Almost out of nowhere, the momentum behind clinical information technology and electronic medical records began to build in the early spring and had fanned out in every direction by summer's end.
Long-inert obstacles to sharing healthcare information-such as a lack of standards for providers' computer systems--were getting the push needed to propel them toward a solution. The impetus was coming simultaneously from top leaders in government, the healthcare IT vendor community and trade associations.
But behind the scenes, the origin of much of the activity could be traced to a hastily organized summit on St. Patrick's Day between federal government officials and scores of senior healthcare industry representatives. The heat from that meeting provided the big bang for much of the IT reform that followed--including the resolve to tackle the complicated problem of agreeing on the definition of an electronic health record.
From interviews with nearly a dozen of the people who crowded into a federal office in Washington that day, as well as others plugged into the issue, Modern Healthcare pieced together the picture of a government impatient with the pace of IT deployment in healthcare and willing to use a combination of veiled threats and potential incentives to provoke progress.
To get things rolling, HHS Secretary Tommy Thompson asked experts at the CMS and HHS to explore incentives that will help providers use electronic health records, an HHS source says.
No program has been decided on and any further discussion would be premature, he says. But several senior leaders working in or with the CMS during the past year say the agency is seeking to test the idea of payments to physicians and other providers in conjunction with their use of an electronic record.
"(The) CMS is going to test payment incentives soon. That will happen," says Janet Marchibroda, chief executive officer of the eHealth Initiative, a Washington-based coalition working with government and private healthcare interests to advance IT adoption. Marchibroda was among the organizers of the March summit meeting on behalf of the CMS.
Other participants in the March summit say CMS Administrator Tom Scully made mention of that possibility, although interpretations of his comments varied widely. Through a spokesman, the CMS declined to comment on the issue of electronic standards.
An incentive to speed up the work
The observed ambitions partly explain what's at stake in the push by HHS to achieve industry consensus on elements of an electronic health record, seeking to accomplish in a matter of months what expert panels in the industry had made only rudimentary progress on after years of effort.
In May, Thompson gave the Institute of Medicine a rush order to propose key capabilities of an electronic record and then hand the work off to a standards organization called Health Level 7, also known as HL7, which he challenged to reach final consensus on a commonly defined electronic record by January 2004.
The first step in deciding on a reward system is to "create a set of objective criteria for which you can design incentives to move people along," says Paul Tang, who chaired the IOM committee that sent its recommendations to the HL7 panel on July 31.
But that's something the CMS didn't have. "If (the) CMS is going to start paying for incentives to use an (electronic health record), they have to define it first," Marchibroda says.
Tang says the federal government was hoping to work up at least a request for proposals on a demonstration project for payment incentives by year-end, and that depended on establishing a basis for payment by that time.
"The whole sense of urgency was communicated to us," Tang says of the IOM report. "If (Scully) says, 'I'm going to compensate everyone for an (electronic health record),' everyone's going to say they have one."
Hopes for a quick turnaround on the complex set of technical priorities in a health record model suffered a setback when the first draft of the proposal was voted down in early September by HL7 members. The work to reorganize and modify the model to the satisfaction of those with objections and concerns will delay the next vote until February 2004 at the earliest, says Wes Rishel, chairman of the HL7 board.
"We're certainly thinking spring 2004 is the most likely date for a published standard," says Rishel, a consultant with Gartner, a Stamford, Conn.-based information technology research and advisory firm.
The first round of debate showed that the standards were too complicated and needed simplification despite "pressure on the part of government to get this through," says Charlene Underwood, an HL7 committee member and global market manager of clinical systems at Siemens Medical Solutions Health Services Corp.
The initial failure to pass a standard was not unexpected, Rishel says. "It's a normal part of the process," he says, noting that standards proposals usually don't pass on the first ballot.
In this case, he says, the proposal wasn't meant to pass because the standards panel had to rush the inclusion of the IOM recommendations just days before a deadline to publish the ballot. And public comments stemming from a series of hearings by the eHealth Initiative were not incorporated, Rishel says.
The early-stage ballot, distributed in time for a September HL7 meeting, served to jump-start discussion, draw out opposing views and ultimately increase the chances of reconciling objections and getting an acceptable proposal the second time around, he says.
The breathing room also helps to "assuage the fears of people who thought (the proposal) was being railroaded by the federal government," Rishel says.
Underwood says government pressure is greater now, and the implicit understanding is that "most likely this next ballot is going to pass." That means the authors need to get it right, she says.
A catalytic moment
For years, if not decades, government and industry leaders have lamented the lack of a computerized patient record and spoken in generalities about the need for progress. But adoption of clinical information systems has been slow and adoption of standards slower.
The IOM's 1999 report on the prevalence of medical errors in healthcare highlighted information technology as pivotal to reducing medical mistakes, and the sequel in 2001 on reorganization of the healthcare system hammered harder on the need for electronic patient records. But the IOM had issued a call for computerized patient records as far back as 1991, without much effect.
However, actions have been speaking just as loud as words at the federal level during the past year, starting with Thompson and filtering down to the CMS, Tang says. "Everybody seems to believe that this is different from all the generalities of the past," Tang says. "That passion in his gut is the real difference," he says of the HHS secretary.
The turning point came last year when Thompson became convinced of the need for a national health information infrastructure to transform healthcare quality and shore up readiness for bioterror threats, says John Lumpkin, chairman of an advisory panel to HHS, the National Committee on Vital and Health Statistics, that had recommended such a national initiative as early as mid-2000. Lumpkin had met with Thompson to discuss the project's importance.
In early March, President Bush talked about his commitment to gathering industry experts to explore how IT can make a difference in healthcare, says Stephanie Reel, vice provost for information technology and chief information officer of Johns Hopkins University in Baltimore. Within days, senior clinical and executive leaders from consulting firms, healthcare IT companies and hospitals were being rousted to attend a meeting with Scully and other government officials on a week's notice to discuss the industry's record on adoption of electronic health records. "In my mind it sounded a little bit like cause and effect," Reel says.
"It was a watershed meeting because it shook up the troops," says Marion Ball, a longtime hospital CIO and now a consultant with Healthlink, a Houston-based IT advisory firm.
Some saw the meeting as a dressing-down by Scully; others say the CMS administrator was trying to determine what the federal government should do to help move the industry forward.
"There must have been a hundred people in the room," Ball says. "Scully, he ruled the roost. He was very direct and matter-of-fact."
Stephen Lieber, president and CEO of the Healthcare Information and Management Systems Society, says Scully "chided" industry leaders and "called us on the carpet for healthcare's failures of the past."
"Mr. Scully was calling it not only the way he sees it but the way it is," Lieber says. "He was very straightforward, very forthright that 'You need something to move you along and we're willing to do that.' "
But Marchibroda says Scully and other officials were just trying to get impressions of how healthcare industry leaders would react to the government's plans to influence adoption of standards in crucial areas of healthcare IT. Scully also wanted to float the idea of incentives to foster deployment of electronic transactions and health records, she says.
"It was very simply Tom taking the temperature," says Scott Young, then a senior clinical adviser to the CMS Office of Clinical Standards and Quality. Young now is an adviser to the Agency for Healthcare Research and Quality, a division of HHS.
Tension about how to proceed
To many, the temperature rose when Scully compared lagging private efforts in adopting electronic records with a successful decade-long effort by the Veterans Affairs Department to improve quality of care and measure clinical performance with the aid of a homegrown clinical information system known as VISTA.
"He said, 'Look, guys, if the VA can do it, why can't you?' " Ball says. "He was devastatingly clear in saying that it was a standard that (government officials) were going to make everyone live up to."
Marchibroda says Scully was trying to represent the problem of clinical IT adoption as solvable and "referenced VISTA as a low-cost example of one method to move into the area."
Not many saw it that way in the conference room at the Hubert H. Humphrey Building. "The clear message he said was, 'If you can't do it, we'll use VISTA. ? We're not going to wait a whole lot longer,' " Reel says. To that, industry representatives "reacted with a fair bit of passion," she says.
Rishel says discussion focused on the prospects for "a revenue-neutral incentive for the use of an electronic record" and that if government officials "want to be fair in this incentive, they have to have criteria for determining what the goal is."
But he says it was clear at the outset that the incentive goal applied specifically to those using VISTA, which is in the public domain, or another so-called "open source" computer solution not tied to any particular vendor.
Vendor representatives and hospital information officers countered that the lack of IT adoption wasn't related to software but more a problem with stiff implementation costs--traceable partly to lack of industry standards and the resulting complexity--along with the obstacles of getting the medical community to change its culture and embrace computers as clinical tools, Reel says.
That created some common ground, participants say. Another purpose of the meeting was to test reaction to an imminent announcement that HHS, the Defense Department and the VA were about to rally around common sets of standards for exchanging computerized information, Marchibroda says.
A coalition of more than 90 private and public healthcare organizations already had reached consensus in September 2002 on the same set of standards the federal departments identified. And the health statistics advisory committee had isolated federal action as the spark needed to get the industry moving in a singular direction.
Four days after the meeting adjourned, Scully peppered an address to the Federation of American Hospitals with calls to work with government to develop standards for electronic health records.
That same day, HHS formally announced the federal standards-forging effort as part of a larger program called the Consolidated Health Informatics initiative. At an IT town hall meeting in Detroit, Thompson expanded on the standards effort, presenting it as part of "a vision in which physicians can focus on the quality of their care, not the quantity of their paperwork."
Listing what he said were the major medical revolutions of each century--vaccinations in the 18th, knowledge of disease transmission in the 19th, antibiotics in the 20th--Thompson said he was "convinced that the medical revolution of our children's lifetimes will be the application of information technology to healthcare." He added that "this is the year we can turn the corner" on that vision.
In July, HHS announced it will pay $32.4 million to license a leading database of clinical terms and definitions called the Systematized Nomenclature of Medicine, or SNOMED, and make it publicly available for free. That promised to gradually remove millions of dollars in upfront expense and annual information technology maintenance costs now devoted to translating terms from one computer system to another (July 28, p. 31).
At the same time, HHS launched its drive to design a standard model for an overall electronic health record, which it also will share free with all sectors of the U.S. healthcare system.
Financial support for that initiative includes a $100,000 grant from HIMSS, a matching $100,000 from the CMS and $50,000 each from the VA and from the AHRQ, the latter through a grant from the Robert Wood Johnson Foundation, HIMSS President Lieber says.
Multiple needs for standard IT
The possibility of IT incentives that the government unveiled in March had taken form over a period of months as the CMS and HHS discussed how to foster the reforms laid out by the IOM in its two reports on safety and industry change, Young says. But whenever the idea of basing incentives on deployment of an electronic health record came up, nobody knew what it encompassed, he says.
"We really need to start defining this as a primordial step," Young says. "You can't even design a testable question without it."
Though he left the CMS shortly after the March 17 meeting to take the AHRQ position, Young remembers that the agency "recently started thinking about doing this in an ambulatory setting, not as a demonstration project but more as a research project."
Regardless of whether the federal government decides to authorize financial incentives or rewards for IT deployment, observers say, the standards movement could supply some needed propulsion by making clinical information advances quicker to purchase and install. They also could help make it unlikely that today's computer investments will be rendered obsolete in the future because of shifting technical and functional priorities.
"It's important for both the buyers and sellers to at least have an idea of what each other is talking about," says Barry Hieb, a Gartner consultant. With a common basis for starting negotiations, "the vendors have a little better target to shoot at," Hieb says. And with a baseline level of agreed-upon attributes of such a complex system, providers are "protected at a certain level if it doesn't achieve that," he says.
Providers also could avoid placing losing bets on IT purchases that turn out to have little staying power.
"One of the deterrents beyond the actual cost investment required has been the experience and fear that many have that the investment they do make will prove to be a dead end, a bottomless pit, a mistake, because technology or standards will move away from the direction of the vendor or the system they deploy," IOM President Harvey Fineberg says.
An important factor in lowering the barrier to investing in healthcare IT, he says, is "to have in place the kinds of standards and national assurance that when you as a hospital make this investment, you can be confident you're building in a way that will fit, that will endure, that will not put you in a cul-de-sac from which you cannot escape and you just wasted a lot of money."
Fineberg's comments came in a wide-ranging interview in July with Modern Healthcare on issues the IOM is planning to tackle during the next few years, including the priority of healthcare IT.
Among other projects, the IOM is readying a report on data standards that closely tie the issues of safety in patient care to IT tools, says Tang, who chairs the IOM panel compiling the report. The same IOM committee authored the HHS-commissioned request for key capabilities of an electronic health record.
Advocates of using accepted clinical guidelines for treatment of disease conditions as a marker of quality care say the data-collection burden now emerging from trial runs demonstrates how automation of clinical information can grease the way for proliferation of performance measures--and how lack of computerization can stunt its growth.
Agencies rushing into the area of clinical performance measurement include the CMS, the Joint Commission on Accreditation of Healthcare Organizations and the National Quality Forum.
The Washington-based NQF drafted 13 measures of quality nursing care early this month from a pool of 57, partly on the basis of importance and relevance to the care process but also with consideration for the burden of collecting the necessary data (Oct. 6, p. 8). Much of the resistance to the remaining measures involved how to collect the data, typically by manually searching records, says Lillee Gelinas, vice president and chief nursing officer of healthcare alliance VHA and an officer on the selection committee.
It costs about $40,000 a year in nurse time for a 300-bed hospital in Maryland to collect data from records for the reporting requirements on recommended care for pneumonia and heart failure, says Susan Glover, vice president and chief quality officer of Adventist HealthCare, Rockville, Md. That includes the duplication of completing forms with the same information for the CMS, the JCAHO and state agencies, she says.
With increased requirements on the horizon from those agencies as well as business coalitions such as the Leapfrog Group, "there's a curve up on the data abstraction burden," Glover says. An electronic medical record's main purpose would be to support daily clinical care, but "our CEOs are acutely aware of the secondary benefit of moving to the (electronic medical record)--for the data capture."
Adventist is in the beginning stages of such an electronic system, which she says would capture much of the required data from daily operation and allow harvesting of information that's already there through automatic compilation of whatever data is needed. That's a far lesser burden than hunting through records for each report, she says.
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