Step back from the details and what emerges is an enormous challenge in design innovation. What role should the Government? What is the right mix of top-down and bottom-up? Drive change through the system will lead to changes in technology, economic incentives and the culture of health care.
"This is a great social project, not just a technical effort," says Dr. David Blumenthal, national coordinator of the Obama administration for health information technology.
This year is when the project really takes off. In the 2009 economic recovery package, the Administration and Congress appropriated billion — the current estimate is of 27 billion dollars — on incentives to doctors and hospitals to adopt electronic records.
Now, a new Congress with Republicans trying to budget cuts could take back the money. Legislation was introduced by Representative Tom Latham, an Iowa Republican, to reclaim dollars spent stimulus — and money to accelerate the adoption of electronic health records could be a target.
Still, measures to promote the adoption of computerized health records have had bipartisan support over the years, although only the Obama administration has pushed to finance major. Most health policy analysts say it is unlikely that the legislation will be reversed.
When properly designed and used wisely, computerized accounts have proven valuable for improving care. Doctors have more complete information in the treatment of patients, while reducing the chances of medical errors and unnecessary testing.
But the stories of success to date come mainly from major health care providers, such as Kaiser Permanente, the Mayo Clinic and a handful of others. Most doctors are small practices, lack of financial and technical support, that large groups provide to their physicians. It is so little surprising that less than 30% of doctors nationwide now use digital records.
Late last year, the Administration, working with health professionals and the technology industry, establish a roadmap for what should include digital and how records should be used, for doctors to qualify for the incentive payments, typically up to $ 44,000. The program starts this year and the requirements to use the records to report and share health information increases in phases through 2015. After that, penalty kicks from Medicare and Medicaid for physicians that do not meet the rules and usage reporting.
The initial requirements to qualify for "meaningful use" are minimal, including being able to electronically collect and report basic information, such as vaccinations for children or for patients with diabetes blood glucose levels.
The long-range vision is that computerized patient data are a step toward what they call a health specialists ' learning health care system. " This means that data for diverse populations of patients can be analyzed to determine which treatments are more effective or arrive early warnings about dangerous drug interactions.
"Islands" of these learning networks already exist, notes of Charles p. Friedman, chief scientist at information technology Federal Office of public health. Data mining his patient, Kaiser, for example, was the first to identify a link between pain relief medication Vioxx and a high risk of heart failure, well before Merck pulled the drug off the market in 2004.
Yet the way to a citizen enabled on computer learning system, experts agree, promises to be long. A major obstacle is that many doctors, especially in small practices, are leery of technology which they see as unnecessarily long and difficult to use. "Doctors don't want to become employees," says Dr. Isaac Kohane, an expert on health technology at Harvard Medical School.
And complex technology — designed for large groups, small practice health — ben could increase medical errors, specialists say.
These issues, Dr. Blumenthal says, are a reason that Government standards, and perhaps also the timetable for the adoption of electronic health records, evolve and remain flexible.
The Government, he adds, is examining carefully the security and usability. Dr. Blumenthal's Office gave the Institute of medicine a grant of almost a million dollars for a yearlong study electronic health records and patient safety. And his Office is working with the National Institute of Standards and technology to develop a "usability assessment tool" that can be used to evaluate digital records offered by different companies.
Under Dr. Blumenthal, the Office has tried to build out a consensus on the criteria and technical standards, rather than issuing edicts. However, the President's Council of advisors on Science and technology, an independent group of academics and industry experts, said in a report last December that it was time for more "top-down design choices," which is called "a proper government role" and that "requires a more aggressive approach, which was taken in the early stages."
This month, the Office of health information technology has announced a move that showed his preferred approach to standard setting, one who has borrowed from the model of open source software development in an initiative called project direct Internet.
Many companies and groups contributed to Internet-based tools for Government-approved for health data exchange between institutions. Developers have written code and suggested ideas and consensus built around an approach that has been selected by the Government. The design was inspired by the Web, with its minimum specifications that leave plenty of room for innovation, says Dr. Douglas Fridsma, head of standards at the Office of health technology.
Without a lively exchange of information, the campaign to adopt electronic records really can't pay. And more is needed than standard data sharing and privacy and security protections, says Dr. Blumenthal.
Incentives must change as well. Two hospitals, a few miles away, he notes, do not now see themselves as allies, but as competitors. For a doctor or a hospital, a patient is, among other things, a financial activity — and keeping patient information is valuable.
Insurers, he suggests, will have to pay for vendors to share data or penalize them if they don't. "Exchange of information has a business goal, rather than a competitive threat, for this job," he says.
No comments:
Post a Comment