Reality Bytes

President Obama has called for all medical records to be available in electronic format within five years, but how does this translate to the real world? Hospital system CIOs from four geographically disparate areas of the country give Marie Shields the inside story.

“It will be a challenge both technically and politically for the country to find solutions”
-Cedric Priebe, SVP and CIO for Care New England Health System

There’s a lot of optimism in the healthcare sector at the moment, arising from the election of President Obama and the announcement of the money to flow from the stimulus package. Some of that money is aimed squarely at healthcare IT, but it comes with a caveat: that all health records be available in computerized format within five years.

Michele Chulick, Associate Vice President and Executive Director, Clinical Operations for the University of Miami Health System, believes this five-year goal to be unrealistic. “I don’t think everything can be done in a five-year period,” she explains. “We’re looking at implementing an EHR for the health system. In our system, for example, we have over 800 physicians in three separate healthcare facilities and two ambulatory facilities. Quite frankly, I don’t think we could do it in five years because we have so many other priorities in place. It takes adaption. It takes change management. It’s a cultural change. Five years might be a lofty goal. I don’t think that we as a country can get everyone on electronic records in that period of time.

“It’s overly optimistic, and again you’re looking at so many different factors. You’re looking at a physician’s office, you’re looking at the dollars that are required to certainly buy the system and implement it. You’re looking at it at hospitals. You’re looking at it for rural clinics. That’s a huge undertaking in a 60-month period of time.”

George McCulloch, Deputy CIO at Vanderbilt University Medical Center, disagrees. “I think it’s doable,” he says. “It will be a challenge both technically and politically for the country to find solutions and come to agreements on those kinds of things. There’s certainly the technology component, but I think the privacy issues will be the biggest issues we’ll continue to face.”

“I think it will be challenging, but optimism is a good thing,” counters Cedric Priebe, SVP & CIO for Care New England Health System. “Hope is based on faith and optimism is based on facts. I think it’s reasonable to be optimistic that we can do this. The technology has gotten to a point where it’s doable. The culture is improving, in that physicians are more and more ready and expecting this to happen, and finally we have some funding. It may be not sufficient but at least there is enough to give the organizations that weren’t necessarily capital rich the opportunity to afford.

“One of my concerns though is the way it’s structured it doesn’t provide you with the capital up front. You have to invest yourself, get to that point of being a meaningful user and then you’ll benefit. So there still is an access to capital challenge for organizations.”

Tanya Townsend, CIO at St. Mary’s Hospital and St. Vincent Hospital, is a little more on the fence. “I can’t say that it’s for sure going to be an absolute going to happen; however I think Obama has got the right strategy around putting the incentives in place to continue to not only enforce it through incentives but also providing infrastructure and budgets to help us be able to implement it. That’s been a barrier in the past is partially culture and then partially the cost. It’s been cost prohibitive.”

Implementation
The four executives we spoke to are at different points of implementation in their various systems. At the University of Miami Health System, Michele Chulick and her team are focusing on cultural change through technology implementation, aiming to implement electronic medical records system-wide.

“We are not only healthcare facilities, we also have our physician practice, and under one umbrella we would like to create one record that can be seen whether you’re in the clinic 50 miles away or whether you’re in a clinic that’s simply right next door to you. The connectivity that you need to have in today’s healthcare environment requires that our healthcare providers should be able to pull up your record in any location and see what the doctor that you saw two weeks ago, three weeks ago, or two months ago prescribed for you so that we’re making judgments and prescribing appropriately based on the history of the patient rather than just this particular episodic incident.

“Our goal will be obviously to within that IT cultural change improve quality, improve patient safety, improve communication, improve patient satisfaction, and also provide the patient the tools to be able to improve access to us, because that’s really critical. Patients should be able to take their health record on a little portable drive, if they travel during the year throughout the country. We’re looking at options like that so that our patients will be able to feel comfortable knowing that everything that’s been prescribed for them or everything that our physicians are recommending can be carried to that next provider, should that be necessary.”

Tanya Townsend has faced the challenge of consolidating and integrating two hospitals at St. Mary’s and St. Vincent’s. She says the overall goal was to gain efficiencies and reduce the duplication and reduce the levels of redundancy. “We had two organizations that were doing great things,” she explains. “They were just doing them in silos and this was duplicating efforts, duplicating resources and duplicating systems. My primary goal was to look at where it makes sense to consolidate, where it makes sense to reduce that duplication, and then have more availability to do new things

“It’s one thing just to merge the people part of it, but now it’s really merging the systems as well, so looking into duplication of every possible system and the different vendors in place. They’re right across town from one another, with different vendors for just about every product you can think of, so we have the challenge of trying to pick one and leverage our combined volumes to negotiate with vendors for cost savings.”

Cedric Priebe has been involved with the Rhode Island Quality Institute Project, in creating a statewide network for clinical information. “I’m Co-chair for the steering committee for that project called Current Care focusing first on the governance and community involvement, and we’ve come a long way in creating a governance model with a lot of community involvement to manifest by the fact that we’ve gotten statewide enabling legislation passed. We’ve got regulations being written now that will clarify and harmonize some of the disparate patient confidentiality and privacy issues that have been out there. 

“We have data submitting partners like our health system and our peer health system and other hospitals all ready to start. Our biggest challenge is that our community involvement led to an insistence on an opt-in model, that the patients will need to actively enroll or authorize enrollment of their participation in this, which means we have to grow from zero to a meaningful, critical mass of citizens.

“We’ll need to find the opportunities to explain it to patients why it’s here, what value it will bring, how it’s protected, and then to physically enroll them, authenticate them and enroll them. Until we get to that critical mass of people or patients it’s not really worth even presenting to the physician users or the clinical users, because nine out of 10 times if they go there and they don’t find their patients enrolled they’re going to stop going.”

George McCulloch is working on the development and implementation of VUMC’s informatic strategic plan. He believes that by improving quality he can impact cost. “The major driver is the quality initiatives that we have. We have established metrics at an institutional level around quality, of which the technology is component. We’re there to enable the business to focus on the quality issues that they think are important and provide tools for them to manage, disclose and figure out what are the right things to do.

“I think we have a claim that we have one of the best O to E ratios in the country and we believe it’s because of the technology in place that allows clinicians to have great clinical decision-making, have a DHR that gives them appropriate information that they can act on, so we really do believe that the technology has impacted that statistic and that’s a very, very important statistic to us and to the country.”

Security
Naturally this idea of giving patients responsibility for their own records leads to questions of security: how to keep data safe from prying eyes once it’s in electronic format. “People who understand IT security need to inform the people who are working to build these health information exchanges to make sure they are compliant with all our regulations and good practices,” says Cedric Priebe. “The high tech legislation has helped clarify some of the levels of privacy and security that health information exchanges need to meet, which is a good thing, but it’s not rocket science. Once you’ve defined the bar, it’s just a matter of implementing it.

“We’re in a better situation now on that perspective than we have been a period of time ago. I think that if you just limit it to coordination of care it’s pretty straightforward. Once you get into secondary uses of data for either public health or clinical research I think then it gets much more cloudy as to who has rights and what is the extent of patient consent for participation.”

“Security is huge,” adds George McCulloch. “It’s hot. When the Clintons tried to have a record, back then it was all about security. It wasn’t about anything else. That’s going to remain the issue: Who gets to see my record? All the security issues around that I think are going to remain. It’s going to be very challenging to implement. It may be unrealistic if we can’t come to an agreement. I don’t know that we will come to an agreement because there are a lot of competing interests for that apart from the patient and again I think a lot of people are worried about their employer or their insurer seeing things that they don’t want them to know about.”

Michele Chulick underlines that security issues arise on a daily basis in the healthcare environment. “You have Health Insurance Portability and Accountability Act data breaches. We don’t always realize how capable people are of violating HIPAA or trying to access information, and so facilities have to be extremely careful and extremely diligent in all of their policies and procedures and security rules. It’s only going to be expanded as we look at how we create master medical records within IDMs that expand across states. Look at where we have some of the for-profit facilities or even not-for-profit Catholic health services, where they have multiple facilities.

“Data management is something that no one can take for granted. Data security again has got to be at the pinnacle of any system that you look to put in and obviously on a day-to-day basis we all have to be careful with every employee in the hospital working with patients that we monitor HIPAA.”

“Obama has got the right strategy around putting the incentives in place”
-Tanya Townsend, CIO at St. Mary's Hospital and St. Vincent Hospital

“I have two most frequently asked questions that I get whenever I talk about implementing electronic medical records,” points out Tanya Townsend. “One of them is security, so how do I make sure that my information is protected and confidential? The other one is what do you do when the system goes down for faster recovery, so how do we make sure the information is secure if something were to fail? Those are extremely important and as we continue to grow electronic medical records and continue to stop relying on paper those are concerns that we need to have, but they shouldn’t be barriers.

“That would be my message: that we certainly want people to feel that their information is protected and private and we have all of the safeguards in place. I think the computer is more secure than paper because at least there’s not a trail, so we can proactively track who’s looking at what, versus on paper you don’t know where it was. The benefits and the efficiencies to electronic medical records are what we should really focus on, and then the security piece is certainly something to be concerned about but should not be a barrier.”

Identification
Another challenge facing the implementation of electronic health records on a nationwide scale is the lack of a single patient identifier. According to George McCulloch, this is likely to remain a difficult hurdle for Obama and his government to overcome: “It’s going to remain a huge issue. We tried it again a long time ago, and it certainly makes life a lot easier. It’s an enabler. The problem is the privacy issues that surround it, I don’t know if people will change enough to allow us to have a single identifier, but technically it would be fabulous.”

In McCulloch’s opinion, though, the lack of an identifier should not prevent us from instituting electronic records. “It’s not a barrier, if we don’t have it. We worked our way through that. It just makes it harder and there are some risks involved in the technology that does the matching. It’s not impossible, but it’s going to make it a little more difficult.”

Cedric Priebe hasn’t yet confronted the identifier issue at Care New England, though he believes that may come. “We may come up against this as we start to grow our master person index to the point where we’re having trouble doing the patient matching. We’ve got a good sense with the tools we have in the product to do the patient matching based on probabilistic algorithms and then manual processes to deal with situations where we can’t do with it.”

Priebe also believes that the lack of an identifier will not stop the new electronic system from working. “Would life be easier with a national person identifier? Absolutely, but I think we can be successful without it until our culture is ready for that kind of thing. I think we made a big step forward with the national provider physician identifier. That will help with our provisioning and identification of physician users greatly, but I think we can be successful without a national person identifier. It’s a wonderful goal, but there are some significant operational and civil liberties concerns with it. We’re not a country of individuals who like to be identifiable in all situations, nor do we have a reliable set of infrastructures to identify people.”

Tanya Townsend, on the other hand, feels that coming up with some kind of identifier is critical and integral to the development of a national system. “I can even use my own organizations as an example,” she says. “My two hospitals, because they’re on two different platforms they don’t share a common master patient index or a common medical record identifier and the same thing with our ambulatory arm, which has between 50 percent and 90 percent of our patients in their system, and that also is a separate medical record identifier. Even within our own organization to try to share records and share information across those platforms is extremely challenging from an IT perspective as well as from the patient perspective.

“When a patient goes to see their primary care doctor, then goes to the hospital, while we do have access to the information, it’s not seamless. There are times when we’re asking the patient to repeat themselves or potentially even repeating tasks because patient A didn’t map to patient A on the other side. It’s extremely important to have a master patient identifier so that we know we are talking about Joe Smith across the continuum.”

Michele Chulick is also very much in favor of an identifier: “You have to have one identifier. We have so many people who are called David Smith. If we’re going to that level of flexibility within our national healthcare system should one truly be created, we have to have one identifier that’s specific for that particular individual, otherwise we’re going to have issues of medical malpractice, risk, patient safety, all of the above. I don’t know how anybody could even have a differing opinion. It’s essential. It doesn’t mean that everybody has to have just a number. There can be sub-components of that number and that identifier so I think it’s a goal that I think is achievable.”

Personalization
The questions of personalization often comes up in this discussion – how will electronic health records help doctors tailor treatments to suit an individual’s unique needs? Michele Chulick expains that the answer is tied to history. “It’s an automatic history, so the physician that you saw two months ago, if you see the physicians in the same system they will see what someone else has maybe identified as a problem or prescribed as a solution.

“Sometimes patients themselves aren’t great historians. And the older you get the harder it gets to actually be an accurate historian. After all, who accesses the most healthcare? It’s our older population who accesses healthcare more frequently than anyone, and so I believe that an electronic medical record will provide you that personalized history and actually improve the quality of care. There’s no question in my mind that it will improve the quality of care, let alone all the issues with drug interaction, allergic reactions, susceptibilities. All of that will be at someone’s fingertips, but more it’s the history. It’s an accurate history that will be available.

George McCulloch also feels that the introduction of electronic records will have a major impact on personalization. At a macro level I think it will have an impact, but we will have to see what the quality of the data is to see how what the impact is.  It’s clearly a good start.  We’re involved in genomics as well and we have a large DNA databank, so we’re beginning to use that information even in our own practice.”

Tanya Townsend believes that EHRs will lead to more consumer-driven healthcare, so that patients have choices. “They know that they can see their information. They can see the quality initiatives that each organization has so they can make a choice in where they receive their healthcare, and they’ll be far more involved in their care.”

“If they’re well implemented, electronic records will be what makes personalized medicine possible,” says Cedric Priebe. “It will not be possible to do personalized medicine on a grand scale without a strong EMR. The average hospital encounter generates about 60,000 data elements. Once you introduce concepts of personalized medicine, like some human genotyping or other aspects, a single test could be tens of thousands of data points. There’s just no way you could bring all of those data points to bear to that point of decision in a meaningful way without an EMR, so it will be essential.”

Michele Chulick is Associate Vice President and Executive Director, Clinical Operations for the University of Miami Health System in Miami, Florida.

Cedric Priebe is SVP and  CIO for Care New England Health System in Providence, Rhode Island.

George McCulloch is Deputy CIO at Vanderbilt University Medical Center in Nashville, Tennessee.

Tanya Townsend is CIO at St. Mary’s Hospital and St. Vincent Hospital in Green Bay, Wisconsin.