When Flora Jones visited two doctors in two days, her charts went straight into a computer database — and pointed the way for Connecticut and the rest of the nation.
Jones (not her real name) is a patient at the Hill Health Center n New Haven. She has diabetes.
Her primary care provider, physician’s associate Gary Spinner (shown in file photo with a different patient), saw her one day recently. The next day she was seen in the ophthalmology clinic.
“Were we not using a system that allows everybody to have access, the paper chart would have gone to medical records in the afternoon, then been filed and put back on the shelf,” Spinner said. “But meanwhile the people in opthalmology who needed her record would have had a difficult time finding it.
“All the lab tests I had done on that visit were sent to me electronically. I reviewed them and signed off on them, and through an interface they were entered into the patient’s record. All this happened without anyone touching a paper record.”
Proponents of electronic medical records promise it will improve health care and save money in the long run. But getting there will cost billions. And many are concerned about patients’ privacy.
And connecting small practices to a master database is proving to carry its own unforeseen challenges.
Both the country and the state will be working to meet that challenge in coming months.
The economic stimulus bill becoming law this week contains some $20 billion for putting medical records online.
And in January 2006, Governor M. Jodi Rell established eHealthConnecticut. Its goal is to bring hospitals, private medical practices, pharmacies and testing laboratories together to create an electronic regional health information organization. The organization would link them all together and promote sharing of health care information, while protecting patient privacy.
In addition to Rell’s experiment, in Connecticut the Universal Health Care Foundation has made widescale digitization a central part of its SustiNet proposal for achieving statewide universal coverage.
Scott Cleary, program director for eHealthConnecticut, said the organization is working on five projects, all related to creating and sharing electronic health information among all relevant entities around the state. (To read more, visit the website and click on “Projects.”)
Cleary said much progress has been made. Several insurance providers — Aetna, HealthNet, Anthem, Connecticare and United Health Care — are providing funding and data to help create a database, known as the Connecticut Health Quality Cooperative.
“It’s being piloted statewide this spring,” Cleary said, “and will be focused on primary care physicians. The information will be posted to a private website, available only to physicians. We hope to have public reporting capabilities in the future, so anyone can go on-line and view quality reports by provider and become more empowered consumers.”
Trickier: Small Practices
A special challenge is the structure of health care delivery in the state. “Connecticut is the land of small group practices,” he said, where about two-thirds of doctors have no more than two partners, and only one in five private doctors is online. “We need to figure out incentives for people to more rapidly adopt digital health records.”
Cleary said one incentive is that Medicare is offering a 2 percent increase in reimbursement rates for physicians who use e-prescribing. One version of the federal stimulus package under consideration by Congress includes incentives of $41,000 per physician over five years for Medicare and Medicaid reimbursement for those who convert to digital health information technology. (That provision may die in negotiations between the House and Senate.)
As for existing connectivity, Cleary said, “Many hospitals have their own information exchange initiatives to connect with their private physicians who have admitting privileges. That’s great, but kind of a hub and spoke configuration; what happens if a doctor works at two different hospitals?
Chris Bruhl, president and CEO of the Business Council of Fairfield County, outlines some other problems as well. He said doctors in small practices could have different data base programs, and the record itself has to be standardized so all the component parts of the health care system can communicate with each other. He said progress is being made toward a national standard.
“But where do the small doctors’ offices fit into that? There’s a conversion cost. They have to convert their old records into digital formats and then you’d have some kind of second round of assembling the records of each patient, for example, if I have a cardiologist and a primary care physician and an ophthalmologist — my medical record includes all of those and therefore the digitized standard used in each of those offices needs to be the same. The smaller the practice, the higher they perceive the cost to be and the tougher the training curve.” He predicted It will be dealt with eventually, but it won’t necessarily be smooth sailing.
Cleary said, more hopefully, “This year we are going to get this Health Information Exchange piloted by the end of this year among doctors, hospitals, pharmacies and labs. It’s not the only information exchange in the state, but it is statewide — a network of networks.”
Health Clinic On Board
Gary Spinner, chief operating officer of New Haven’s Hill Health Center and a practicing physician’s associate (PA), sits on the board of eHealth. Hill Health is in the process of converting to an all-digital record system.
“The advantages are huge,” he said, “especially for an organization like Hill Health Center where we have multiple sites. It’s not uncommon for paper charts to get misfiled. There’s nothing worse than having a patient ready for an exam and being told the file’s not available. [Electronic] patient records are always accessible to providers, and they allow providers to have simultaneous access, which is a big thing.”
He added that electronic interfaces also allow providers access to information 24 hours a day, which is especially useful in an emergency. And digital records document all ancillary procedures, such as lab tests or letters from consultants.
Hill Health Center is ahead of many other health providers in this process, but it has a ways to go. Spinner said he expects medical records will all be on-line shortly, and then the center will focus on behavioral health (mental health and addiction services) records. He noted that the center’s dental records were digitized eight years ago.
Spinner mentioned one of his own patients to illustrate very concretely the advantages of the new system. She is an 80-year-old woman with diabetes, whom he saw last November. The next day she was seen in the opthalmology clinic. “Were we not using a system that allows everybody to have access, the paper chart would have gone to medical records in the afternoon, then been filed and put back on the shelf, but meanwhile the people in opthalmology who needed her record would have had a difficult time finding it. All the lab tests I had done on that visit were sent to me electronically; I reviewed them and signed off on them, and through an interface they were entered into the patient’s record. All this happened without anyone touching a paper record.”
Who’s Watching?
Critics or questioners of e-health records are less sanguine about privacy protection. While small slip-ups might be more likely with the current paper system, digital records present the possibility of massive unauthorized exposure.
The American Civil Liberties Union has made that case. It calls on Congress “to require patient control of medical records and compensation for privacy breaches to be a part of the standards set for converting to electronic patient records.”
A recent editorial http://www.nytimes.com/2009/02/01/opinion/01sun2.html?_r=1&scp=1&sq=Your%20E-Health%20Records&st=cse in The New York Times echoed that concern. It cited possible scenarios like unscrupulous individuals buying and selling data, or employers not hiring prospective employees who they learn require expensive medical care.
Hill Health Center’s Spinner is less worried.
“Whether something’s electronic or on paper, all the same policies and procedures to keep health information secure continue to exist, so only people who have a need to know will have access,” he argued. “We trust our financial records to e-security and we’re not afraid to put money in a bank. The efforts to protect health information are at least as fastidious as that in terms of who’s allowed access.”
To some advocates of e-health records, the current paper-driven system is a good advertisement for a change when it comes to protecting privacy. “Do you think the current system is secure,” eHealthConnecticut’s Cleary asked, “with people faxing your private information all over the place?”
$100 Million Quest
Debates about cost abound, as well. Solid cost estimates for digitizing all the players around the country who need to be connected are hard to come by. Cleary predicted it would cost at least $100 million to implement statewide, including for private physicians and hospitals to be online.
A piece of that $100 million is the Health Information Exchange, the central shared service. He added that it will be worth the money. “The value is there. You have to get over the hump where nobody’s connected to a critical mass where enough are connected — then the value explodes.”
To illustrate, he cited a technological advance from a generation ago: “If you have a fax machine, but you’re the only one, it’s worthless.”