Article Date: 4/1/2008

Prepare to go Paperless
health information technology

Prepare to go Paperless

Federal and state initiatives as well as other factors may influence your decision sooner than you think.

FRANCIS L. McVEIGH, O.D., F.A.A.O., M.S.,
Woodbridge, Va.


ILLUSTRATION BY GARRY NICHOLS

Many new initiatives and some incentives — at both the national and state levels — indicate that the employment of Health Information Technology (HIT) in your practice may soon be a necessity to ensure a healthy practice revenue.

Here, I discuss the six converging factors that make this scenario seem very likely. (See "Key Health Information Technology Terms," below.)

1 U.S. healthcare savings

A January 2005 Center for Information Technology Leadership (CITL) Study revealed that a standardized encoded, electronic healthcare information exchange would save the U.S. healthcare system $337 billion, through a 10-year implementation period and $78 billion in each year thereafter.1 CITL assists healthcare providers in making information-technology investments.

Also, a Research and Development (RAND) September 2005 study revealed that HIT improvements, such as widespread adoption and effective use of Electronic Medical Record (EMR) systems could save the U.S. healthcare system $162 billion dollars annually; that potential health and safety benefits could double savings; and that EMRs could improve quality and efficiency of the healthcare system.2,3

Because of the outlined projected healthcare costs and potential cost savings, I believe that HIT initiatives will continue regardless of the political party of our new president.

2 National government initiatives

In his 2004 State of the Union address, President Bush called for electronic health records (EHRs) to be available for use by most Americans by 2014. Following this speech, he issued executive orders 13335 and 13410. The former established the position of National Health Information Technology Coordinator within the U.S. Department of Health and Human Services. He issued the latter order to ensure that Federal Government-administered or sponsored healthcare programs promote quality and efficient delivery of health care through the use of HIT, transparency regarding health care quality and price and better incentives for program beneficiaries, enrollees and providers.

Key Health Information Technology Terms
Healthcare professionals and legislators have used the following six terms in varying context and, often, interchangeably, causing confusion as to their true definitions.
The National Alliance for Health Information Technology, a non-profit, member-based group focused on how healthcare information technology can and will improve healthcare outcomes, is leading an important effort for the Office of the National Coordinator for Health Information Technology (ONC) to develop consensus-based definitions for key health information technology (HIT) terms. The ONC provides counsel to the Secretary of Health and Human Services and departmental leadership for the development and nationwide implementation of an interoperable health information technology infrastructure. The ONC's Interim Draft Report, dated February 21, 2008, revealed the following definitions, on which the public is currently commenting. (Visit http://definitions.nahit.org/doc/InterimDraftPublicComment2.22.pdf for more information.)
EMR (electronic medical record). This is a computer-accessible resource of medical and administrative information available on an individual collected form and accessible by providers involved in the individual's care within a single-care setting.
EHR (electronic health record). This is a computer-accessible, interoperable resource of clinical and administrative information pertinent to the health of an individual. A broad-spectrum of clinical personnel uses this information — drawn from multiple clinical and administrative sources — so they can deliver and coordinate care and promote wellness.
Further comments in The National Alliance for Health Information Technology Draft Report state that, EMRs, in contrast to EHRs, are specific to a care setting/institution. Although interoperable within the care setting and with capabilities, such as importing records from labs, pharmacies and other services within the institution, EMRs aren't interoperable among non-affiliated institutions.
PHR (personal health record). This is a universally accessible, layperson-comprehensible, lifelong tool for managing and assisting with chronic disease management via an interactive, common data set of electronic health information and e-health tools, as defined by the Healthcare Information and Management Systems Society.
The individual or his legal proxy(s) own, manage and share the e-PHR, which must be secure to protect the privacy and confidentiality of the health information it contains. It is not a legal record unless so defined and is subject to various limitations. (Visit www.himss.org/asp/topics_ phr.asp for additional information.)
Interoperability. This is defined as the ability of different information technology systems and software applications to communicate, to exchange data accurately, effectively and consistently and to use the exchanged information, according to The National Alliance for Health Information Technology, July 2005, "What is Interoperability?" article. (Visit www.nahit.org/cms/index.php?option=com_content&task=view&id= 186&Itemid=195, for the full article.)
HIE (health information exchange). This is the electronic movement of any and all health-related data, according to an agreed-upon set of interoperability standards, processes and activities across non-affiliated organizations in a manner that protects the privacy and security of that data; and the entity that organizes and takes responsibility for the process.
RHIO (regional health information organization). This is a multi-stakeholder governance entity that convenes non-affiliated health and healthcare-related providers and the beneficiaries they serve, for the purpose of improving health care for the communities in which it operates.
It takes responsibility for the processes that enable the electronic exchange of interoperable health information within a defined contiguous geographic area.

Robert M. Kolodner, M.D., National Coordinator of HIT within the U.S. Department of Health and Human Services, recently stated at the Healthcare Information and Management Systems Society (HIMSS) 2008 Conference and Exhibition in February, that nine health information exchanges (HIE), such as the Delaware Health Information Network, would begin trial implementations of the Nationwide Health Information Network (NHIN) (a uniform, secure exchange of health information that follows consumers for the duration of their lives), in the fall of 2008.

Other national initiatives have included congressional mandates on inter-agency sharing. For instance, section 722 of Subtitle C — Department of Defense-Department of Veterans Affairs Health Resources Sharing, under Public Law 107-314 — Department of Defense and Veterans Health Administration, is a Healthcare Resources Sharing and coordination project.

3 State Initiatives

Individual states have also gotten involved in promoting HIT:

► Minnesota is mandating paperless health-insurance claims, e-prescribing for state employees and e-health records by 2015.

► California and Indiana have initiatives that Virginia has mandated. These initiatives: That the state-agency purchase of EHR systems adhere to accepted standards for interoperability or those certified by the Certification Commission for Healthcare Information Technology (CCHIT). (The CCHIT is an independent, nonprofit organization that the Federal government has officially named as a "recognized certification body" for EHR products. Its mission is to speed the adoption of HIT by creating a credible, sustainable product-certification program.)

► Maine healthcare leaders have announced the building of a statewide health information exchange this year.

(Visit www.himss.org/advocacy/d/HIT_Crosswalk0907.pdf, for additional information on legislative initiatives.)

4 Electronic prescribing

Prescription-drug errors injure 1.5 million Americans every year and kill at least 7000.4 This is because 95% of the three billion annual prescriptions are hand-written, leading to mistakes.

A February 19, Associated Press article titled: High Costs Drive Online Prescribing Push, revealed that healthcare costs are on track to account for $1 of every $5 spent in the U.S. by 2018. The article further revealed that a broad shift to electronic prescribing has the probability of saving the government $29 billion through one decade.

In addition, at a recent budget hearing, Michael O. Leavitt, U.S. Secretary of Health and Human Services (HHS), said that Medicare is on course to go bankrupt in 11 years. As a result, he urged Congress to push cost-saving technology, such as electronic prescriptions, now before the healthcare costs of retiring baby boomers overwhelm the system.5

Also, in December 2007, Sens. John Kerry (D-Mass.) and John Ensign (R-Nev.) introduced an e-prescription bill in Congress.6 Specifically, the bill would:

► provide permanent Medicare funding for one-time grants to physicians to help off-set the start-up costs to you of acquiring and implementing e-prescribing technology.

E-Prescribing Pilot Study Results
A survey of physicians who recently participated in a three-year e-prescribing pilot study, say they now believe that e-prescribing enables them to practice better, safer medicine. Specifically, three out of four of the prescribers said they strongly believed e-prescribing improved their patients' safety. In addition, almost 70% said they felt it improved their quality of care.
Haldy McIntosh & Associates, a marketing research company, conducted the survey for the Southeastern Michigan e-Prescribing initiative (SEMI), which consisted of a three-year pilot program and a one-time survey administered to 500 of the participating practices and their staff who used the health information technology.

► provide permanent Medicare funding for payment bonuses to you for use of e-prescribing. For every Medicare prescription you write electronically, you would be paid an extra 1% bonus.

► You'd be required to write your Medicare outpatient prescriptions electronically starting Jan. 1, 2011. If you continued to give patients hand-written prescriptions, you'd face a per-claim financial penalty.

► The Secretary of the HHS would be given authority to grant you one- or two-year hardship waivers if you face particular difficulties in acquiring and implementing e-prescribing, especially if you practice in a very small or rural solo practice.

To date, the e-prescribing mandate has been directed toward pharmacies under Medicare part B. But, this may be extended to providers in the future. (See "E-Prescribing Pilot Study Results," above.)

5 Physician Quality Reporting Initiative (PQRI)

The PQRI is a voluntary program that provides a financial incentive to eligible professionals, such as physicians, who successfully report quality data related to services provided under the Medicare Physician Fee Schedule. The program consists of 119 quality measures, including two structural measures. One structural measure conveys whether you have and employ EHR or other types of electronic prescribing. Its first year of operation was 2007.

A Medicare-enrolled optometrist who successfully reports a designated set of quality measures electronically on claims for January 1 through December 31, 2008 may receive a bonus reimbursement of 1.5% of the Medicare Physician Fee Schedule-allowed charges (subject to a cap) for eight covered services. (Visit www.aoa.org/PQRI.xml for additional information.)

6 Others are using HIT

Many of your colleagues are currently using HIT. In addition, many schools of optometry are currently teaching its students how to use HIT. This means that if you don't currently employ HIT, you may alienate astute practitioners from joining or working for your practice.

In addition, other healthcare providers with whom you work, such as primary-care physicians, may soon begin requesting information electronically. The bottom line: You could hurt the financial health of your practice by not implementing HIT.

Moving forward

Now, that you know employing HIT may soon be a necessity, you're no doubt wondering what both the U.S. government and individual states require of HITs, in terms of features. Because the role of HIT is still evolving — as illustrated above — there is currently no answer to this very practical question.

Therefore, you should base your decision on whether to purchase HIT now on the benefits vs. the risks in employing such software.

The benefits:

Practitioner cost savings. At the American Optometric Association's (AOA) recent "Building the Paperless Practice: AOA's Electronic Records Seminar," EMR/EHR lecturer Scot Morris, O.D., of Conifer, Colo., discussed how implementing HIT can save you costs on paper and free up practice space, while improving efficiency, coding accuracy and access to patient information.

Ease of acclimation. Because many of you already use an electronic means to manage your practice (i.e. billing, insurance, etc.), implementing a practice-management system that interfaces with an EHR should be easy and will actually further streamline these and other tasks.

The risks:

Incompatibility. Currently, just a few existing eye-related EHRs are certified by CCHIT. Their seal of approval ensures that an EHR product meets the basic requirements for functionality (ability to create and manage electronic records and to automate office workflow), interoperability (ability to receive electronic health data and send it to other entities, such as labs and pharmacies) and security (ability to safeguard patients' personal health information).

Therefore, if you're interested in an eye-related EHR, you may want to ensure it's CCHIT ready (meets the three above mentioned criteria). Also, you may wish to visit CCHIT's new physician education site at http://ehrdecisions.com.

Phillip J. Gross, O.D, a member of the AOA's Health Information Technology and Telemedicine Project Team, discussed the issue of compatibility at the AOA's EHR Seminar. Specifically, he said that it's imperative you check with the folks with whom you do business to assess whether their systems will be compatible with your own. Without compatibility, you won't be able to effectively communicate with other key healthcare members or integrate your ophthalmic equipment with your electronic management system. This will adversely affect efficiency, reimbursements, record documentation and ultimately your income. (See "Checklist Before Purchasing," below.)

It seems the future is knocking at your practice door. Whether you let it in is your practice-management choice. OM

  1. Walker J, Pan E, Johnston D, Adler-Milstein J, Bates DW, Middleton B. The Value Of Health Care Information Exchange And Interoperability. Health Aff (Millwood) 2005 Jan-Jun; Suppl Web Exclusives:W5-10-W5-18
  2. Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff (Millwood). 2005 Sep-Oct;24(5): 1103-17.
  3. Taylor R, Bower A, Girosi F, et al. Promoting health information technology: is there a case for more-aggressive government action? Health Aff (Millwood). 2005 Sep-Oct;24(5):1234-45.
  4. Parade Magazine, Government Watch, Rx for Medicine Mistakes. www.parade.com/articles/editions/2008/edition_01-20-2008/Intelligence_Report (accessed 3/11/08)
  5. Perrone M. High costs drive online prescribing push. Denverpost.com www.denverpost.com/nationworld/ci_8304920 (accessed 3/11/08)
  6. Senator John Kerry. Newsroom March 9, 2008. Kerry Ensign Introduce E-Prescribing Bill to Modernize Medicine and Save Lives: Bipartisan effort is supported by Senate and House Colleagues, patient advocates, medical experts. http://kerry.senate.gov/cfm/record.c fm? id=288317.
Dr. McVeigh, a retired U.S. Army Colonel is a senior clinical consultant at the Telemedicine and Advanced Technology Research Center (www.tatrc.org) in Fort Detrick, Md. He is co-founder of the Walter Reed Army Medical Center's TBI-Optometry Service, and he wrote "Time to get serious about electronic health records," featured in the January 2008 issue of Optometry. E-mail him at fran.mcveigh @gmail.com.


Optometric Management, Issue: April 2008