The New England Journal of Medicine Assesses the Real EHR Use in the USA

The following abstract is from a full article published in last week’s NEJM.

Electronic Health Records in Ambulatory Care — A National Survey of Physicians

Catherine M. DesRoches, Dr.P.H., Eric G. Campbell, Ph.D., Sowmya R. Rao, Ph.D., Karen Donelan, Sc.D., Timothy G. Ferris, M.D., M.P.H., Ashish Jha, M.D., M.P.H., Rainu Kaushal, M.D., M.P.H., Douglas E. Levy, Ph.D., Sara Rosenbaum, J.D., Alexandra E. Shields, Ph.D., and David Blumenthal, M.D., M.P.P.

ABSTRACT

Background Electronic health records have the potential to improve the delivery of health care services. However, in the United States, physicians have been slow to adopt such systems. This study assessed physicians' adoption of outpatient electronic health records, their satisfaction with such systems, the perceived effect of the systems on the quality of care, and the perceived barriers to adoption.

Methods In late 2007 and early 2008, we conducted a national survey of 2758 physicians, which represented a response rate of 62%. Using a definition for electronic health records that was based on expert consensus, we determined the proportion of physicians who were using such records in an office setting and the relationship between adoption and the characteristics of individual physicians and their practices.

Results Four percent of physicians reported having an extensive, fully functional electronic-records system, and 13% reported having a basic system. In multivariate analyses, primary care physicians and those practicing in large groups, in hospitals or medical centers, and in the western region of the United States were more likely to use electronic health records. Physicians reported positive effects of these systems on several dimensions of quality of care and high levels of satisfaction. Financial barriers were viewed as having the greatest effect on decisions about the adoption of electronic health records.

Conclusions Physicians who use electronic health records believe such systems improve the quality of care and are generally satisfied with the systems. However, as of early 2008, electronic systems had been adopted by only a small minority of U.S. physicians, who may differ from later adopters of these systems.

The Full Text is available (for free) at the URL below.

http://content.nejm.org/cgi/content/full/NEJMsa0802005?query=TOC

The study has been warmly received by a number of commentators.

The following long article provides a lot of detail.

EHR access sparse in ambulatory-care environment

By: Joseph Conn / HITS staff writer

Story posted: June 19, 2008 - 5:59 am EDT

The summary report on a comprehensive survey, funded by government and private organizations, of physician adoption of electronic health-record systems finds that after more than four years of federal ballyhoo of health information technology, only 17% of physicians in the ambulatory-care environment have access to an EHR.

Just 4% of physicians in ambulatory care have available a “fully functional” EHR system, including patient-safety features such as drug-drug and drug-allergy alerts and full electronic prescribing.

Anticipating just such a low adoption rate, researchers graded on a curve, giving partial credit to physicians who have something less than the best EHR system in their offices. Another 13% of physicians surveyed have such “basic” EHRs with a minimum set of functions.

Given that 83% of ambulatory-care physicians don’t have an EHR, “the U.S. healthcare system faces major challenges in taking full advantage of EHRs to realize its health goals,” according to an executive summary of the published survey in the June 19 issue of the New England Journal of Medicine. A copy of the full report should be released July 2.

The survey was conducted between September 2007 and March 2008 by the Institute for Health Policy at Massachusetts General Hospital, Boston, the Harvard School of Public Health, George Washington University and RTI International, working under a contract with the Office of the National Coordinator for Health Information Technology at HHS. The initial contract was awarded in 2005 to develop a standardized methodology to measure the rate of adoption of EHRs among physicians and hospitals.
More here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080619/REG/785336712/1029/FREE

There is additional Coverage here:

'Full function' EHRs may not get full CMS incentives

By: Joseph Conn / HITS staff writer

Story posted: June 20, 2008 - 5:59 am EDT

Only 4% of U.S. physicians in ambulatory care have access to an advanced, "fully functional" electronic health-record system, but even those top-tier systems may not be fully featured enough to qualify for maximum payments under the new CMS pilot program to boost EHR adoption.

Still, most healthcare information technology experts contacted for this story reacted favorably to the release of the executive summary of what may be the most authoritative and methodologically solid study of EHR use to date.

The summary was published in the New England Journal of Medicine. The survey work was conducted under two $600,000 grants from the Robert Wood Johnson Foundation and another $3.6 million grant from the Office of the National Coordinator for Health Information Technology at HHS, the latter of which paid for both the ambulatory-care EHR survey and a separate hospital IT survey that is yet to be completed. A final report on the ambulatory survey is due July 2.

The survey of 2,758 physicians was conducted between September 2007 and March 2008 by the Institute for Health Policy at 902-bed Massachusetts General Hospital, Boston, the Harvard School of Public Health, George Washington University and RTI International.

See full article here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080620/REG/739079971/1029/FREE

The New York Times also covered the report.

See:

http://www.nytimes.com/2008/06/19/technology/19patient.html?_r=1&oref=slogin

Most Doctors Aren’t Using Electronic Health Records

A very important aspect of these studies is that a methodology has been developed that really assesses the quality and depth of the EHR being used. This is clear recognition of the fact that it is only when the more advanced forms of functionality are not only present, but actually used, will the hoped for benefits and improvements in care quality be achieved.

It would be invaluable if such a detailed study were carried out in Australia.

I look forward to the full paper on July 2.

David.

Health Information Exchange – Some Really Sound Thoughts and Why NEHTA might be Off Course.

The following post appeared on the e-CareManagement blog a day or two ago.

Untangling the Electronic Health Data Exchange

Posted by Vince Kuraitis on June 19, 2008

by David C. Kibbe MD, MBA

The purpose of this post is to help a non-technical audience untangle some of the confusion regarding health data exchange standards, and particularly come to a better understanding of the similarities and differences between the Continuity of Care Record (CCR) standard and the CDA Continuity of Care Document (CCD). But what I’m most interested in is getting beyond the technical, political, or economic positions and interests of the proponents of any particular standard to arrive at some principles that demonstrate in plain language what we are trying to achieve by using such standards in the first place.

Frankly, I don’t give a hoot about what standardized XML format for capturing clinical data and information about a person becomes the norm in the health care industry over the next several years. I do care that the decision is made by the people, institutions, and companies who use the standards, and not made by a quasi-governmental panel or a group of “industry experts” whose economic or political interests are served by the outcome, and dominated by a particular standards development organization with whom they are very cozy.

In other words, I do want free and open market forces to be able to operate freely and openly as health information exchange evolves, in part because I believe market forces will work in the direction of continuously improving health IT, whereas in my experience top-down efforts are often protective of established interests and discouraging to innovation.

Herein lies the problem, in my opinion, with the standards adoption process that the Office of the National Coordinator of HIT (ONC) and HITSP have overseen during the past four years.

It is the epitome of a top-down, large established player-controlled, and anti-competitive juggernaut in which a “one size fits all” paradigm has been promoted and lobbied for. In this case, HITSP has “selected” the CCD and not the CCR standard, despite the market forces that seem to be continuing the use of the CCR standard. This is simply stupid and likely will turn out to be futile.

I am one of the many volunteer co-developers of the Continuity of Care Record standard, which has been developed under the auspices of ASTM International, a not-for-profit organization that develops standards for many industries, including avionics, petroleum, and air and water quality. The CCR is sponsored by the American Academy of Family Physicians and numerous other physician groups. I am also the 2008-2010 chair of the E31 Technical Committee on Healthcare Informatics, the leadership group within ASTM that is working with Google Health and many other individuals and organizations on the implementation and use of the CCR standard in this country and abroad.

Much more here:

http://e-caremanagement.com/untangling-the-electronic-health-data-exchange/

It needs to be said that while there is a risk of some sort of partisanship in all this David Kibbe is a man who knows what he is talking about. Some of the points he makes I find really compelling – especially in the light of some of the choices NEHTA is making in the same domain at present.

Of special importance is the last paragraph of the blog.

“Which brings me to the finale of this post, namely, to state in plain language that interoperability can only be approached in incremental stages when so much health data and information exists in non-structured formats. The principle to uphold is the encouragement of any and all efforts to innovate in the direction of computability and interoperability, even if some of these appear less than perfect or even piece-meal. One size will not fit all uses or use-cases, and what is good for consumers’ PHRs may not be the same thing that works in a very large medical enterprises. Control over standards by large enterprises and/or their vendors is spurious, anti-competitive, and probably won’t be effective. The standards are supposed to make our lives simpler, not more complicated.”

What Dr Kibbe is saying you is you have to start simple and grow – not do a NEHTA and come up with untested – and probably unusable – 100+ page documents defining how to do a discharge summary or referral.

He also clearly recognises the inapplicability of the top down ‘we will instruct and you will comply’ approach, so beloved of NEHTA, in the e-Health domain.

A great read. Certainly a blog to subscribe to notifications of updates!

David.

Just Why are NEHTA’s Plans for the Shared EHR a Secret?

The following is adapted from the NEHTA web site (captured 22/06/2008)

http://www.nehta.gov.au/index.php?option=com_docman&task=cat_view&gid=130&Itemid=139

Shared Electronic Health Record

NEHTA is working to develop specifications and requirements for a national approach to shared electronic health records. These records will enable authorised healthcare professionals to access an individual's healthcare history, directly sourced from clinical information such as test results, prescriptions and clinician notes. The shared electronic health record will also be able to be accessed by individuals who have received healthcare services.

Specifically, NEHTA will focus on developing:

• Operating concepts for a national approach to establishing and maintaining shared electronic health records;
• Policies, requirements, architecture and standards for a national approach to shared electronic health records; and
• A business case to substantiate and validate the proposed approach.

For the health system within Australia to reap the full benefits from the IT, governments and healthcare providers need to make the case for undertaking further investment including the development of a national system of shared electronic health records. The case for the required level of investment depends on the credible quantification of the costs and benefits of providing such.

Contact

Dr Andrew Goodchild - Shared Electronic Health Record Design

Fact Sheets

Shared Electronic Health Record Fact Sheet 19/08/2006

Context and Strategic Direction

Standards for E-Health Interoperability v1.0 - 08/05/2007

Review of Shared Electronic Health Records Standards v1.0 - 21/02/2006

What this shows us is that it is over 14 months since NEHTA has published anything on the Shared EHR.

However we have had Dr Haikerwal running around the country spruiking the plans for having a new electronic record implemented over the next few years – following the receipt of funding from Council of Australian Governments which is to meet in October this year.

See:

http://www.misaustralia.com/viewer.aspx?EDP://20080620000020806080&magsection=news-headlines-list&portal=_misnews&section=news&title=Electronic+health+system+on+the+mend&source=/_xmlfeeds/mis/news/feed.xml

It seems, from the reports I have received, NEHTA has been conducting briefings about such a plan to a collection of clinical and consumer peak bodies. (The last one was on June 18 in Canberra).

The obvious concern is just what they are telling these audiences and what commitments are being made that have not been subjected to any technical scrutiny other than the NEHTA staff. The situation we have here is that NEHTA (a publicly funded organisation) is providing private briefings on topics where it has by no means the monopoly on expertise trying to get very substantial ($billions I would not be surprised) funding to keep itself in existence while having been reviewed by the Boston Consulting Group recently as a failed organisation – especially in the area of Shared EHRs (now somehow renamed Individual EHRs).

In the meantime we also have the following:

3 years away">Surprise, surprise - e-health records >3 years away

17 June 2008

The Australian Doctor website reports today that Australia “is at least three years away from introducing shared e-health records for every patient — despite $150 million being sunk into e-health programs over the past eight years.”

Federal Health Minister Nicola Roxon, when interviewed by the Australian Financial Review last week, refused to commit to a 2012 deadline for a national e-health record system.Clinical leader of the National e-Health Transition Authority (NEHTA) and ex-AMA president Dr Mukesh Haikerwal told Australian Doctor, “There is no element of the reform agenda that can succeed unless we have a decent underpinning by a robust e-health system.”NEHTA is believed to be looking initially at a minimum-quality data set - limited to information such as allergies, hospital history and medical conditions to ensure there is enough information “to treat the patient safely”.

For more see:

http://wellingdigital.com.au/

Worse we have a National E-Health Strategy being developed by Deloittes which NEHTA is clearly making bets on the outcome of. This is a governance and management farce. Either NEHTA or Deloittes are setting the direction for the future of e-Health. I know which is should be and it isn’t NEHTA!

Deloittes need to be allowed to finish their work – have it made public for consideration by all relevant stakeholders - and at this point NEHTA should be invited to consider how it can actualise whatever is recommended.

I believe both Ms Roxon and Mr Hockey (the Opposition spokesman) should be asking some hard questions of NEHTA right now as to just what they are up to and how they justify it. At the very least the public (and not just a select few) is entitled to know what they have in mind!

David.

Useful and Interesting Health IT Links from the Last Week – 22/06/2008

Again, in the last week, I have come across a few reports and news items which are worth passing on.

These include first:

CBO director stands by criticized IT report

By: Joseph Conn / HITS staff writer

Story posted: June 17, 2008 - 5:59 am EDT

The director of the Congressional Budget Office has rallied to the defense of his troops, one current and one former CBO researcher, who in a report last month criticized two older and oft-cited studies touting the macroeconomic benefits of widespread, national deployment of healthcare information technology systems.

Peter Orszag, director of the congressional watchdog agency, took to his blog earlier this month to answer criticisms of the CBO report sent to him in a letter and an attachment from officials at the RAND Corp.

To paraphrase, the RAND folks wrote to the CBO people saying, "You done us wrong," and the CBO boss blogged back, answering, "We stand by our men."

"Nothing in the RAND letter would cause us to modify our previous conclusions," Orszag wrote on his blog.

"The RAND study estimated potential savings of approximately $80 billion per year from health IT if it were widely adopted," Orszag continued. As the "CBO concluded in its recent report, however, that $80 billion figure is not an appropriate guide to the effects of legislative proposals aimed at increasing the use of health IT for several reasons. For example, the RAND study attempted to measure the potential impact of the widespread adoption of health IT—assuming the occurrence of 'appropriate changes in healthcare'—rather than the likely impact, which would take account of factors that might impede its effective use.

More here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080617/REG/247135062/1029/FREE

This and the article following show just how hard it can be to draw firm conclusions in the absence of real life implementation. Sadly, if done well, the implementation process always changes things in such a way that pre / post comparisons are very difficult if not impossible. It seems unlikely we will ever have a randomised controlled trial of health IT – so we need to look for other indicators to show health IT makes a difference. I would suggest measures that reflect the quality and safety of treatment before and after would be a good place to start.

Second we have:

Health IT Might Not Produce Immediate Savings, But It Could Improve Quality of Care, Reduce Health Disparities, According to Analysts

[Jun 16, 2008]

Health IT Now! Coalition on Friday at a Capitol Hill briefing asked lawmakers to pass legislation that would subsidize health care providers for the adoption of electronic health records, ensure interoperability among health care information technology platforms and address privacy concerns, CongressDaily reports (CongressDaily, 6/13).

At the briefing, RAND researcher Richard Hillestad cited a study he led that found implementation of an interoperable health care IT system by 90% of the U.S. health care system would save $80 billion annually after 15 years. He added that preventive care and chronic disease management efforts that use health care IT could prevent 400,000 deaths and add 40 million workdays annually (Wyckoff, CQ HealthBeat, 6/13). Hillestad also said that use of health care IT could prevent more than 2.2 million adverse events related to medications annually (CongressDaily, 6/13).

More here:

http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=52757

This is an important briefing that makes it clear the objective of Health IT is better and safer care and not savings in the short term.

Third we have:

N.Y. Medicaid ups the ante

By refusing to pay for 14 ‘never events,’ the nation’s biggest Medicaid program could propel other states into action

By: Jean DerGurahian

Story posted: June 16, 2008 - 5:59 am EDT

In a relatively short period for the healthcare industry, several insurers and hospital associations have adopted positions of not paying for certain medical errors; now, with the New York state Medicaid program establishing its own policy, the stage is set for an even faster growth in the trend, industry experts say.

New York, with the nation’s largest Medicaid budget at $47 billion, stands to garner attention as to how it structures its policy, which was announced earlier this month. New York’s approach is noteworthy and has been met with approval by hospitals because they prefer a list of “never events” instead of the more complex hospital-acquired conditions that constitute Medicare’s nonreimbursement policy. The state is not the first to jump on the nonpayment bandwagon and its list of events is not as lengthy as lists of other groups with similar policies.

More here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080616/REG/564730725

This is a very interesting article where it is explained that the US Health Insurance system will now refuse to pay for the management of complications in treatment that should never happen – e.g. wrong side surgery, lost sponges inside the patient, development of pressure ulcers and so on.

Seems like this could certainly be applied in Australia to make sure there is focus in Hospitals on preventing complications that should not happen.

Fourthly we have:

Telemedicine In Emergency Departments - Medical Journal Of Australia

16 Jun 2008

The use of telemedicine in emergency departments (EDs) is most effective for moderate trauma patients, according to a research paper published in the latest issue of the Medical Journal of Australia.

Professor Johanna Westbrook, from the Health Informatics Research and Evaluation Unit at the University of Sydney, and her co-authors evaluated whether the introduction of an emergency department telemedicine system changed patient management and outcome indicators. The study looked at the use of the Virtual Critical Care Unit (ViCCU), a telemedicine system that allows real-time, broadcast-quality, low-latency audiovisual communications between ED clinicians at different sites.

The study was conducted in the EDs of an 85-bed district hospital and a 420-bed metropolitan tertiary hospital - for one year before and 18 months after the introduction of the ViCCU.

At the end of the study, doctor and nurse clinicians were interviewed on their perceptions of how the ViCCU system impacted on the care provided and their work.

More here:

http://www.medicalnewstoday.com/articles/111404.php

This is an interesting study.

The full paper is found here and is well worth a browse.

http://www.mja.com.au/public/issues/188_12_160608/wes11019_fm.html

Fifth we have:

Vic's Eastern Health moves from legacy to leader

Virtualisation, VoIP, wireless networks, electronic documents all overhauled as part of massive upgrade.

Darren Pauli (Computerworld) 19 June, 2008 10:37:36

A four-year IT modernisation overhaul of Victorian health provider Eastern Health will spell the end of server sprawl, expensive Private Automatic Branch Exchanges (PABXs), and soaring printing costs.

The government organisation has 8000 staff spread across more than 60 sites including hospitals, aged care facilities and rehabilitation clinics, making it the second largest in the state and among the biggest in the country.

So it is no surprise that inefficiencies in IT have inflated top end operating costs and damaged the role of technology as a business enabler.

But like all IT trailblazers, Eastern Health CIO Mark Gardiner has focused the renovation cross-hairs on improving efficiency rather than frugality.

"Healthcare is not just a people-business, it's an information business that relies on the right information to get to the right place at the right time. And IT is key to helping us operate more efficiently, effectively and provide better care to patients," Gardiner said.

The project, which kicked off in 2006, is part of the Victorian government's $360 million six-year HealthSmart initiative to spruce-up IT operations across the public health sector. Gardiner headed-up the project.

More here:

http://www.cio.com.au/index.php?id=1066434940&eid=-601

This sort of report really makes me sad. The best that can be said about progress in health IT in this area (Eastern Health) is that issues like network infrastructure should have been addressed years ago. The lack of discussion about application upgrades I find very revealing indeed. To describe getting decent infrastructure in place as trailblazing really is just hopeless.

Sixth we have:

Pedophile fears as student profiles go on net

Article from Courier Mail.

James O'Loan and Melanie Christiansen

June 16, 2008 12:00am

A PHOTO of every state school student will be posted online by the Government, sparking fears pedophiles could use the database.

The intranet database, dubbed OneSchool, will profile each of the state's 480,000 public school students enrolled from Prep to Year 12.

Photographs, personal details, career aspirations, off-campus activities and student performance records are being collected from all 1251 state schools.

Education Queensland said details of 180,000 students from 637 schools already were online and the database would be completed by December.

About 80,000 students are expected to be added to the internal education department database each year.

The site already has been labelled a likely target for computer hackers.

"The social fabric of hackers is such that this database (OneSchool) is going to be a fair target," Queensland University of Technology deputy dean of Information Technology professor Mark Looi said.

More here:

http://www.news.com.au/couriermail/story/0,23739,23868131-952,00.html

Most worrying is this quote from the Minister

“Education Minister Rod Welford has warned the state-wide rollout of the OneSchool database is "non-negotiable" and students could be refused an education if they don't divulge required information.

He also said he understood some people might have concerns about the security of online databases but OneSchool was designed to be more secure than the current system.

"If they don't want to have any of their information recorded ... how else does one record a student's results," he said.”

Now while I am sure this will all be managed sensibly – with all teachers having access to the whole database one really has to wonder just how long it will take for one ‘bad egg’ to abuse the information for some reason or other. Also to not permit individuals to opt-out if they have some concern – perhaps about bullying, family violence etc is just plain wrong in my view.

I suspect the Minister is just a bit too arrogant for his own good by not showing some reasonable level of flexibility in all this.

More on this here:

http://www.news.com.au/couriermail/story/0,23739,23875371-3102,00.html

Government secrecy 'favours the state, not individual'

Last we have out slightly technical note for the week:

Test Center review: Firefox 3 comes out sizzling

After an eight-month beta phase, Firefox's major update scores big with unprecedented ease, snappier performance, and sensible security features.

Paul Venezia (InfoWorld) 18/06/2008 17:22:03

As the window to the Internet, the Web browser is arguably the most important application ever developed, and it will only become more important in the coming years, as applications continue their retreat from the local system and into Web frameworks built on Apache, IIS, Python, PHP, Perl, Ruby, and countless other languages and tools. Against this backdrop, today's official introduction of Firefox 3 may in fact be a watershed event in the history of computing.

It's no secret that Firefox isn't the most popular browser. Internet Explorer, for better or for worse, enjoys a significant advantage in market share, but data gathered from all corners of the Internet show this advantage eroding. Judging by the traffic at a Web site that handles more than 100,000 unique visitors a day, Firefox gained almost 8 per cent over Internet Explorer for the month of May, year over year, moving from just over 26 per cent of all visitors to 33 per cent. Internet Explorer lost a total of 9 per cent to other browsers in that time frame.

Oddly, the difference seems to have been taken up by Apple's Safari, which gained almost 3 percent. These numbers will differ depending on the site — for instance, sites focused on technology will have higher numbers for Firefox, since most tech-savvy users prefer Firefox over Internet Explorer — but the general trend shows that Firefox is making significant inroads all over the globe. Judging by the advances in Firefox 3, this is likely to accelerate.

Continue reading here:

http://www.computerworld.com.au/index.php?id=1922793285&eid=-255

All I can say is I use it and the features it has, and the speed, make it great fun to use! Go get it from www.mozilla.com if you are not already a user. You will not regret it!

This article is also fun.

Stupid user tricks: IT admin follies

IT heroes toil away unsung in miserable conditions -- unsung, that is, until they make a colossally stupid mistake

Andrew Brandt (InfoWorld) 17/06/2008 09:05:55

Go here:

http://www.computerworld.com.au/index.php?id=692810722&eid=-6787

More next week.

David.

Issue No 2 of [Pulse+IT] eNews Available

Pulse+IT eNews

Edition 2: 20th June, 2008

Click here to download this edition

Contents

- Simon James - 1800-Skype: Free phone calls for all.

- Dr David More - What is Big Blue up to in E-Health in Oz?

- Dr Sam Heard - Guest commentary: Why is it taking so long?

- In other news...

Events calendar

Edition Sponsors

- GPA Accreditation Plus

- eVisit

Enjoy!

David.

The USA Plans to Prove Ambulatory EHRs Really Make a Difference!

The following release appeared a few days ago:

http://www.hhs.gov/news/press/2008pres/06/20080610a.html

HHS Secretary Announces 12 Communities Selected to Advance Use of Electronic Health Records in First Ever National Demonstration

FOR IMMEDIATE RELEASE
Tuesday, June 10, 2008

HHS Secretary Mike Leavitt today named 12 communities that will participate in a national Medicare demonstration project that provides incentive payments to physicians for using certified electronic health records (EHR) to improve the quality of patient care. The five-year, first-of-its-kind project is expected to improve the quality of care provided to an estimated 3.6 million Americans.

“The use of electronic health records, and of health information technology as a whole, has the ability to transform the way health care is delivered in our nation,” Secretary Leavitt said. “We believe that EHRs can help physicians deliver better, more efficient care for their patients, in part by reducing medical errors. This project is designed to demonstrate these benefits and help increase the use of this technology in practices where adoption has been the slowest – at the individual physician and small practice level.”

The communities selected to work with the Centers for Medicare & Medicaid Services (CMS) on the EHR demonstration project range from county- and state- level to multi-state collaborations. They include:

• Alabama
• Delaware
• Jacksonville, FL (multi-county)
• Georgia
• Maine
• Louisiana
• Maryland/Washington, DC
• Oklahoma
• Pittsburgh, PA (multi-county)
• South Dakota (multi-state)
• Virginia
• Madison, WI (multi-county)

These 12 communities were selected through a competitive process from a field of more than 30 applicants. They demonstrated active collaboration among stakeholders, including physicians and other providers, health plans, employers, government and consumers; existing or planned private sector initiatives related to health information technology and quality reporting; and adequate size to recruit a sufficient number of primary care physician practices. They also demonstrated close ties to the medical community and ability to work closely with CMS to recruit physician practices to participate in the demonstration.

In letters sent to communities not selected for the demonstration, Secretary Leavitt urged them to consider pursuing EHR incentive projects of their own, based on the work they have already done.

“A tremendous opportunity exists for communities to impact and improve health care delivery starting at the local level,” Secretary Leavitt said. “While the number of sites selected was limited to 12, we are greatly encouraged by the substantial multi-stakeholder initiatives ongoing across the nation. It is my hope that those communities not selected and others that were not yet prepared to apply will continue working together to improve health care – and consider creating their own incentive-based projects to advance the use of EHRs.”

“Broad adoption of EHRs has the potential to transform health care and the way medicine is practiced in our nation,” said Acting CMS Administrator Kerry Weems. “Medicare has chosen the communities whose proposals will work best for this demonstration project. But other communities can still build on the outstanding work they have done and consider designing and carrying out their own incentive-based projects. In a community where health care providers and payers have already achieved significant coordination in applying for the Medicare demonstration, it may be possible to design independent incentive programs even without Medicare’s participation.”

Over the five-year demonstration project, financial incentives will be provided to as many as 1,200 primary care physician practices in the selected communities that use certified EHRs to improve quality as measured by their performance on specific clinical quality measures. In addition to the incentive payments, bonus payments may be awarded based on a standardized survey measuring the number of EHR functionalities a physician group has incorporated into its practice. Total payments under the demonstration for all five years may be up to $58,000 per physician or $290,000 per practice.

Findings from the demonstration will help determine the role of EHRs in delivering high-quality care and reducing errors. The demonstration will also assess the role of incentive payments in encouraging adoption and use of EHRs.

The project will be implemented in two phases. CMS will begin working with partners in four Phase I communities over the coming months to develop site-specific recruitment strategies, and recruitment of physician practices will start in the fall. For Phase II sites, these activities will begin in 2009.

The EHR demonstration project is an important step toward President Bush’s goal of most Americans having a secure, interoperable electronic health record by 2014. For more information on the project, visit http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/2008_Electronic_Health_Records_Demonstration.pdf.

This initiative is also part of HHS’ bold vision for health care reform built on the four cornerstones of value-driven health care. These include: adopting interoperable health information technology; measuring and publishing quality information to enable consumers to make better decisions about their providers and treatment options; measuring and publishing price information to give consumers information they need to make decisions on purchasing health care; and promoting incentives for high-quality, efficient delivery of care.

To learn more about Connecting to Better Health Care, please visit www.hhs.gov/secretary/connecthealthcare.

• Fact Sheet: Electronic Health Records Advancing 21st Century Medicine

Many more details are available here:

http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=3&sortOrder=descending&itemID=CMS1204776&intNumPerPage=10

The bottom line is that ambulatory EHRs of known and certified capability are going to be compared with that status quo (paper records) to see how much improvement is quality, safety etc can be achieved.

The aim is to have 1,200 physicians use certified systems (that could involve up to 3 million patients) and to demonstrate they provide improved care.

I sure would not want to be a patient whose doctor was part of the control group! Indeed this very problem has raised concerns with some

EHR study raises docs' concerns

By: Matthew DoBias / HITS staff writer

Story posted: June 13, 2008 - 5:59 am EDT

Some physicians have expressed concern over a new federal electronic health-record demonstration project that could divide volunteers into the haves and the have nots.

The project, announced by HHS in February, aims to scientifically determine whether the use of EHRs in physician practices will live up to its promise of improved, higher-quality care at lower costs. Medicare, private payers and many providers say they already know the answer to that question, and the CMS is betting $150 million that its new study will spotlight the benefits of health IT.

But to do so, the CMS must first divide participating doctors into separate study and control groups. Those in the study group will be given incentive payments to help defray the cost of buying and implementing an EHR system, while those in the control group will continue to eschew computers for paper.

Not surprisingly, it's the latter group that has raised preliminary concerns by some physician groups.

More here (free registration required)

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080613/REG/411266165/1029/FREE

All in all this is a great study and I hope I am still about to hear the outcomes. It really is wonderful the US is attempting a proper trail.

David.

A Correspondent Wonders About the Ethics of Some Advertising.

This e-mail arrived today! I quote:

“Crash of a shocking bunch of cowboys - long awaited by many of my mates in learning difficulties/child psychologists.

Just six months ago they were hiring marketing people to go out and sell their program - which costs $$$thousands per child - throughout Australia. Just snake oil

Unfortunately they were very greatly helped by many news media that wanted to say doctors are drugging kids, let's try this nice non-drug treatment. Several appearances on TV of "happy customers" delighted with the program's results were made by staff members and people associated with the company…

http://www.dore.com.au/Home.aspx”

I hope we can all learn from this sort of behaviour and presentation of false hope!

David.

Microsoft and Kaiser Join Forces to Refine Personal Health Records.

The following article appeared a few days ago:

Kaiser, Microsoft to test PHR data exchange

Story posted: June 9, 2008 - 5:59 am EDT

Kaiser Permanente and Microsoft Corp. will test the capabilities of their personal health records to exchange data in a pilot program, the companies announced.

The organizations, which have partnered in the past, said that they hope the exchange will expand consumer access to online health management tools. Kaiser’s 156,000 employees are eligible to opt into the voluntary project, which will test the reliability of secure data exchange, according to Kaiser. “In the early stages, we’re very interested in testing industry standards,” said Anna-Lisa Silvestre, vice president of online services for the insurer, during a news conference announcing the pilot.

During the pilot the PHRs will exchange immunization records, information on allergies and medications, and demographic data under standards outlined in the standard organization Health Level 7’s Continuity of Care Document, Silvestre said. If the pilot is successful, Kaiser will open the program to its 8 million members.

More here (free registration required)

http://modernhealthcare.com/apps/pbcs.dll/article?AID=/20080609/REG/848430230

More information (with links) is available:

Kaiser Permanente, Microsoft Launch Personal Electronic Health Records Pilot Program

[Jun 09, 2008]

Officials from Kaiser Permanente and Microsoft on Monday announced that the companies are developing a patient information exchange pilot program, Reuters/Washington Post reports (Kaufman, Reuters/Washington Post, 6/9).

Under the program, patients who use Kaiser's personal electronic health record system, My Health Manager, will be able to transfer medical data -- including prescriptions, allergies, immunization information and medical conditions -- from My Health Manager to Microsoft HealthVault accounts. Users will be able to dictate what information is transferred and will have access to their profile via the Internet (Lawton, Wall Street Journal, 6/9). Initially, the program will only be available to Kaiser's 156,000 employees (Reuters/Washington Post, 6/9).

The pilot stage will last until November. If successful, the program would then be offered to Kaiser's 8.7 million members in nine states and Washington, D.C. (Lohr, New York Times, 6/10). During the pilot stage, Kaiser will be testing the program's security to ensure it meets safety standards, according to Anna-Lisa Silvestre, Kaiser's vice president of online services (Wall Street Journal, 6/9).

More here:

http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=52619

Importantly this test program is evaluating a range in information sources that may be integrated with the Microsoft system and additionally we are told that both Google and MS are adopting standards based approaches.

“Silvestre said Kaiser also considered partnering with Google on its project but chose Microsoft in part because of its privacy protection and personal security technology. In addition, Microsoft and Kaiser are using the same Web-based format, called a Continuity of Care Document, while Google has focused its initial efforts on a Continuity of Care Record Web format. Google and Microsoft each are committed to supporting both formats, the Times reports.”

This is good news as it may lead to interoperability between PHR providers (as both are HL7 Standards I believe) in the future.

A visit to HealthVault is well worthwhile to see the various partners and approaches that MS is adopting.

Go to:

http://www.healthvault.com/

This whole space certainly has a way to go yet!

David.