It's not that David Brailer, M.D., doesn't know what to do as the nation's new healthcare information technology czar. The question is: What comes first?
Just four days into the job as the Bush administration's first national health information technology coordinator, Brailer today told members of the press at the TERP 2004 trade show in Fort Lauderdale, Fla., that he's still working on a batting order.
"Coming down on the plane, I made the 15th short list," Brailer said.
While Brailer's plan is not set yet, his time frame for creating one is -- by late July, 90 days after Bush signed the April 27 executive order mandating the IT coordinator position and assigning the coordinator the task of developing a national plan to promulgate healthcare IT.
What you won't see from Brailer's office is another new government program, he said.
"We're not here to start programs. We don't have a top-down model. We live or die on what the private sector does. Because of the way our market works, you will not see me announce the backbone and say, 'Here it is, come enjoy it.'"
In fact, one administrative task near the top of Brailer's list is simply to identify all ongoing government activities that could have an impact on healthcare IT.
"I don't have a baseline yet (for) what we're working with," he said. "The first thing I'm trying to figure out is what assets I have at my disposal."
That's not to say the government won't have a role. What he's seen so far of government activities in IT has been impressive, he said.
"What sold me (on the job) was the number of things going on," Brailer said.
One challenge to rapid IT deployment that Brailer will face is where to focus government energy -- at the hospital and large medical group level, or at groups of 10 physicians or less, where the bulk of patient encounters occur but where significant barriers exist, including limited or no return on investment in IT systems and lack of support staff to roll out and maintain the systems.
Still, Brailer said, "My personal view -- and it's not policy -- is it's time to address the physician issue head-on. Physicians are the flexion point. It's time to work with those who directly are ready."
A lack of money for IT at all levels is clearly an issue, he said, but money isn't the only problem. Helping physicians financially in larger groups might be beneficial, because they have the infrastructure and the training capabilities to tackle IT implementations and succeed.
Simply throwing money at physicians in smaller groups without these capabilities "will only increase the failure rate," Brailer said. And without the communication of physicians' and hospitals' IT systems, all of the full benefits of IT won't be realized.
Brailer said regional coalitions or hospitals could provide the assistance that smaller groups and solo practitioners need.
"I am an interoperability maven," said Brailer, who spearheaded a coalition of providers in Santa Barbara County, Calif., who share patient information through a peer-to-peer network connected by a common interface.
Brailer said he planned to turn the upcoming National Health Information Infrastructure meeting on July 20-23 into a platform for policy discussion as well as a vehicle to present his strategic IT plan.
In his keynote address to about 500 tech-savvy physicians and IT professionals at the TEPR morning general session, Brailer asked the audience for help in several key areas.
First, he said the private sector should define a minimum set of EHR functions to set a floor for future government assistance to providers for IT initiatives. Putting healthcare records on a spreadsheet and calling it an EHR just won't fly with federal budget watchdogs, he said.
Also, Brailer said he needed case studies demonstrating a return on investment in EHRs.
The clinical case has been made for healthcare IT, he said, but "the amount of information about the economic benefits of these is poor at best."
Given that, Brailer says he sees a similar challenge convincing payers to participate in helping providers purchase IT systems. For individual payers, there has not been a demonstrated return on investment in provider IT subsidies, but Brailer says he intends to pitch the idea to payers and to the employers who hire them.
"I would hope health plans would see the opportunity to be the broker of the personal health record," he said. "It would be a win-win with administrative simplification.
"I clearly am going to be calling on health plans to match or exceed the government's investment in this.
"We cannot expect them (the plans) to do things that are not good business decisions," he said. "But if they consolidate and syndicate their investments in an area, then a small group of plans can actually capture and share that benefit.
"I'm pretty sure the purchasers in American are going to hear me when I call for that, because they've been calling for it for a long time."
Joseph Heyman, M.D., who heard Brailer's speech, is a member of the board of trustees of the American Medical Association and chairman of its EHR workgroup. A gynecologist in solo practice in Amesbury, Mass., and an electronic medical records system user since 2001, Heyman for the most part liked what he heard.
"He understands the importance of physician involvement in development of this stuff," he said.
Heyman said he adopted an EMR with no government or payer assistance. "For me, there was an economic imperative," he said, because he set up his solo practice in 2001 and bought his integrated EMR and computerized practice management system as a suite from the same vendor to cut office overhead. Professional associations could help provide the tech expertise and advice that Brailer noted small groups and solo practitioners lack.
While Heyman is an IT booster, "One of the concerns we have at the AMA is if there's going to be an unfunded mandate to adopt this technology."
Brailer is scheduled to address the National Alliance for Health Information Technology June 16 in Chicago.