The reaction of a handful of physician leaders and informaticists to the national information technology plan unveiled Wednesday by IT czar David Brailer, M.D., was largely positive, but not universally so.
"There was a little bit of religious zeal there, 'Let's everybody get on board with electronic health records,'" said William Jessee, M.D., president and CEO of the Medical Group Management Association.
But the atmospherics were better than the bottom line, according to Jessee, who remained underwhelmed.
"The presentation was very long on strategy and short on specifics," said Jessee. "There was a lot of hype and a lot of enthusiasm, but the truth is, there is going to need to be a massive infusion of funds, but there were little details where that was going to come from."
"Remember what Cuba Gooding (Jr.) said, 'Show me the money.'"
Jessee also noted that CMS Administrator Mark McClellan, M.D., talked about funding some Medicare demonstration projects in which Medicare would pay physicians for using electronic medical records systems.
"On Jan. 1, physicians are going to see a 5% across the board pay cut from Medicare. That's not going to help much."
William Bria, M.D., is medical director of clinical information systems at the University of Michigan and president of the 1,300-member Association of Medical Directors of Information Systems, a professional association for physician leaders in applied medical informatics.
Bria said informatics "has been waiting for over 40 years for a clear strong voice to articulate a national agenda for the needed revolution in American medicine to achieve improvements in the quality of daily care by the integration of information technology into the care of every American, whether in a university hospital or rural practitioners office."
In his plan, Brailer "met that challenge," Bria said.
He said Brailer's his four-point program, which called for introducing information tools into clinical practice, electronically connecting clinicians to other clinicians, using information tools to personalize care delivery, and advancing surveillance and reporting for population health improvement, "is the opportunity in our generation to move beyond the disconnected, proprietary history of healthcare information systems to a national information network that will ensure accurate, secure , patient centered information throughout America."
"Our organization, (AMDIS) has been focused on achieving improvements in the quality of U.S. healthcare by the integration of HIT into the daily practice of all clinicians," Bria said. "With Dr. Brailer's landmark clarion call today, we now appear to have the national will and resolve to achieve through HIT to deliver on the promise of safe, quality, and secure healthcare for all Americans."
David Kibbe, M.D., who heads Center for Health Information Technology for the American Academy of Family Physicians, said Wednesday's meeting at the National Health Information Infrastructure summit in Washington, D.C., where the Brailer plan was released, didn't quite have the fervor of a tent revival, but "there certainly was a call for action and quite a lot of response."
Kibbe noted that not only Brailer, but other key speakers at the conference, including HHS Secretary Tommy Thompson and Sen. William Frist, M.D., (R-Tenn), alluded to the importance of extending healthcare IT to physicians in group practices.
"That was new," Kibbe said. "I think this was really the first time at one of these grand events that the pivotal role for the small and medium sized physician practices was discussed.
"It came from Brailer's mouth. In his list of four major areas, he specifically mentioned the importance of small and medium sized practices and of them acquiring information technology," Kibbe said.
Frist, meanwhile, noted there were 900 million patient encounters a year in ambulatory care, Kibbe said. In the past, discussions about healthcare IT have typically centered on hospitals, "so there was a balance that we in the American Academy of Family Physicians have felt was lacking in the past."
Kibbe said he was satisfied with the limited role Brailer outlined for the government in promulgating healthcare IT.
"It is primarily the responsibility of the private sector to adopt standards and see that they're implemented and I think the government has a role to encourage that and facilitate it, but none of us wants the government to come in and mandate things we can't live with," Kibbe said.
"I think the government has a very important role, though, in financing healthcare in small and medium sized practices. Senator Frist mentioned that as well, that there is a requirement that we change our tax structure to facilitate those changes," he said.
Howard Landa, M.D., is a physician informaticist with Hawaii Permanente Medical Group, and is a member of the board of directors of AMDIS.
For years, Landa said, medical informaticists have extolled the virtues of healthcare IT and been ignored, but finally they have "a voice in the darkness" in Brailer, whose plan "is a call to arms for medical informatics."
"In the first page of the executive summary he points out the potential for the reduction of preventable medical errors and treatment variation," Landa said. "While the former has gotten much press since the IOM report 'To Err is Human,' it is the latter that really hits home. The waste within the system is substantial, especially when you look at our per capita spending on healthcare and measure the success (or lack of it) that we have obtained in improving the nation's health.
"There is a ridiculous delay in the adoption of evidence-based medicine driven by many factors," Landa said. "One of the most prominent is the lack of a mechanism for getting the information in a usable form to clinicians, and a well designed EHR can help substantially.
"Among Dr. Brailer's first goals is to incentivize EHR adoption. This is one of his most important potential strategies. Legislation such as creating a Stark 'safe harbor' for EHR implementation will substantially increase adoption and reduce the risks and costs associated," Landa said.
"He also advocates fostering regional collaborations. He did this in Santa Barbara and it has also been done in Indianapolis with great success. In my own environment (Hawaii) we have 3 major healthcare systems implementing the same EHR. It would be criminal not to have effective data interchange due to political issues at a time when we have substantially reduced the technical barriers.
Landa said he hopes Hawaii will take advantage of opportunities and funding being suggested in Brailer's plan to become a regional health information organization and "foster this kind of information sharing and the associated potential for care improvement."
The Brailer report advocates establishment of a Health Information Technology Leadership Panel and Landa said that he hopes Brailer, an AMDIS member from the early days of the 13-year-old organization, will look to the organization for help.
Landa said he was "less optimistic" about other parts of the Brailer plan.
Developing a national health information network with intercommunication tools and effective data interchange standards is a laudable goal, but it is "a great deal to bite off."
"The data interchange for HIPAA has been much more difficult and taken longer than anticipated, and these are orders of magnitude simpler data sets then those required by clinical applications," Landa warned.
"I am also questioning whether the resources exist to drive this sophisticated technology deep into rural areas as suggested.
"While delivering on the promises in this report will be a Herculean task, at least now we have the framework to develop a system to better utilize the burgeoning technology and dwindling resources available."
Michael Shabot, M.D., also an AMDIS board member, is director of surgical intensive care and medical director, enterprise information services at Cedars-Sinai Medical Center in Los Angeles.
Shabot called Brailer's report "a landmark . . on problems with and solutions for the adoption of healthcare information technology in the United States."
Shabot said Brailer clearly stated the key reasons for inadequate adoption of IT early in the report: high costs, medical errors, variable quality, administrative inefficiencies, and lack of coordination.
"Dr. Brailer provided a general framework for solutions to these problems," Shabot said. "All his points are cogent and important, but I believe the most important is the provision of incentives to provider institutions and physicians for the adoption of HIT.
"Brailer correctly notes that HIT is considered a risky investment and he outlines several ways to reduce the risk. But even with reduced risk, HIT is expensive in cost, time and effort.
"Dr. Brailer's proposed solutions, including the provision of grants for regional information sharing, low rate loans for EMR system acquisition, updating the Stark laws to allow partnerships between physicians and hospitals for HIT adoption, differential payments to providers based on use of EMRs and e-prescribing, and pay-for-performance plans that include EMR use are critical to the adoption of electronic health records on a large scale," Shabot said.
But Don McCanne, M.D., past president of Physicians for a National Health Program, which supports a single-payer, government sponsored universal healthcare system, saw things a bit differently.
In his daily newsletter, McCanne noted that the Veterans Administration, a government-run healthcare entity, "is far ahead of the rest of the nation in developing and utilizing an integrated IT system."
He said the Brailer report, "should alarm us all. Although we all agree on the importance of an integrated IT system, the Bush administration is limiting the role of the government to being an enabler that encourages the private sector to develop a successful business model. Rather than higher quality at a lower cost, we'll end up with mediocrity at a much higher cost, wasting even more of our health care dollars."
McCanne, in a telephone interview, said there is a role for private sector entites, to develop IT and contract with the government to run some of them. But the government, he said, "ought to pretty much, and I hate this word, dictate the formats."
"When they put the committees together they should say this is the way we're going to do it; this is the way the records are going to connect," McCanne said.
"And the programs to run these things out to be in the public domain, free, so then the cost would be negligible," he said.
To obtain a copy of Brailer's 178-page report, click here.