Introducing electronic health records

In March of last year, the Department of Health and Human Services announced the selection of David Blumenthal as the Obama Administration’s choice for National Coordinator for Health Information Technology. In a statement accompanying the announcement, Blumenthal was charged with leading the implementation of a nationwide interoperable, privacy-protected health information technology infrastructure, as called for in the American Recovery and Reinvestment Act.

“We want to get doctors and hospitals on the escalator towards the adoption and meaningful use of electronic health records. We don’t want them to trip and break their necks on the first step because it’s so high, but we also don’t want them to just be able to walk on it and never ascend.”
-David Blumenthal

Part of the motivation behind the appointment, and indeed for the emphasis being placed on the Office of the National Coordinator, is the desire to show that President Obama and his team are serious about pushing through the electronic revolution.

"President Obama believes we must take serious steps to modernize our healthcare system in order to improve the health of all Americans, bring down costs and ensure sustained long-term economic growth. Health information technology is a critical part of the President's strategy to reform our health care system and as one of the nation's leading health information technology experts, Dr. Blumenthal has the experience and the vision to help make this effort a reality," said HHS spokeswoman Jenny Backus at the time of the announcement.

A big role to fill, and one that will be frequently in the spotlight, making it even more ironic that the man chosen to lead the nation's healthcare sector in its pursuit of the digitization of health records does not come from an IT background. Far from it, in fact - Blumenthal started his working life as a primary care physician.

As he himself admits, "I was not an expert on technology and never have been. I wasn't the kind of person who in high school learned to program and came in on weekends to get all those cardboard cards and run them through the computers. That was never my thing; I was much more a liberal arts person.

"But I've learned a lot from practicing over the years and many of my research interests were fed by my experience. I began using  an electronic system and I came to believe that it would have an important influence on care. That tickled my antennae as a researcher, because one of the things that researchers try to do is decide what hypotheses are important and which trends are going to matter, then get ahead of the curve and try to identify them sooner than their colleagues do and write the grants and begin the work that will have a real impact."

While the development of electronic health records (EHR) piqued Blumenthal's interest, he says he never envisaged himself ending up where he is now. "As a health services researcher, I could see the importance of this technology - I could see it as something that was going to change medicine, and so I put my research skills to work tracking it. I didn't think of myself as someone who was going to be working on it as a public official; I was just being a researcher.

"But I did have this other life of being involved in the public sector through advising campaigns, and when I was involved in the Obama campaign and we were putting together his plan, he was extremely receptive to the idea that technology could be a big influence on care and make it more cost effective.

"A lot of people around him shared that point of view, so it became a piece of Obama's campaign platform, a distinctive piece, and then one that carried over into legislation shortly after he took office.  And then, of course, this office - the Office of the National Coordinator - suddenly became an interesting place to be."

While Blumenthal says he wasn't expecting to be appointed to the National Coordinator role, he says that he is "grateful to have it," calling the position "a very unusual and important opportunity, especially after the stimulus legislation passed and made this a new office authorized by law, with significant potential to affect the way the healthcare system develops, using electronic health systems."

Achieving the goal

Blumenthal's overriding goal as National Coordinator will be to lead the effort to modernize the US healthcare system by catalyzing the adoption of interoperable health information technology by 2014. The Obama government hopes this will reduce health costs for the federal government by an estimated $12 billion over 10 years.

Blumenthal believes his office needs to develop a series of regulatory and programmatic foundations in order to achieve this goal. "The regulations will govern how we spend the money that the Congress has made available to reward meaningful use of electronic health records," he says. "We are in the process of writing the regulations, which is a very carefully scripted process, governed by law and precedent. And we are on the cusp of completing the first set of regulations that will create the rules that will govern the use of the incentives and the rewards that will be available to doctors and hospitals.

"We'll also govern the evaluation of the records themselves to make them capable of supporting meaningful use, and that will create standards around the packaging of information so that it can be exchanged. That is a whole set of regulatory activities, and that's the core of them, but there are others that are more complicated and less of a new departure.

"The other thing we're doing is creating support structures for doctors and hospitals to become meaningful users. The foremost of those is our program of Regional Extension Centers, which have now all been funded; there are 60 of them around the country. They are going to be available to doctors and smaller hospitals that need help getting up and going with electronic health records so that they can be meaningful users. We have already brought in all the leaders of these new centers and we are working with them around the clock, trying to get them ready to help people in the field."

These Regional Extension Centers are interesting in that they are modeled on a program for farmers called the Agriculture Extension Program, which was designed to get the most modern techniques from the laboratory out to family farms at the beginning of the last century. Extension agents were based in an office of the Department of Agriculture and traveled between a school of agriculture and farms in rural states, bringing information about the latest seeds, fertilizers and irrigation techniques. In Blumenthal's words, "They were very influential in increasing the productivity of American farming in the 20^th century."

"The Congress decided that perhaps getting the best information about the use of health information systems out to family doctors could be done the same way," Blumenthal continues. "We are creating multidisciplinary teams in 60 locations around the country, each of which is taking responsibility for up to 1500 physicians and a set of smaller rural hospitals. They will be focused on small practices and hospitals, developing whatever resources are needed to make those physicians and hospitals successful in adopting and using electronic health records.

"Those teams will be doing a variety of things, including helping physicians and hospitals pick the right record system, helping them buy it or buy those systems as groups so they get better prices, helping them install the systems, helping them set the systems up and use them so that they can be effective users, and then helping them adapt their office processes and their work design to the new technology."

The reasoning behind having the extension center program target smaller offices and institutions is that big hospitals and group practices will be able to hire large 'integrator' companies to help them with their IT installations. "For the amount of money that we're making available, those larger organizations are going to be able to afford those services, and the larger companies will be happy to go to work with the larger organizations, because there are economies of scale," Blumenthal points out. "But for your average four- or five-person family physician or primary care practice, it's just not worth it to most of these big companies to have a contract, or if they do, if you're trying to get to some far-away small-town practice, and it's not worth sending your technician out there, or if you do, he or she is not going to get back there very often."

Challenges ahead

In his keynote address at the HIMSS10 Annual Conference & Exhibition in March, Blumenthal outlined the challenges faced by his office in the following manner: "No one in the history of healthcare or any other sector has tried to do something as complicated and difficult in such a large, heterogeneous, diverse country with the kind of independence of spirit and commitment to local autonomy and professional autonomy that we have in the United States."

When asked about the challenges that will result from this "diversity" and "independence of spirit", Blumenthal says that while it's still early days, the Office has in place a set of programs appropriate to the challenges and is rolling them out. "One of the biggest challenges that we have is the great variety of healthcare providers in this country, and their physical distance from one another, and therefore the challenge of meeting them where they are, both in terms of their level of adoption and their capability of adoption and use, and their physical location.

"In the former case, the tool we have for that is the definition of meaningful use and trying to find a set of performance requirements that are reachable, but not necessarily easily reached. I use the analogy of an escalator; we want to get doctors and hospitals on the escalator towards the adoption and meaningful use of electronic health records. We don't want them to trip and break their necks on the first step because it's so high, but we also don't want them to just be able to walk on it and never ascend. Getting that balance right has been a tough challenge.

"We've gotten lots of comments from the public about the original proposal we made; a proposal that we're in the midst of modifying right now. The goal is to challenge the profession and challenge hospitals, but make it possible for most of them initially to become meaningful users. And that's a tricky job, given the variety of institutions out there and the variety of practices."

Another potential challenge facing the introduction of electronic records is resistance from prospective users. While it would be wrong to subscribe to stereotypes, data compiled by the Office of the National Coordinator show that older doctors are less likely to be users of EHR.

"I do understand that some doctors out there may decide that it's too much trouble," Blumenthal says. "We'll try to help them the best we can, but there will be I think an age-related trend towards more rapid adoption among younger physicians." He knows whereof he speaks, with a daughter and son and a daughter-in-law who are young physicians or physicians-in-training, and who have grown up using computers, are being trained on electronic records and will never use anything else. But Blumenthal also points to himself as an example of someone of a slightly older generation who has obviously become very comfortable using electronic systems. "This transition between old and young is inevitable," he says. "But we don't want to wait for this new generation to take over; we want to make the existing practitioners part of the 21^st century as well."

Information exchange

As has been pointed out previously in this magazine, even if every healthcare organization in the country implemented an EHR system, that does not necessarily mean these systems would be able to talk to each other. "There are challenges, and we're working on them," Blumenthal agrees. "We're trying multiple tactics. First, we're incenting doctors to exchange information and hospitals to exchange information using the incentives under the meaningful use regulation.

"Second, we are developing standards that will be part of certified electronic health records that will facilitate communication among different systems. Third, we are giving the states funding to promote health information exchange. And fourth, we are developing systems that can be used by states and institutions that can be used to create private and secure exchange over the internet.

"We're doing all these things. The one thing we can't do is sit down with every doctor and every nurse every moment of the day to make it possible for them to use the resources we're creating. At some point they have to take over and make this happen. We're just trying to make that as easy as we can."

Another oft-cited potential snag is the lack of a single patient identifier. Harking back to his comment about the "independence of spirit" that prevails within the US, Blumenthal feels that a personal identifier is unlikely to be introduced any time in the near future. "We have to solve this problem without it. There are technologies for establishing patient identity and matching patient identity, and they work reasonably well in particular health systems that use them right now. We don't need to wait until the time that we have such an identifier, if ever. We can do this without it and we are going to have to just get on with it.

"The personal identifier is not perfect either as a matcher. Those countries that use an identifier will tell you that there are mistakes, people enter the wrong digits; there is a need, even with a personal identifier, to use identification protocol. So we're going to rely more on those identification protocols than would be true in other countries."

There are those who feel that data stored electronically are less secure than they would have been under the old, paper-based system, but Blumenthal is quick to refute this argument. "Paper was neither perfectly secure against any sort of breach, nor was it physically secure. It's very interesting that our Surgeon General, Regina Benjamin, told me that she had adopted electronic health records when she ran a very small practice in the Mississippi Delta. She said that after two hurricanes in two years, losing all her patients' records both times from flooding, she decided it was time to have an electronic health record system, where she could store her patient's records off-site on a secure server. Certainly she wasn't going to have to worry anymore about floods destroying all her patients' records. That's one way in which records get more secure.

"And the other is that you can track who has had access to your records. I remember when I was a hospital administrator we had a famous person hospitalized at one point. And a member of the press put on hospital scrubs and found their way to the nurse's station and got a hold of the record. That breach of security we couldn't track. If it hadn't been someone who'd wrote about, we never would have known about it."

Despite the concerns, the case made by Blumenthal shows that the benefits of digitization outweigh the challenges. Healthcare organizations - especially the smaller physician practices and hospitals - need to take that first step on to the EHR escalator, or risk being left behind.

Certification

In addition to its focus on meaningful use, one of the things the Office of the National Coordinator is working hardest on now is creating a certification process. Because it has to certify electronic health records as being capable of meaningful use, that has meant it has had to create from scratch a process of certifying electronic health records, which has turned out to be fairly complicated.

"One of the biggest challenges we're working on is how to evaluate the usability of electronic health records," says David Blumenthal. "It turns out that there isn't a good science there, so we're working with the National Institute for Standards and Technology, NIST, which is the organization that creates public standards, such as setting the nation's clocks and determining units of measure and monitoring the setting of standards around critical infrastructure capabilities. We're working with them to create metrics for usability that we could make available for consumers to use, and that maybe even at some point, when they're ready, we could use to certify electronic health records.

"Usability is really, really important. My goal would be to make it possible for providers to look forward to using their electronic record system, because it works so well and it's easy to use. Having something as easy as the iPhone so that you always want to play with it, if we could get doctors and nurses to feel that way about electronic records we would have accomplished a lot. Given the pace at which technology changes and improves, if we create a vibrant market with good measures it could happen very fast."

Beacon communities

HHS Secretary Kathleen Sebelius and Dr. David Blumenthal, HHS' National Coordinator for Health Information Technology, announced in December last year plans to make available $235 million to support a Beacon Community Program.

The awards will help 15 communities around the country become beacon communities for the meaningful use of electronic health records. "What we specifically focused on was helping them to use electronic health systems to improve health and efficiency in their population areas for their populations," Blumenthal says. The specific communities were named in May, after which Blumenthal and Sebelius visited one in Indianapolis. "It was a very interesting place." Blumenthal recalls. "The community has made a long-term investment in electronic health systems, and the result is that they are able to set pretty ambitious goals for this beacon program, and that was what attracted us to that setting.

"In Indianapolis we saw a demonstration of how their information exchange program works and how they can locate all the information on a patient within their geographic location and ways in which that enables them to reduce duplicate tests and avoid unnecessary drugs and understand drug/drug interactions and all those things that are critical for care. That was a very encouraging demonstration for myself and for the Secretary.

"The Secretary has now visited a lot of hospitals and practices and she always comes back to what she sees in her experience as someone who has been for years an elected official, who is very much in touch with the views of average citizens and people who are at the front lines. What gives her a lot of assurance that we're on the right track is that whenever she talks to a doctor or hospital they may find some problems with their systems, but none of them ever want to go back to paper."

“Usability is really, really important. My goal would be to make it possible for providers to look forward to using their electronic record system, because it works so well and it’s easy to use.”
-David Blumenthal