MEMPHIS--When a 27-year-old pregnant woman arrived in the emergency department of a hospital complaining of severe abdominal pain, doctors suspected a miscarriage.
But the diagnosis quickly changed after the woman's medical records were retrieved from a secure Web site. Two days earlier, the data showed, the woman had undergone an ultrasound test in a doctor's office. While inconclusive, the test suggested a life-threatening possibility: a ruptured tubal pregnancy.
When he saw the results, Jerry Edwards, the emergency physician on duty at Saint Francis Hospital, rushed the woman into surgery rather than waiting for new tests. "The information saved a life that day," he says.
The Memphis area is one of a growing number of regions or states with a health information exchange, which enables electronic patient data to be shared among hospitals and physicians. Nearly all of the hospitals and public clinics participate, which allows their emergency department doctors and other authorized personnel to call up patients' blood tests, imaging scan reports and hospital discharge summaries. The three-year-old exchange is helping doctors make better decisions and avoid wasting money on duplicative tests. Records for about one million people have been collected so far.
Memphis is shaping up as a critical test at a time when emerging exchanges are looking to the federal government for capital. The $787 billion federal stimulus package contains $19 billion for health information technology, including $300 million for exchanges, sometimes called RHIOS, short for regional health information organizations.
Data exchange capabilities already exist within large medical organizations such as the U.S. Veterans Health Administration. But information sharing among unaffiliated institutions is rare because of technical, economic and legal challenges. Some hospitals and physicians worry that sharing information could weaken bonds with their patients, or make them vulnerable to lawsuits if private patient data were to fall into the wrong hands. Many providers lack the millions of dollars needed to install electronic records and their systems, built by competing companies, often don't talk to each other.
The Memphis project has succeeded so far because it worked around hospitals' existing systems and didn't require them to switch to a common system. Memphis also moved forward without waiting for the completion of government standards to connect competing software companies' systems. The project has strong backing from Democratic Gov. Phil Bredesen, a self-described "wonk" who started his career as a computer programmer. "Technology won't fix our health care system, but it's a necessary component," the Democratic governor said recently in an interview in his Nashville office.
Over the past decade, however, many similar efforts have flopped. A high-profile venture in Santa Barbara, Calif., shut down after millions of dollars were spent. Such failures are spurring fears that the Obama administration is preparing to dish out billions of dollars for half-baked projects on the assumption that the technology will eventually save money. The projected cost savings are "more theoretical than proven," says Julia Adler-Milstein, a health policy researcher at Harvard University.
"I'm hugely skeptical of these projects. They tend to be interesting science experiments by well meaning people but with no economic justification yet," says Benjamin Sasse, a professor at the University of Texas's Lyndon B. Johnson School of Public Affairs, and a former assistant secretary at the U.S. Department of Health and Human Services.
Doctors and hospitals want to deliver good care, but it's hard to get them to embrace--let alone pay for--changes that run counter to their own economic interests, he says. And duplicative medical tests drive up volume, which generates revenue. "You won't change behavior without changing the payment systems," he warns.
There are about 50 operating RHIOS today that are all different, says Adler-Milstein. Among the oldest are the Indiana Health Information Exchange and HealthBridge in Cincinnati. Initiatives are emerging in nearly every state, with state or local networks formed or about to launch in such places as California, New York, Delaware, Massachusetts, Maine and Rhode Island. Eventually, the government wants to create a national network by linking all the RHIOS together.
Memphis is one of the more active exchanges, but even its future is uncertain. Its initial funding runs out in September, though it's hoping for a one-year extension. After that it needs to earn its keep by collecting fees from hospitals, or perhaps charging health plans on a per-member basis. Annual operating costs are running at about $3 million.
"We're living on the abyss. We might not be here in two years," says Mark Frisse, director of the Memphis project and a professor of biomedical informatics at Vanderbilt University in Nashville.
The Memphis exchange provides access to the records of people who have been treated in any of about 30 clinics and hospitals. Patients are given an opportunity by each facility to opt out of the system, but only a few hundred have done so.
Software interfaces translate data from each site into a standard easy-to-read format. An electronic identification token is required to securely log onto the exchange Web site from any computer terminal. Up pop entries for patients who have just registered at the front desk. Records also can be pulled up using a patient's name or Social Security number.
Christopher Sands, an internal medicine hospitalist at Methodist University hospital, has made the exchange part of his regular routine. When he arrives at about 6 a.m., he logs onto the exchange to dig out records for patients who were admitted the night before. He prints out their reports and attaches them to the patients' chart.
"Patients are sometimes confused about what they were told" about a previous hospital visit, Sands says. Finding lab and pathology reports, and especially discharge summaries, "is gospel," he says. He cancels diagnostic tests, including expensive radiology scans, when he finds one was done days earlier at another hospital.
Another benefit: spotting suspecting drug abusers who sometimes come to emergency departments complaining of pain in hopes of getting narcotics. Sands says he recently decided against a battery of tests for a 37-year-old man who complained about pain after records showed he had just had a complete workup while spending a week at another hospital.
Physicians say their patients are delighted that their records are online. Ron Bolen, a 64-year-old furniture salesman who suffers from diverticulitis, was able to stay out of the hospital recently after Edwards ordered a CT scan and compared it to the results of three others performed at other facilities. "He told me those records influenced what he did," says Bolen, who went home that night with painkillers and antibiotics.
The exchange has had a few unintended consequences. Baptist Memorial Hospital says a disgruntled patient dinged it on a satisfaction survey. "She said she had been to three hospitals and we had given her the least amount of care," says Mark Ottens, a nurse manager who reviewed the complaint. The woman's online records indicated that she had already been tested at other facilities that same week for the same physical complaint.
The Memphis exchange grew out of a major policy speech that Bredesen gave in February 2004. Costs of the state's health care program for the poor, called TennCare, were spiraling out of control, he told the state's lawmakers, as he outlined an array of cost-saving steps. (Ultimately, huge numbers of people were cut from the TennCare rolls, a move that ignited fierce controversy.)
Deep in his speech, Bredesen talked about the importance of harnessing technology for better results. Imagine a system, he said, where technology helps spread the use of best medical practices by all doctors. When a practitioner who uses such technology does something "that he learned in medical school but is no longer the preferred way, it is flagged and he is referred to the research," he added, noting that Vanderbilt University, a few miles away, was a leader in the emerging field of medical informatics.
The reference caught the attention of Vanderbilt's informatics wizards, who invited the governor across town for a briefing. The group made a case for improving care and saving money in the three-county Memphis region, which has a large TennCare population.
That summer, Bredesen convened local health care leaders in Memphis and told them that "this is something we need to do." Frisse, who had been recruited to Vanderbilt to lead the effort, says the governor's prodding was crucial. The hospital CEOs were competitors, not team players. "They didn't think it would work," Frisse says.
A few years earlier, a similar project had bombed. So when the hospital CEOs gathered to discuss the governor's proposal, they talked first about why the first effort had failed. "It had nothing to do with technology; nothing to do with software development, and everything to do with learning how to work together and trust each other," says Bob Gordon, executive vice president of Baptist Memorial Health Care Corp.
Sharing proprietary data is a sensitive issue for hospitals. They all agree that it's the right thing to do for patients, but they're conflicted about whether it's a healthy step for their business. Some hospitals worry that a rival might use proprietary information to lure lucrative patients through targeted marketing, or to gain advantage in negotiations with managed care plans. "The mind conjures up all the terrible things that can happen," says David Archer, chief executive of Saint Francis Healthcare, part of Dallas-based Tenet Healthcare Corp.
But despite their reservations, the hospital executives started coming regularly to joint meetings, spurring their chief lieutenants to cooperate with their counterparts. The MidSouth eHealth Alliance was created in late 2004 and funded with $7 million from Tennessee and $5 million from the federal Agency for Healthcare Research and Quality, part of HHS. The Memphis exchange is one of six demonstration projects funded by the agency.
The board, guided by Frisse and the Vanderbilt team, made a series of key decisions. Most importantly, they didn't try to make the system do too much. Other exchanges have stalled because they "tried to build version 10.0 before there's a version 1.0," says Frisse. Vanderbilt programmers designed interfaces around the hospitals' technology, so they didn't have to switch to a common system, or make new investments. Each participant retained control over its own data, with the power to shut off outside access.
There are now about 400 users, including emergency room physicians, nurses and authorized clinic personnel. But utilization could be significantly higher and Frisse's team is constantly looking for ways to make the system easier for physicians to use.
Meanwhile, the trust among local healthcare organizations has improved so much that they are discussing ways to cut costs by centralizing certain administrative functions, such as management of the electronic security tokens, says Jill Eugena, the information security officer at Christ Community Health Services, which operates five clinics in the Memphis area.
But the day of reckoning is coming for the exchange. "The biggest thing we're wrestling with is how to fund it permanently," says Archer, the St. Francis CEO and a member of the exchange board. One internal study shows that the exchange is saving at least $500,000 a year by avoiding duplication of certain high-cost imaging tests. Frisse says those are the savings he can document, but that the total is much greater.
The savings are shared by the federal Medicare program, the state TennCare program and private health plans, which all pay for care in the facilities. The board is discussing ways to obtain financial support from all the payers, including the state's biggest private insurer, BlueCross BlueShield of Tennessee.
"The jury is still out," on health information exchanges, says Bredesen. But they may turn out to be so valuable to society that they should be supported by taxpayers like a lighthouse, public utility or major highway.
Some Memphis physicians are aghast at the possibility that the exchange could be unplugged. "I would mourn," says Edwards, the Saint Francis hospital emergency department director.