Sharing data a big complicated step for health care system

From SouthCoast Today article October 21, 2012

To those in fully automated industries, like banking, the state’s roll out of a new health information network last week must seem sadly behind the times.

Massachusetts officials declared the Health Information Exchange open for business Tuesday by sending Gov. Deval Patrick’s medical data from a hospital in Boston to a trauma center in Springfield. The electronic information traveled halfway across the state and, just as importantly, crossed tricky medical provider boundaries.

But, the experience can leave anyone who has ever used an Internet driven technology like Facebook or even simple email wondering just how exciting it can be to send one file electronically from one organization to another?

Very exciting, say those in the health care profession.

In a medical industry that relies heavily on antiquated paper-based communication systems, being able to access up-to-date patient information whether you are a primary care physician seeing your own patient, or an emergency room doctor tending an unconscious patient you don’t know, is game-changing, they say.

“It’s quite the revolution in care,” said James Albert, vice president and chief information officer of Jordan Hospital in Plymouth. “The trend in the health care reform movement is to share information to reduce costs, reduce errors, reduce redundancy and improve overall coordination of care and ultimately to improve outcomes and effectiveness of care delivery.”

“We have to tie everybody together so we can exchange information and share information, so medical staff in LA have access to your medical record. So they know what you’re allergic to, that you had a heart attack two years ago and broke your wrist three years ago,” Albert added. “All of those things become medically relevant when you’re lying there in a coma and the ER doctor has one to three minutes to treat you.”

Jordan Hospital leaders are so confident of the benefit of shared data they’re not waiting for the state to fully build its exchange and have already begun work developing their own network, called the Greater Plymouth Health Information Network. The network will connect the hospital system’s electronic medical record software, made by MEDITECH, with other software systems being used by multiple medical providers in the region.

“At Jordan Hospital, all I want it to do is talk between my hospital physicians and my hospital, but the fact of the matter is there are far more physicians and health care providers in the community than Jordan Hospital’s own that use other systems,” said Albert. “The only way to link all of these together is if they share a common language, a common standard nomenclature of what an aspirin is or what code you use if you’re taking an MRI. Then you can electronically link them together to create a health information exchange.”

Agreeing upon a common language is one of the obstacles to a fully functional information exchange nationwide. While the state will have to deal with hundreds of software vendors, and the nation potentially even more, Albert said there are probably only five or six that Jordan will need to connect.

Also, while state and national access will be important, Albert believes most of the information exchange that takes place will happen at the local level.

“The state connectivity will help, but the connections locally between “Dr. XYZ” on Main Street and “Dr. ABC” on another street is where most care happens,” said Albert, likening connections to early phone exchanges. “Ultimately our local phone exchange, where physicians can dial each other without a toll charge, is where most of the calls are going to happen.”

To date, the state is focused on connecting software systems from some of the largest product vendors, the 15 or so who each have more than three percent of market share, including names like eClinicalWorks and Epic, Stuntz said. Secondary efforts will look to provide grants on a competitive basis to smaller vendors to also get them hooked up, he said.

The state is also offering a very low connect rate, $5 a month to individual physicians, for the information exchange, thanks to state and federal funding, Stuntz said. Large medical systems will pay a subscription fee that is negotiated with them, he said. Partners, for example, is paying $27,000 a year for all of its physicians, according to Stuntz.

Another obstacle and unanswered question for sharing communication is whether or not sensitive medical information will be accessible to a provider who is not directly sent a health record. The exchange version that the state rolled out this week allows data to be sent from one provider to another, but does not yet allow health care professionals to look up health records.

“We very specifically excluded “look up” in the first phase (of the exchange) because of privacy concerns,” said Stuntz. “We wanted to get everybody connected and exchanging information first.”

That will likely come in a later phase, Stuntz said.

“There will be an ongoing community conversation about what types of patient consent will be needed to allow look up,” he said.

Issues about privacy and security and even medical liability are other obstacles to what might seem like an easy communication system.

Albert believes many of these issues will ultimately be played out in the courts in coming years. The debates won’t just be about patient privacy rights, he said, but will also encompass liability issues for doctors who treat patients who have held back information.

In a clipboard world, doctors didn’t know what they didn’t know, he said. But now they’ll have data in front of them that will tell them if a patient has chosen not to disclose medical information.

“It’s a balance between the medical necessity of seeing information against a patient’s privacy and security rights,” he said. “That’s the part the state is still wrestling with and at the national level there are going to be an awful lot of big legal debates going on about if a doctor is being asked to treat you and you are purposefully holding back information and who is liable for what.”

At Jordan Hospital, its health information network will follow a predetermined set of rules about how much information can be shared and to whom. Patients will need to opt in to have their records shared, he said. Doctors, too, will have opt-in control over the level of information they receive.

“If you end up in our ER at 3 a.m. Sunday you have to have a rule that says does your primary care doctor automatically want to know when you’ve ended up in the ER on a Sunday,” said Albert. “If the answer is yes, all the information and notes from the ER doctor will go to the primary care doctor including lab results and images taken.”

Jordan isn’t alone in working on its own network outside of the state exchange. Two New Bedford physicians, frustrated by a system that forced them to fax and re-fax important medical information, decided to design a system of their own.

The enterprising physicians are now marketing the product to medical providers, including physicians, visiting nurse associations, medical suppliers and others. The software will also be used to train medical records students at Bristol Community College.

Drs. Arun Rajan, a neurologist and Pedro Falla, a primary care physician, both of Prime Medical Associates, described a system that takes hours every day to schedule appoints, get necessary forms signed, and get medical information needed including important test results as the motivation for creating Emerald Health LLC.

“We were looking ultimately at how to provide better patient care. So the whole thing was developed because we have so many problems and issues on how to deliver good care to the patient,” said Falla. “Communication is broken among physicians. Referrals are not done in time. I rarely get a phone call from a physician these days, rarely. They’re busy. They know I’m busy. They think that I shouldn’t bother him or if I bother him a lot maybe he won’t send me referrals. Who knows what the mentality is on the other end, but communication is completely broken.”

Emerald Health started out developing an electronic medical record system and this spring turned its attention to communication problems, developing a web-based software that simplifies the process.

While access to data is everyone’s prime goal, the first step before connecting any medical providers is making sure they are using an EMR. That transition is well under way thanks to state and federal mandates and incentives. Under the 2009 American Recovery and Reinvestment Act, physicians can receive incentives for “meaningful use” of electronic medical records up to $44,000 over five years from Medicare, or $63,750 over six years from Medicaid, for those who meet requirements.

But the transition is taking time, particularly because it can be a painful process for medical providers.

Stuntz estimates about 65 to 70 percent of Massachusetts physicians are already using some form of an electronic medical record. Albert believes the Plymouth County area percentage is higher than that, perhaps as high as 90 percent.

At SouthCoast Hospitals Group, all primary care physicians are on an electronic medical record, one developed by eClinicalWorks, as of this summer and the goal is to start working with specialists in early 2013, according to Martin O’Neill, chief administrative officer, SouthCoast Physicians Group.

The transition hasn’t exactly been easy, he said.

“There’s no other way to describe it other than it’s a painful process,” said O’Neill. “For everyone in the office, especially the provider, what they do everyday changes”¦Now they have to think about every step.”

The learning curve can slow an entire office down, reducing the number of patients that can be seen in a typical day.

“Some may never get back to that productivity level,” said O’Neill. “It gets better week by week. We’re already seeing physicians who went up in the first week back in June who are getting close to seeing the same number of patients as they (had been).”

Even without an exchange of information across networks, having data electronically accessible means being able to provide better care, said O’Neill.

“It allows us to be much more proactive in managing patients’ health,” he said. “Now you can look at a record, extract information, and see trends much more easily than you could with a paper chart.”