Statewide Health Information Exchange: The Physician's Viewpoint

Good morning. I’m Ralph Schmeltz, MD, a retired endocrinologist from Pittsburgh, and president of the Pennsylvania Medical Society. I want to thank Chairman Folmer for the opportunity to testify about the value of electronically exchanging health information with the practice down the hall, the hospital on the other side of town, or the furthest corner of the state. We applaud you for holding this open forum and giving this issue the attention that it deserves.

Let me begin by stating unequivocally that the Pennsylvania Medical Society supports the development of a statewide health information exchange. Our reasoning is simple. A statewide health information exchange would open the door for better health in Pennsylvania. Given our conviction that such technology can save lives and improve care, our board of trustees adopted as policy our commitment to seeing statewide health information exchange become a reality.

But, our mission for today is that you leave this hearing with a greater understanding why all of us in this room should care about HIE.

As physicians, we recognize that the key to optimum care is to have the right information at the point of care for the patient being seen. Electronic health information exchange, or HIE, has the potential to provide that While technology alone cannot “fix” everything that is broken in our health care system, it is a tool that we must use to its best advantage.

When physicians are asked about the barriers which make it difficult to give the recommended treatment to their patients every time, one of the things heard consistently was “lack of data”. Most remain dependent on keeping paper files updated with information coming from multiple sources. Data “lived everywhere” in these offices. Lab reports and insurance company aggregate reports arrived asynchronously with patient visits. All too often, precious minutes of a 12 to 15 minute patient visit was spent tracking down lab results and other information vital to the effective treatment of the patient, particularly if the patient was being cared for by multiple physicians. Even when the practice has an electronic health record, or EHR, the paper then needs to be scanned in by hand, or typed into the appropriate field in the computer. HIEs will enable this data to be uploaded directly into the EHR.

Another problem with the lack of necessary data at the time of a patient visit was traced to the current fragmented system of care. A specialist who needed to know what a PCP was doing to treat a disease would have to pick up the phone and request the information. There was no simple system for patient information to become portable across different caregivers. We need a system that would help reduce this fragmentation of patient data across different physician offices, hospitals, and health care systems by populating an EHR for each patient with relevant data from multiple treating physicians.

Without HIE, the patient possibly faces delays in care. Consider the following scenario. Today, most medical information is shared through the use of fax machines or by mail. Mail is great if you have several days to wait. Fax machines can do a good job, but only if the office on the other end is open. In the middle of the night, emergency room physicians encounter patients who are experiencing cardiac symptoms. The patients’ prior care may have been provided by an unaffiliated physician from a different health care system. The patient knows he had an echocardiogram recently, and is not sure of his medications. Absent a health information exchange, the doctor can’t get the results until after the office that has the report opens the next morning. Given the patient’s current symptoms, tomorrow morning may be too late. The doctor has no choice but to repeat the test, or prescribe a medication which may have an unfavorable interaction with one previously taken. This delays treatment, risks an adverse drug event, and may unnecessarily increase the cost of care.

If a physician can query the patient record using HIE and obtain the report within minutes, care can be prompt, safe and appropriate.

Benefits to physicians
Organized data at the point of care
Under the current system, physicians receive different reports with different formats from each insurance carrier, provider, or consultant in their office. They also receive test results for their patient pool from multiple labs which arrive out of synch with individual patient visits. The HIE would allow similar data to be gathered together into a single format report for all providers, no matter where it was generated, and make it available on demand to be retrieved when the patient is there for a visit.

Ability to generate reports
The HIE would give practices the ability to populate their own EHRs and generate reports to look at their practices in new ways. With more information about their patients, physicians would be able to gain a better understanding of their patient population, plan quality initiatives, and monitor their own progress toward best practices.

Benefits to patients
Better coordinated care between physicians
Patients could also access their data as a step toward becoming more educated and active in their own disease management. By establishing a link between physician practices though the patient, care can be coordinated between involved practices. Redundant unnecessary procedures and tests can be eliminated while visits that are not completed can be made apparent to all practices involved in care. Patients who are then lacking particular treatments or tests can then be contacted by the practices for any necessary follow up.

You will hear, in later testimony, of the impressive accomplishments of some of Pennsylvania’s integrated health systems in use of EHR’s within the confines of their own institutions. I spent many years at one of them, where my office was a beta test site for their EHR. I left in 2004 to go to a community hospital, with a different EHR. Unfortunately they could not communicate with each other. So we had to download the patients’ records to paper, put them in a truck and drive the 30 miles to my new office, where they had to be keyed in by hand to the new system. What would I have given to have an HIE at that time.

Better record-keeping for many patients
Data tends to live “everywhere” in paper-based systems. By capturing as much data as possible in electronic form and repackaging it in a single document available on demand, many patient files will be more complete and will include at-a-glance histories of past treatment for a chronic illness.

More quality time with doctor during visit
Much of the time spent in healthcare may be classified as “non-value added”, such as searching for information or material needed for patient care rather than actually providing patient care. This can be eliminated.

The HIE could provide physicians and patients with real time “decision support” tools necessary to support care, thereby improving the quality and value of the time spent with physicians without an increase in overall time for the physician or their staff.

Benefits to community
Because the exchange will solicit data from every health insurer, both public and private, all patients in PA will reap the benefits of having their data compiled and readily accessible. Health care can become more efficient without increasing resource utilization.

HIE is also important because of its implications for the future of the medical practice. It will be the backbone and infrastructure which will drive and transform collection and utilization of healthcare data. Federal incentives for e-prescribing, adopting of EHR, implementation of “meaningful use” criteria include provisions for “exchanging “ data with entities outside of your own practice are already in regulation, with penalties to reimbursement if not accomplished by 2015.

If we build it, will they come?
EHR systems have been around for well over a decade. Yet, EHR adoption was slow until the last few years. In 2004, President George W. Bush set in motion a chain of events that has increased the adoption of electronic prescribing and EHRs. He set a goal that every American would have an electronic health record by 2014. He envisioned a host of statewide and regional HIE networks that would come together to form a nationwide network. The national network would enable the transfer of health records in a matter of minutes to any place in the nation. Among various initiatives to increase adoption of health information technology, the Center for Medicare and Medicaid Services (CMS) instituted a bonus for electronic prescribing. As a result, Pennsylvania saw a significant increase in the use of this technology.

President Barack Obama took this goal a step farther by providing financial incentives for the adoption of EHR as part of the American Recovery and Reinvestment Act. These incentives, which began on Jan. 1, 2011, have fairly rigorous requirements. The physician cannot merely use his EHR system as a fancy electronic file cabinet. He has to use it in a “meaningful” way. CMS has laid out specific requirements for what constitutes “meaningful use.” The HIE requirement for 2011 and 2012 requires physicians to at least test their ability to perform HIE with an entity outside of their own practice. We anticipate that the HIE requirements will expand in future years. Other “meaningful use” requirements, such as reporting immunizations to an immunization registry or reportable diseases may also be eventually accomplished through a statewide health information exchange. Physicians who fail to achieve “meaningful use” will not only lose the financial incentives, they will also see their Medicare fees penalized beginning in 2015.

CMS’ EHR incentives are just one of the pressures that are driving physicians to adopt health information technology. The emphasis on the Patient Centered Medical Home and the anticipation of accountable care organizations give doctors plenty of reasons to get on board with EHRs and HIE.

But, why does it have to be statewide HIE? After all, all health care, like politics, is local, isn’t it? Today you will hear from others about HIE activity at the local level and within Pennsylvania health systems. HIE is costly to set up and requires ongoing revenue. A statewide HIE can provide the initial investment in infrastructure, sustainability, and consistency that would give all Pennsylvania providers access. This has been difficult to achieve in the private sector. We believe, however, that these challenges can be surmounted when the private sector and public sector come together. Challenges such as governance, financing, and privacy and security concerns may all be overcome through collaboration and full transparency.

We are neither unfamiliar nor fazed by the challenges and rigors of the development of such an enterprise. We stand ready to continue what we have helped to begin, a health information exchange for Pennsylvania.

In conclusion, I would like to again thank Senator Folmer for giving the Pennsylvania Medical Society the opportunity to share our thoughts on this important topic as we work for the better health of Pennsylvanians. Needless to say, a statewide HIE would be a wise investment for the health of all Pennsylvanians.

Thank you.