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For other articles and previous issues click here. April 4, 2005 Where
IT’s At — A Look at Healthcare Information Technology
Today, Where It’s Heading, and How It Might Change Your Facility How much does the digital world correspond with the real world in healthcare? Although the answer depends heavily on how you measure, that topic was a recurrent theme at last month’s Healthcare Information and Management Systems Society (HIMSS) annual meeting in Dallas. The increasing interaction between radiology’s information technology (IT) systems—RIS and PACS—and the rest of healthcare IT prompted Radiology Today to attend and cover HIMSS for the first time. Although PACS, RIS, and digital modalities were developed in radiology departments, enterprisewide systems managed by hospital IT staff represent the future of healthcare information. But that future isn’t here just yet, cautioned Dave Garets, CEO of HIMSS Analytics, the data-analysis and consulting subsidiary of HIMSS. Garets spoke in several sessions at HIMSS, including Sun Microsystems’ SunSHINE Summit. He launched his presentation, “A Dose of Reality: The State of IT Innovation in Healthcare,” by telling the audience he was “trying to disabuse as many people as possible about what you’ve heard and read.” To help achieve that objective, Garets discussed some data from the HIMSS Analytics database of nearly 4,000 hospitals surveyed in 2004. Of special interest to radiology departments were the findings showing that 33% of surveyed hospitals reported having PACS installed, and another 10% were under contract but have not had their systems installed. Another 32% plan to purchase their first PACS in the “foreseeable future.” That leaves 25% with no current plans to give up film. Wish Lists Garets cautioned that planned installations and actual implementation remain very different realities. To illustrate the point, he said 10% of surveyed hospitals have CPOE systems installed and another 12% are under contract but haven’t yet installed the systems. That 22% figure suggests real traction for CPOE. Garets contrasted that data by citing a figure from market research company KLAS—that between 1% and 2% of hospitals use CPOE for more than one-half of their physician orders in 2004. The 2005 KLAS report on CPOE came out just after Garets spoke and put the number at 2.5%. But his point remains valid: Shifting the definition from having CPOE to truly implementing it dramatically changes the numbers. “It [CPOE] is exactly what we need to be doing,” Garets said, “but we’re just at the edge of getting started.” Garets made the same point more broadly about digital hospitals. Excluding military and Department of Veterans Affairs (VA) facilities, he said he knows of zero general medical surgical hospitals and just three specialty heart hospitals in the country that are fully digital—including image-based EMRs, CPOE, PACS, digital modalities, and point-of-care and remote access to records. The Department of Defense launched its second-generation EMR project in January 2004. The Composite Health Care System II, known as CHCS II, will eventually connect 9.1 million beneficiaries with 139 military treatment facilities, according to a recent article in American Medical News. Similarly, the VA is planning to link the facility-based record systems of its 157 medical centers so data can be shared throughout the VA system, including providing patients access to their records. When it comes to implementing systems, military healthcare facilities have the huge advantage of the military chain of command. Everyone being served in the military system basically has the same health plan and gets their care within the network. Military brass issue orders about what will happen within the system to patients, doctors, and local management. Outside the military health infrastructure, there are many different systems and payors with much less capability to share data between systems. “Digital hospitals are going to happen,” Garets said. “They’ve got to happen. They’re not happening yet.” Radiology in Front The Cleveland Clinic maintains its own storage network, which Cecil said is a combination of hard disk and tape to balance cost and access. While the Cleveland Clinic is a massive operation, Cecil believes most facilities will find it less expensive to maintain their own data storage than to use an Application Service Provider (ASP). He said that an ASP is usually a logical option only for hospitals with fewer than 200 beds where the study volume is modest and IT staff is limited. Cecil also pointed out that hard disk storage costs are not dropping as much as many people think and some vendors suggest. The reason is that while hardware costs are indeed dropping, they make up roughly 20% of the disks’ acquisition cost. The remaining 80% of the purchase price is software and administration costs, which are not declining. In addition to discussing the situation within the Cleveland Clinic system, Cecil shared some thoughts on where healthcare IT integration is heading. While EMR and PACS/RIS seem naturally related, Cecil noted that “they are two very separate animals.” Speaking to an audience primarily composed of IT professionals with computer backgrounds, he pointed out the important difference between healthcare IT and digital imaging: frontline patient care. The traditional IT processes of registration and billing, business-hours help desks, monitoring records, and data management starkly contrast with the 24 hours a day, seven days a week diagnosis and intervention background that digital imaging grew from. Cecil’s point is increasingly important as enterprise-level IT staff assume more radiology department IT decisions. It is vital that they understand the patient care demands of the technology on the clinical front lines. Many PACS administrators are former technologists who subsequently learned the IT side. As the traditional IT people expand into managing these areas, they’ll need to understand the difference between the IT and patient-care ways of doing things. The Goal is Interoperability Keynote speaker David J. Brailer, MD, PhD, kept circling back to interoperability, which is a goal we’re not close to yet. The “inter” part is the tough part. Plenty of companies offer electronic records systems that integrate digital data and images and deliver it via computer throughout the facility or system, and a modest number of facilities have EMRs or EHRs (electronic health records; see box). But the objective and challenge is making the data portable between different companies’ systems—the way your ATM card works at banks around the country. “EHRs must be in physician offices, hospitals, and other clinical settings routinely used by clinicians,” said Brailer, who is the national coordinator for health information technology. His task: pushing the issue forward so there’s such a network in place by 2014. “Without EHRs in place, there is little chance of gaining significant improvements in quality and cost-effectiveness and of unifying the clinical process around the consumer,” he added. “We are looking at how we can continue to lower the risk of EHR investments and support their adoption, particularly for smaller practices and hospitals.” Brailer said the Certification Commission for Healthcare Information Technology “is on track to develop a standard for EHRs in ambulatory settings by summer 2005.” He sees that as a key to developing a workable network based on what’s often called a “system of standards” rather than a standard system. The standards would provide a floor of interoperability among different companies’ systems. “The work of the Certification Commission is critical to physician hospital buyers who want to know what product to buy,” Brailer said. “[It’s critical] to established vendors who want to grow their markets, to new technology innovators who want to offer a module within a broader solution, to investors who want to know where to put their capital, and to policymakers who want to make sure that public funds are invested wisely.” Coming up with a standard for formatting data is a crucial step but isn’t the end of the issue. Lots of healthcare IT systems—including many radiology RIS—use Health Level 7 standards, but many still can’t exchange data. As a product manager at one system developer explained it, companies frequently tweak existing standards within their products in ways that essentially make them proprietary systems. Similar adjustments happen in systems supposedly adhering to DICOM standards. One presenter at HIMSS joked that he wouldn’t be confident betting his soul that a DICOM image would be portable from one major system to another. The solution, the product manager said, is to develop standards and hope the government’s nudging can influence companies to implement them completely. Proprietary Systems An executive with another large medical systems player said he expects that it will take seven to 10 years until standards truly make their way into products. He noted that in many cases, companies are not that interested in standards because they take away exclusivity of their products. He believes companies are not racing to make the switch. Another criticism of the EHR issue is that ambulatory care physicians are largely the ones who pay for these systems while the insurance companies and the patients derive most of the benefit. “Clinicians are indeed using EHRs today,” Brailer said, “but some clinicians are adopting EHRs more readily than others—creating an adoption gap based on the size of the practice. This could prevent market forces and competition from improving healthcare. According to a Commonwealth study, 57% of large group practices of more than 50 physicians are using an EHR, but only 13% of solo physicians are doing so. Larger practices, by their very largeness, have more resources, more ability to acquire information technology, and more capacity to mitigate risks. Their investment in EHRs is strategic, intended to shift the market toward them. I am very proud of these innovative risk-taking early adopters who have led the way with EHRs. They should be recognized for their leadership and not faulted for their inventiveness. However, if we believe that EHRs improve health status—as evidence says they do—then we have an obligation to level the playing field so that all practices and hospitals can adopt these lifesaving tools.” Brailer noted that regional efforts supported by federal dollars—called regional health information organizations (RHIOs)—have been started in Colorado, Indiana, Rhode Island, Tennessee, and Utah. Florida, Wyoming, New Jersey, and Minnesota have introduced legislation to form similar prototype RHIOs. The newly elected governor of West Virginia recently announced that he plans to pursue such a program. The ball is rolling—slowly still, after just one year with Brailer and the federal government pushing it—and when it rolls into radiology, departments will just have to be ready to achieve interoperability with it. — Jim Knaub is editor of Radiology Today.
“In my experience, doctors tend to use EMR because it reflects the digitization of their traditional paper medical records,” said Lee DeOrio, editor of For The Record, the leading national newsmagazine on medical records. “EHR means the same thing and sometimes seems favored by nonphysicians talking about an individual’s health record. I don’t know which term will win out.” Walking through the exhibit hall at the Healthcare Information and Management Systems Society (HIMSS) annual meeting in Dallas last month, EMR seemed more prevalent in vendor discussions, but EHR was also used. Perhaps more telling was the keynote speech by David J. Brailer, MD, PhD. Brailer, who is President Bush’s national coordinator for health information technology, repeatedly used the term EHR in his keynote speech to HIMSS attendees. — JK |
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