I often hear how other countries are ahead of the United States when it comes to using electronic health records and exchanging electronic health information. For example, Don E. Detmer, MD, president and CEO of the American Medical Informatics Association, referred to Scandinavia, the Netherlands, Denmark, the United Kingdom, Canada, and Japan as countries that are ahead of us in this arena at a recent Nashville Health Care Council meeting. "We can learn a lot from these experiments," he said, acknowledging that no one has it totally figured out yet. "It is a tapestry that has different bright spots."
That is why I found a recent report, Accomplishing EHR/HIE (eHealth): Lessons from Europe," by CSC, a global consultancy firm, so interesting. It focuses on those "bright spots" and pulls 25 lessons learned from initiatives in Denmark, the Netherlands, and the United Kingdom.
Granted there are key differences between these countries' efforts and the United States. The size of the European efforts is far smaller, for one. However, the initiatives are comparable and have encountered many of the same obstacles and issues. "The UK is 60 million people," says Fran Turisco, a coauthor of the report and research principal, emerging practices for CSC. While smaller than the US, "it is not eeny meeny," she says. Many of these countries also had a different starting place. In Denmark, The Netherlands, and Norway, EHR adoption by general practitioners is approaching 100%, compared to 20%, at most, in the United States, the report says. The U.S. effort is still focused on changing workflows and switching from paper to digital records in addition to exchanging data and becoming interoperable.
Turisco says that one of the most surprising results was that no one did any of these studies before, other than collecting anecdotal information such as the wait time for physician appointments. "We are spending billions of dollars easily, but there wasn't anything built into these initiatives to say, 'This is how we'll know we got value for our money,'" she says, adding that the UK is now going back and studying benefits. The U.S. is doing a better job on that front, she says, because the "meaningful use" matrix is tying elements like data capture, patient safety and quality reporting, and outcomes measurement to the technology.
The report offers lessons learned and best practices in six key areas: planning and sustaining the initiative; major issue management; governance and communication; technology and interoperability; and implementation. It also offers a comparison of the United States efforts at the end of each section that includes a HITECH update. Here are some of the best practices shared:
eHealth initiatives should be supported by technology not led by it. The UK's program was called the National Program for Information Technology and led by a CIO at each hospital. That was the wrong approach, says Turisco. "There was a lot of backlash," she says, noting that in other countries it went more smoothly because it started as part of healthcare reform. "They are going through a whole rebranding effort to say, 'You misunderstood. This is healthcare reform in the UK and technology is needed to support healthcare reform,'" Turisco says.
Those who gain value from HIEs need to be willing to pay for it. The report found that payers and patients are the beneficiaries of the improvements made by eHealth such as reduced length of stay, duplicative tests, and medication errors, yet the hospitals and physicians are the ones paying for it and supporting the clinical applications. U.S. providers should have a good business reason to join HIEs, says Turisco. For large-scale eHealth initiatives to be sustainable, financial balance is key. Everyone should "belly up to the bar and put some money into it," she says.
Funding was not as much of an issue in Europe because the eHealth efforts were supported by a government-funded (Denmark and the UK) or private (The Netherlands) healthcare system. However, they all considered government funding as a crucial element to building the infrastructure, central services, core clinical systems, and providing ongoing financial support, the report says.
Data sharing—automatically include patients and offer them the ability to opt out or opt in with restrictions. The report has a nice graph that summarizes the authorized access practices set up in the UK, Denmark, and The Netherlands. For example, patients in Denmark can access data via a user sign-on and password. But the UK and the Netherlands also require patients to have a smart card to access the system. They all had full auditing capabilities, so patients can see who looked at information, when, and for what reason, explains Turisco.
The best way to get patient consent was to automatically enroll them with plenty of advance notice so that they can opt out of data sharing or opt in with restrictions, says Turisco. "Otherwise it will take forever to get adoption," she says, noting that the UK had less than 1% of people opt out. The Netherlands did not address informed consent until much of the system was built and was ready to be rolled out. They chose to send everyone a letter asking for permission. They received 300,000 letters that had incomplete or inaccurate information—all of which needed follow up, which resulted in a lengthy delay.
Factor in a lot of time for communication and education. If you are going from paper to EHRs, it is worth taking the time to understand what processes will change and how that will impact physicians, nurses, and ancillary providers, says Turisco. There wasn't a lot of communication with the public about what was happening in the UK, so CSC ended up spending a lot more time than they had planned in terms of education, allaying fears, and getting people involved in the design, configuration, and testing of the system, she explains.
The United States is doing all the right things, says Turisco. But now it comes down to the tough part—getting the work done. "We are putting the right committees in place, funding, and incentives, but now we have to say here are standards and certification requirements," Turisco says.
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Nobody knows what the final healthcare reform package that emerges from Congress will include. In fact, at this point, nobody knows if anything resembling comprehensive healthcare reform will pass Congress this year.
As Congress goes into August recess, many lawmakers in both parties are saying they intend to hold public meetings with constituents to gauge their support–or disapproval–of the health plans on the table.
Here's a quick look at the three plans now getting the most attention. Keep in mind that there are a lot of moving parts in these plans, and the details can fluctuate dramatically from day to day.
HR 3200, the America's Affordable Health Choices Act, aka The Tri-Conference Bill. This bill is the joint creation of three separate House committees: Education and Labor; Ways and Means; and Energy and Commerce. The bill has passed all three committees, mostly along party lines–with some conservative "Blue Dog" Democrats joining Republicans in opposition because of cost concerns. The bill is expected to be heard by the full House when lawmakers return in September. The most controversial component in the 1,018-page HR 3200 is the creation of a public insurance option and healthcare exchange that would allow consumers the option of choosing either private coverage or a new government-run public plan.
The bill also calls for:
Expanding access to health insurance
Standardized benefits packages
Provisions to end premium increases or coverage denials for "pre-existing" conditions
Eliminating copays for preventive care
"Affordability credits" to make premiums affordable
Caps on out-of-pocket expenses
Employer mandate, which is being called pay or play
Guaranteed catastrophic coverage
The Affordable Health Choices Act, aka the Senate HELP Committee bill. The Senate Health, Education, Labor and Pensions Committee passed this package in mid-July, but it's still in mark-up and has yet to receive a bill number. Supporters of this bill boast that it is truly bipartisan, and includes 160 Republican amendments. However, the bill cleared the committee on a 13-10 party-line vote.
The bill is expected to be merged with whatever bill emerges from the Senate Finance Committee. Like the House bill, the HELP bill has a health insurance exchange, referred to in the bill as an "Affordable Health Benefit Gateway," which states would be responsible for establishing. It also features a government-run, public health insurance option that would compete with private insurers to drive costs down.
Under the "shared responsibility" section, all individuals would be required to obtain healthcare coverage, although some exceptions could be made for those who cannot afford coverage. Employers with 25 or fewer employers also would be exempt from penalties. The bill's minimum penalty to accomplish the goal of "enhancing participation" is $750 per individual annually.
The bill also has a greater focus on prevention and wellness efforts than the House bill. The bill also calls for:
Prohibiting insurers from denying applicants coverage based on their health status
Promoting higher quality of care through health insurance policies that include financial incentives as rewards for providers involved in using, for instance, care coordination, chronic disease management, and medical error reduction
Coverage of preventive health services
Extending coverage for dependent adults, with all individual and group coverage policies being required to continue offering dependent coverage for children until the child turns age 26
No lifetime or annual limits on the dollar value limits of individual or group health insurance policies
The Senate Finance Committee bill. Nobody knows what this bill will include because there is no bill nor is there draft language. There's not even a lofty, official-sounding name like the Liberty and Justice and Healthcare for All Bill of 2009.
There is great debate about whether or not the bill will include the public plan option found in the other bills. Over the last several months, the committee has laid out a series of papers that could be viewed as a possible framework for the eventual bill.
Finance Committee Chairman Max Baucus (D-MT) says the committee will begin the mark up before the Aug. 7 start of the committee's summer recess. The eventual bill may include a mandate for individuals to have health insurance.
To facilitate the requirement, the bill may create a Health Insurance Exchange where people and small businesses can buy coverage with financial assistance available to the poor. The bill is also expected to expand SCHIP and expand at least temporary coverage for Medicare/Medicaid.
John Commins is an editor with HealthLeaders Media. He can be reached at jcommins@healthleadersmedia.com.Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.
A recent federal report casts more concern that hospital emergency rooms are having increasing difficulty treating all comers, especially because federal payments and the uninsured don't pay their full cost of care.
"There is a growing concern that EDs will not be able to sustain care for all persons in the current economic environment," according to the report, entitled "Payers of Emergency Department Care, 2006," that was published by the U.S. Agency for Healthcare Research and Quality.
"Between 1993 and 2003, there was a 23% increase in ED visits and a closure of 425 hospital EDs. In addition, a recent Institute of Medicine report notes that EDs have become increasingly overcrowded, overburdened, and underfunded. Yet little is known about who is paying for ED care, what the charges are for the care, and how to potentially relieve this pressure," the report said.
Of all visits to hospital emergency departments in 2006, 41.8% of the care was billed to the federal government–21.6% to Medicaid and 20.2% to Medicare. Another 17.7% were uninsured. An estimated 34.6% was billed to private insurance, and the rest to other private payers.
But those with no insurance were less likely to have medical problems so serious that their trip to the emergency room ended with an admission to the hospital, according to the report. Only 6.8% of the 21.2 million visits among the uninsured required an inpatient hospital stay; the rest were treated and released.
The report said the low percentage of patients with no insurance who went home without being admitted is "a possible indication of their use of hospital emergency departments as their usual source of care."
For those covered by Medicare, about 38% of the 24.2 million visits ended up with a hospital admission, compared with 11% of the 41.5 million visits billed to private insurers, and 9.5% of the 26 million visits billed to Medicaid.
All hospitals must at the very least provide medical screening exams to anyone who presents to an emergency room regardless of their ability to pay and must determine their need for further treatment for an illness or injury within 24 hours. However the law, called the Emergency Medical Treatment and Active Labor Act is not funded, and hospitals have long complained that their ability to continue providing such care is increasingly limited. Patients are arriving later in the course of their illnesses, and are often much sicker, they claim.
Among other highlights from the report:
The rate of emergency department visits among the uninsured, 452.1 visits per 1,000 persons, was much higher than the rate among the insured, 367 visits per 1,000 persons.
Relative to the population distribution in the U.S., Medicare was billed for more ED visits resulting in admission (50.3% compared to 13.5% of the population); Medicaid was billed for more treat-and-release ED visits (23.1% compared with 12.9% of the population) and private health insurance was billed for far fewer ED treatment and release visits and visits resulting in admission.
Protests organized by a loose-knit coalition of conservative voters and advocacy groups started what is expected to be weeks of political and ideological clashes over the healthcare overhaul President Obama is trying to push through Congress. Conservative groups are harnessing social networking Web sites to organize their supporters. Democrats said they expected supporters of the healthcare overhaul to mobilize against Republican events later in the month.
Senate Democrats won't hesitate to forgo bipartisanship to pass a health overhaul bill if negotiations fail in the next month, Sen. Charles Schumer, a New York Democrat, said. Schumer indicated that Democratic leaders are actively exploring options to pass the health bill that wouldn't require Republican votes. He pointed specifically to budget reconciliation, a parliamentary tactic that would allow passage of a bill with a simple majority.
A union representing about 1,400 health and clerical workers at the University of Chicago Medical Center said that it rejected a three-year contract offer by management. The union contends that the hospital was asking for too steep of increases in medical-care coverage, among other issues. Teamsters Local 743, which represents clerical, service, and maintenance workers, said U. of C. management is asking workers to take on "healthcare increases up to 10% each year of the contract."
When patients understand their choices and share in the decision making process with their doctors, they tend to choose less invasive and less expensive treatments than they would have otherwise received, according to the Wall Street Journal Health Blog. Now around the country, lawmakers are looking at expanding shared-decision making programs, both as a possible cost-cutting measure and as a way to ensure that patients get their legal right to informed consent before medical procedures.
While the rest of the country is suffering from a shortage of primary care physicians, Miami is awash with Cuban doctors who have defected in recent years. By some estimates, 6,000 medical professionals have left Cuba in the last six years. Cuban doctors have been fleeing to South Florida since Fidel Castro seized power in 1959, but the pace intensified after 2006. That was when the Department of Homeland Security began a program that allowed Cuban medical personnel "who study or work in a third country under the direction of the Cuban government" to travel to the United States legally.
For 20 years, staff, visitors and the occasional patient at Dallas-based Parkland Memorial Hospital could go to the McDonald's restaraunt on the ground floor of the hospital. But later this year, Parkland will replace McDonald's with a 10-year-old chain that says its fare is healthier.
Facing a budget shortfall, the 47-bed hospital Sac-Osage Hospital in rural western Missouri is borrowing nearly $1 million to pitch its paper medical charts and purchase a state-of-the-art electronic health records system. The hospital is hinging its survival on what it hopes will be a $3 million windfall of federal incentives for hospitals that go digital. The hospital has already laid off staff, is operating on a $370,000 deficit, and is warning of dozens of deaths if local voters don't also approve a property tax to keep its emergency room open and ambulances running.
