Dr. David Blumenthal, the Obama Administration's national coordinator for health information technology, can recall the day he became a true believer in the potential of electronic health records. He was about to order a lung scan when the computer in his Boston hospital alerted him to a similar image already in the file. The patient was spared an unnecessary dose of radiation and the health care system was spared the cost of an unnecessary test.
Such experiences, he said, "suggest… how small victories… can lead us to be better physicians, higher quality physicians." That thinking is informing his actions as head of the Office of the National Coordinator, which wants doctors to use electronic medical records as part of a broader effort to modernize the health care system.
Blumenthal's office, along with two advisory panels, reported Thursday on their progress in developing the framework for the $33 billion health information technology initiative. The undertaking, which began with the February passage of the stimulus bill, has required that they define key terms, such as "meaningful use," that will guide doctors as they adopt electronic health records. They are also setting the minimum requirements physicians will have to meet in order to receive financial incentives.
For Blumenthal, the most difficult challenge will be to convince doctors that participating is worth it. Even with assistance from the federal government, physicians will have to spend big money on the digital transition. And the return on their investment is murky. Blumenthal must show doctors how this program is good for them by identifying goals for improvements, and ultimately, savings in their practices.
With the stimulus law, Congress laid out two goals -- improving the quality of health care and lowering costs. Lawmakers also offered some specific guidance on how to proceed. They wanted the funds to be used to create, for instance, platforms for e-prescribing and for the coordination of care -- not simply to buy new software. But other than those few stipulations, Congress left Blumenthal in charge.
On Thursday, in a key step, the Health Information Technology Policy Committee -- one of the panels -- reached consensus on the definition of meaningful use. A multipage documents lays out 28 specific objectives. For example, physicians would have to track and report measures such as the percentage of diabetic patients with controlled hemoglobin A1c levels, or women older than 50 who have had recent mammograms.
Their systems also should help prevent dangerous drug interactions, provide clinical decision support and track at least some efficiency measures, such as how often the doctor prescribes generic drugs instead of more expensive brand name alternatives. In addition, the systems should show an ability to exchange health information with other providers or health systems where possible and make electronic records available to patients. The Centers for Medicare and Medicaid Services will use this definition and set of objectives as it drafts its proposed rule, due out in December, for the stimulus health IT funding.
This approach reflects Blumenthal's emphasis on quality as well as his belief that better outcomes lead to healthier patients, fewer errors and hospitalizations, and lower health care costs. He argues the resulting quality improvements would automatically achieve Congress' other goals of increasing efficiency and reducing the costs of health care. "The question is, is it more efficient to treat high blood pressure than not?" he said at a June meeting. "It saves so much money in avoiding strokes and heart attacks, kidney failure and complications from diabetes."
On these points, "Blumenthal has his head screwed on right," said David Merritt, a health policy analyst at Newt Gingrich's Center for Health Transformation.
Doctors would be eligible for the stimulus dollars beginning in 2011 -- in the form of increased Medicare and Medicaid payments -- only after they install the systems and achieve these meaningful uses. Eventually, in addition to the fact that they are tracking the measures, doctors may have to show actual improvements in their clinical performance to get the money. And if doctors don't take those carrots, they face a stick: without systems in place by 2015, their Medicare and Medicaid payments would be lowered as a penalty.
But Blumenthal's other, and maybe even more difficult, challenge is to demonstrate to doctors how this program is good for them. "We really need to be able to sell this…," said Neil Calman, a family doctor in New York, during the June meeting of the advisory panel. "It's really critical that we show efficiency is achieved."
There is a financial reality that makes this proposition difficult: While preventing hospitalizations, medical errors and duplicate tests would cut into America's more than $2 trillion of annual health spending, the savings would go to the insurers, policy holders and taxpayers who pay the bills, but not individual physicians.
"Office-based physicians in particular may see no benefit if they purchase and install such a product -- and may even suffer financial harm," even as their expenditures spare the government about $13 billion, in addition to other savings across the health system, the Congressional Budget Office predicted in a report March 10.
Already that reality has discouraged many doctors from making the hefty investment in e-health. As of last summer, only about 13 percent of physicians were using even basic electronic records, according to a New England Journal of Medicine study.
According to a PricewaterhouseCoopers report, Rock and a Hard Place, the average three-physician practice could spend as much as $300,000 to buy e-health software, cover training costs, and pay for upgrades over two years. But doctors are limited to no more than $44,000 in additional Medicare and Medicaid payments over the life of the program, and they have to buy the technology up front.
Dr. Ted Epperly, the president of the American Academy of Family Physicians, uses electronic records in his own practice in Boise, Idaho. He values them for what they do for his patients, not for his bottom line.
Yet, he said, "This money is going to, in good faith, get most physicians on their way there."