Health care finally moving toward efficient IT systems

by Marjolijn Bijlefeld
For Virginia Business
September 2005

The 62-year-old patient at Kaiser Permanente Medical Center in Fair Oaks has diabetes and heart disease. He didn’t bring his medications with him and can’t remember precisely what he takes. Nonetheless, his doctor, Dr. Paul McClain, an internal medicine and geriatric specialist, already knows these details.

He pulls up the patient’s entire medical chart — including lab test results, pharmacy records, specialist consultations and other relevant information — on a computer screen.

The physician instantly knows, for example, not only what drugs the patient is taking but when they have been refilled. The electronic medical record (EMR) on his computer screen adds a new dimension to a doctor’s appointment. “It’s more of an interactive appointment,” he says. “We can spend the time educating patients. We’re looking at the same information on the screen and I’m talking directly with the patient, rather than flipping through a medical file.”

By the end of the year, the EMR system that McClain is using, HealthConnect, will be fully implemented in all of the 35 locations and 1,000 doctor’s offices in Kaiser Permanente’s Mid-Atlantic region, a managed-care territory that extends from Baltimore to Woodbridge. Next year, when the system is fully online, it will include more business functions for the doctor’s offices and greater electronic communications between patients and physicians. Patients will be able to check their lab test results, refill prescriptions and have secure communications with the doctor’s office.

Studies say that extensive use of information technology in systems such as HealthConnect could save as much as 10 percent of current health-care spending. On a national tab of $1.9 trillion, that’s $190 billion. No wonder polar-opposite politicians like Hillary Clinton and Newt Gingrich are pushing the idea forward.

Before savings can be realized, a vast amount of money will need to be spent on implementing IT systems. HealthConnect, for example, is part of a $1.8 billion national investment in information technology by Kaiser Permanente. Health care is “the last industry in this country that is not technology enabled,” says Ken Hunter, chief administrative officer of Kaiser Permanente Mid-Atlantic. “It’s scraps of paper that float around and get attached to medical records,” Compounding the problem is the variety of people vying for a slice of the health-care pie — primary-care physicians, specialists, hospitals and health-care insurers. Doug Gray, executive director of the Virginia Association of Health Plans (VAHP), calls them “a disconnected, disparate group of people with uneasy partnerships. You can’t impose a solution on them.”

Unlike the highly developed IT systems in retail and other industries where barcodes can track every nut and bolt, information technology in health care is still in its infancy. Dr. Kevin Fergusson, medical director of the Virginia Health Quality Center (VHQC), a Richmond-based organization that promotes the improvement of health care, will work with doctor’s offices to adopt electronic medical records. He says current estimates are that about 10 to 15 percent of primary-care doctors have electronic medical record systems. Among specialists, only about 4 or 5 percent use the technology. During the next three years, the center’s goal is to help 5 percent of the state’s primary-care doctors implement or expand their EMR systems.
The state is pushing the initiative. Fergusson serves on Gov. Mark R. Warner’s Task Force on Information Technology in Health Care. Created last January, the task force plans to issue a preliminary report this fall on how to develop and implement a state health information system to improve quality of care and cost effectiveness. Any provider who transmits electronic data has to comply with federal privacy rules. So a password-protected, limited-access electronic medical record may be more secure than a chart lying on a doctor’s reception counter.

The federal government also is trying to jump-start the EMR movement. It will offer a low-fee EMR program to physicians. Called VistA Office, the program is a small-scale version of the EMR used in all Veterans Affairs hospitals and centers in the country. Fergusson says programs like VistA Office could help speed change. “We’ve been working in the physician office setting for six years. The rate of improvement is there, but it’s linear and incremental. It needs to be more transformational,” he says.

Several initiatives are under way in Virginia, typically led by larger integrated health systems like Kaiser Permanente. “It’s easy for Kaiser,” says Hunter. “We’re not just an insurer or provider, but both.” Easy, however, is a bit of an understatement. Implementation of Kaiser Permanente’s program started two years ago with the addition of flat-screen computers in every exam room. Now physicians can pull up a patient’s chart and use the information as a teaching tool for the patient. “You can look at how a patient has made progress on cholesterol levels over the years,” for example, Hunter says. “The hardest element in introducing a system is that you have to work very closely with the physicians and staff to prepare them for a change. For a 50-year-old physician who has never used an exam room computer, that’s a big change.”

The system, adds Hunter, has to be designed to reflect how a patient moves through the physician’s office, providing the right information when it is needed. Practitioners aren’t going to rely on the system if it is hard to use and information is difficult to find.

That concern is one reason why Hampton Roads-based Sentara Healthcare tested and refined its Sunrise Clinical Manager, a pharmacy alert system, with pharmacists instead of physicians. Sentara’s health system includes six hospitals and a managed-care arm, Optima Health Plan. In 2001, Sentara added a pharmacy alert system, which screens drug orders for their appropriateness for the patient based on lab results, dose, possible drug duplication, medication interactions and allergies. If an order falls outside of the rules, the system sends an alert to the pharmacist, who reviews the information and decides whether the physician needs to be contacted.

The vendor’s product came with 20 alerts, but the IT team constructed thousands. As a result, the system was constantly firing alerts. “If we had allowed the medical staff to see this in development stage, they would never have used it,” says Bert Reese, Sentara’s CIO. With the pharmacists’ help, the system has 550 rules. “Now we’ve honed it to be clinically relevant,” he says. Sentara reports a systems savings of nearly $440,000 in improved medication management and another nearly $200,000 in cost avoidance by decreasing drug interactions.

Sentara also is moving toward an enterprise-wide EMR, but it’s not a quick process. To push it along, Sentara negotiated with Cox Communications when it contracted for phone and cable Internet access a few years ago. “We got a special deal for doctors and staff to get high-speed Internet available at home or in their office. If doctors didn’t have high-speed access, they couldn’t use the technology,” he says, particularly since medical records often include data-heavy files and digitized radiology images.

Dr. Steven Schlossberg, a urologist, is a regular user of Sentara’s system, MD Office. “My old reality when I needed a radiology image was to go down to the film room myself or get the patient to carry the film. It was at a minimum a 30-minute process. Now with digitized images available online, I’m complaining that the system is slow if it takes a minute for the image to load.”

As physicians become accustomed to using the system, Reese says the IT department has to be able to deliver on the promise of data at the doctor’s fingertips. “Our corporate IT goal is zero tolerance for downtime. Twenty percent of our IT workers’ pay is at risk based on system availability,” he says. “Once you make the doctors dependent on the system, it absolutely has to be there for them.” There are 1,700 physicians and 4,500 staff members registered on the system, and about 60 percent are logging in at least monthly.

While EMRs can help streamline care by allowing faster access to health information as well as minimize the duplication of tests and avoid prescription errors, one of the most promising components of data collection is the development of best clinical practices (best practice guidelines, based on clinical evidence, for treating a condition or medical event) and the assurance that they’re being followed. For example, studies have shown that heart attack patients who are given a beta blocker upon arrival at the hospital have better outcomes than patients who don’t receive the drug. Providing the drug is now considered the standard of care, but is routinely done with only 88 percent of the patients. So Anthem Blue Cross and Blue Shield developed its Quality-In-Sights Hospital Incentive Program (Q-HIP) to provide incentives to hospitals that follow best practices strategies.

In March, Anthem awarded $6 million to 16 hospitals in the state for making measurable advances in patient care and safety in 40 clinical measures. It is money well spent, says Dr. Karen Remley, Anthem Blue Cross and Blue Shield medical director for external quality. “The way I look at it is that we’re changing an entire culture. Other industries have long had financial incentives tied to performance goals. That’s something that hasn’t been part of the medical culture,” she says. When hospitals show an improvement in these measured indicators in clinical outcomes, patient care and patient satisfaction, Anthem rewards them with a higher reimbursement rate.

The Q-HIP hospitals last year performed better than the national average on several indicators. For example, beta blockers were given to an average of 92.6 percent of heart attack patients at Q-HIP participating hospitals. The highest performance was 97.2 percent. In another measure, Q-HIP hospitals averaged only half the serious complication rate for diagnostic cardiac catherization — 2.5 percent instead of the national average of 5 percent. In the first half of 2005, the Q-HIP hospitals have continued to show improvements.

Forty-five hospitals are now enrolled in Q-HIP for 2005. That’s nearly half the hospitals in the state, representing about 75 percent of Anthem hospital admissions. Through Q-HIP meetings and teleconferences, hospitals can share their solutions for improvement. Remley says it’s exciting to see a hospital CFO sit down with cardiologists, ER nurses and physicians to brainstorm ways to improve the way heart attack patients are treated at every step along the way. As hospitals routinely achieve better results on some indicators, Q-HIP will expand to address others. “We’ll add maternal care. It’s not our top-dollar hospital admission, but it’s our top frequency admission, so we want to focus attention on improvements in quality,” Remley says. For now, Anthem collects the information without identifying the hospitals to each other. However, at some point hospitals might want some of this data to become public. “We’d like to be able to provide our members lists and say, ‘All seven of your local hospitals have exceeded benchmarks in cardiac care,’” Remley says. Anthem is now working on a system that brings the Q-HIP principles to physicians. “By decreasing the variability of care, it will ultimately allow us to provide better, healthier care. That will ultimately save money for society and the insurance plan.”

Still, VAHP’s Gray doesn’t advise counting those savings yet. “It is hard to promise actual reductions in total health-care costs in an environment that is seeing 8 to 12 percent increases annually in health-care costs. The first hoped-for result from the use of improved technology has to be for improved performance in terms of quality,” he says. “It is reasonable to hope that across-the-board improvement in quality measures will lead to some reduction in the increases in health-care costs.”

Kaiser Permanente’s McClain says medical care in his office will change dramatically over the next few months as the HealthConnect system comes fully online. Patients will like being able to check on lab test results themselves, rather than wait for a nurse or doctor to call them. Older patients, many of whom don’t like to drive on Northern Virginia’s congested roads, will be able to ask him questions via secure e-mail. “Patients will be able to communicate smaller problems at an earlier stage,” he says. Because he’ll have access to the patient’s entire medical record instantly, he’ll be able to provide advice at once or recommend an office visit. “We have to be open to the changes that the technology provides. A traditional face-to-face visit might not always be the most appropriate way,” he says.