V I E W P O I N T

Health Information Technology

The U.S. healthcare system uses relatively little computer technology to support clinical services. There is tremendous potential to improve the quality of care provided and achieve substantial savings throughout the system if the use of computers - or "health information technology" (HIT) - is expanded. These benefits would pertain to the Medicare as well, and Medicare's role as a national standard setter for the larger system offers an opportunity to speed the adoption of this technology.

Improving Patient Care and Clinical Efficiency

Unfortunately, the healthcare industry has seriously lagged behind other industries in the adoption of computer technology. A 2008 study by the George Washington University found that 83 percent of doctors providing outpatient services are not using electronic health records (EHRs) and that only 4 percent employ EHRs with the capacity for electronic prescribing and clinical decision support (e.g., providing clinicians reminders about needed tests and procedures). Bridging this technological gap will improve care and achieve savings by enhancing the performance of healthcare practitioners, reducing medical errors, enabling quality comparisons of providers, and providing infrastructure for "pay-for-performance" reimbursement and comparative effectiveness research.

Computers can improve healthcare processes by supporting the work of clinicians. Reliance on paper records has many drawbacks: practitioners must wait for records to be retrieved; decisions must often be made before information is available; records are not easily shared when patients are referred to specialists; and it is difficult to secure paper records and track who has had access to them. In contrast, computers increase efficiency and accuracy simply by reducing the need to ferry paper from point to point in the system:

• Ready access to clinical data is possible, allowing clinicians to share information quickly and reducing the duplication of diagnostic and radiological tests.

• The capacity to electronically file prescriptions and orders for tests can reduce errors.

• Administrative costs can be reduced, as fewer staff will be needed to process doctor's orders and records.

• Accuracy of medical records is enhanced, as the need for transcription of clinical notes is reduced.

HIT can also enhance the performance of practitioners by employing "clinical decision support" (CDS) tools. Essentially, clinicians can receive reminders about evidence-based practice protocols and receive guidance to enhance cost-savings. For example, based on a patient's history, a nurse could be prompted to do preventive screening. A physician ordering a new prescription could be alerted to a patient's drug allergies or possible adverse interactions with drugs already prescribed. Guidance can be provided on the proper dosage levels for drugs, and to achieve savings, clinicians could be reminded of the availability of generic alternatives to brand name drugs. In assisting practitioners with decision making in the complex healthcare workplace, patient care is improved and processes are made more efficient.

Increased use of computers is also a necessary part of other needed system reforms. Medicare currently provides incentive payments to providers that attain performance goals on quality measures, an approach called "pay-for-performance." EHRs allow for efficient tracking so that payment incentives can spur quality improvement. In addition, a 2008 Congressional Budget Office (CBO) report emphasized the value of computers to collecting data for research on the comparative effectiveness and/or cost effectiveness of different treatments. Patient histories and treatment outcomes can be examined on an anonymous basis for thousands of cases at a time - providing a rich source of data on the effectiveness of care.

 Potential for Cost Savings

A number of studies have pointed to the potential for the healthcare system to achieve substantial savings as a result of the efficiencies enabled by EHRs. According to RAND , computer technology, implemented widely, could yield annual savings of $77 billion through gains to efficiency alone. Research by the Lewin Group in 2007 found that $87.8 billion could be saved over a 10 year period if serious investments were made to employ HIT. CBO has cautioned, however, that significant barriers will slow the adoption of this technology, constraining possible cost savings.

Overcoming Barriers to Adoption

A fundamental problem in attaining the system-wide adoption of HIT is that the resulting cost savings are realized primarily by those who finance health care (payers such as the government and insurance companies) and not by the providers who must cover the bulk of the cost of implementation. Providers face a number of significant costs in obtaining computer technology:

• Paying for hardware, software, and technical assistance to install systems. Since national standards on security and interoperability are still evolving, providers also face the risk of needing to change their systems if requirements change.

• Expenses for ongoing maintenance.

• Costs of lost productivity as staff learn how to incorporate HIT into their daily work.

In their 2008 study, George Washington University researchers found that physicians identified a number of "major barriers" to employing HIT. Doctors not using EHRs reported that a lack of capital (67 percent), the uncertainty of a return on investment (51 percent), difficulty finding an appropriate system (54 percent), and/or a concern that technology would become obsolete (45 percent) stand in the way of implementation.

The federal government, under the auspices of the Office of the National Coordinator for Health Information Technology (ONC) at the Department of Health and Human Services, has begun to address these barriers by establishing processes to develop uniform national HIT standards and to stimulate investment in computer technology. In the 110 th Congress, major legislation was proposed to further these efforts. Both the Wired for Healthcare Quality Act (S. 1693, sponsored by Senators Kennedy, Enzi, Clinton, and Hatch) and the Protecting Records, Optimizing Treatment, and Easing Communication through Healthcare Technology Act (H.R. 6357, sponsored by Representatives Dingell and Barton) had provisions to make the ONC a permanent agency, to provide grants to support provider implementation of EHRs, and to require Medicare providers to use HIT. The bills enjoyed widespread, bipartisan support and were approved by committee votes. In addition, Representative Stark introduced legislation, the Health-e Information Technology Act , H.R. 6898, which pursues policies similar to these other bills but includes expanded privacy protections in some areas. These bills are an important starting point for future legislation.

Need for Privacy and Security Standards

The ability to use computers to quickly share information brings dangers as well as benefits. The need for data security standards gained national attention in 2006 when the Department of Veterans Affairs reported that the personal information of 26.5 million veterans had been stolen. Improper disclosure of health information can be particularly damaging, and concerns about privacy can keep patients from telling their clinicians about mental health disorders, symptoms of sexually transmitted diseases, and injuries resulting from domestic violence.

In 2007, the Government Accountability Office (GAO) issued a report noting that while the federal Office of the National Coordinator for Health IT (ONC) had initiated programs to develop privacy and security standards, "[it] is in the early stages of its efforts and therefore has not yet defined an overall approach for integrating its various privacy-related initiatives and addressing key privacy principles, nor has it defined milestones for integrating the results of these activities." The report identified a number of key challenges that must be addressed to ensure that privacy will be protected as the implementation of HIT proceeds: developing standards to ensure that only the minimum amount of information necessary is disclosed and only to entities authorized to receive it; ensuring that individuals have rights to access and amend EHRs; implementing adequate security measures to protect health information; and resolving legal and policy issues. It is crucial that these issues be addressed as policy on HIT is developed.

NATIONAL COMMITTEE POSITION

The National Committee calls upon the next Congress and Administration to expand the efforts of the federal ONC to provide support to help providers employ EHR systems and to create uniform national standards for their use. The widespread use of HIT is overdue, and the potential to significantly improve healthcare quality and achieve substantial savings throughout the system must be achieved.

Because it is a nationwide program, Medicare is uniquely situated to provide a national framework of HIT standards. Federal policy makers should expand Medicare's current role as a national standard setter to include the propagation of uniform national HIT standards. Specifically, the following goals should be pursued:

•  The implementation of HIT should be expedited to achieve improved medical care and cost savings throughout the healthcare system.

•  Legislation should establish the Office of the National Coordinator for Health IT (ONC) as a permanent federal agency with a mandate to develop uniform standards for interoperability, privacy, and security.

•  Grant programs and technical assistance should support provider's implementation of HIT.

•  After an adequate phase-in period, Medicare providers should be required to use EHRs and electronic prescribing systems that comply with standards established by the ONC.

•  Safeguards should be established to ensure the security of health records and protect patients' privacy.

•  Patient notification when an inappropriate disclosure has occurred.

•  Ability of patients to access and amend EHRs.

•  Provision for the segregation of highly sensitive information and patient authorization for its use - e.g., an electronic "lock box" for sensitive health information such as mental health issues or injuries resulting from domestic violence.

•  Use of authentication controls to ensure legitimate access to information.

•  Audit trail capabilities to allow monitoring of access to health data.

Government Relations and Policy, December 2008

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