant and return on investment is not immediately seen for many facilities, the additional data will position hospitals and other healthcare providers to better save money in the future. Reductions in space requirements, staff time, and duplicate tests make cost savings possible in the short-term, with improvements in care quality offering long-term savings.