2009 Graduate Scholar (Second Runner Up)

In 2004, President George W. Bush set a goal that by 2014 every American should have an electronic health record (EHR). October 1st 2010 marked the government’s foray into the 2011 Fiscal Year -- it is now T-3 years and counting. I have no doubt that every American will have an electronic health record by 2014. And if they don’t, well, they can have one of mine.

As a young person with a medical issue, I have access to upwards of 15 EHRs and their requisite patient portal access. Despite the prevalence of EHRs, I doubt the quality of my care is significantly better. See, my data is stuck in EHRs don’t talk to each other. A few months ago I found myself trying to get care at a well-respected, technologically savvy, teaching hospital. Having not been there before, I attempted to have my medical records sent from another electronically enabled medical center. This task proved impossible and I had to have my friends bring me my hot-pink binder of medical records, which, unfortunately, did not reflect my most recent notes. See, in schlepping my medical records from hospital-to-physician-to-hospital, I had missed a visit. Indeed, it is a pain to ensure that the records are complete, even though many of them originated in EHRs. After all, a paper printout of an EHR is still just paper printout. The point of this anecdote is that if I, a Masters student in Health Systems Administration, cannot figure out the system, neither can your grandmother. This process is not safe or efficient and frustrates providers and patients alike.

2009 estimates show good progress toward President Bush’s goal: 46% of hospitals and 44% of ambulatory providers indicated that they have an EHR. Unfortunately, like my story showed, “adoption” is not indicative of meaningful adoption. When these rates are examined again, fully functional, communicating, EHR systems account for only 1.5% of adoption in hospitals and 6% of adoption in ambulatory providers. I don’t deny that full, meaningful, adoption is difficult -- startup costs are immense, workflow issues prohibitive, the Return on Investment questionable. Anyway the picture is painted, adopting a fully functional EHR is seemingly impossible for all but the largest medical centers. Fortunately, President Obama’s thrown a curve ball with the American Reinvestment and Recovery Act of 2009. Through the Title VII: Health Information Technology for Economic and Clinical Health Act, ARRA promotes the adoption of Electronic Health Records, promising upwards of 20 Billion dollars in incentive payments for the Meaningful Use of EHRs as defined by the Office of the National Coordinator (ONC). Furthermore, it allocates funds to provide assistance in vetting EHR software choices, training workforces, and creating Health IT test-beds.

But these programs are just tools. Indeed, the first step to creating a continuously learning high performing health IT system is to take advantage of these tools and incentives to lay a solid EHR foundation which exchange can be built from. Second, it is time to spend energy not only on adopting EHRs but ensuring that we utilize them in patient centric ways. If patients aren’t engaged by their health information, what is the point? Sure, the physician has a complete record of care and is held responsible by mandatory quality reporting. Sure, with clinical decision support tools and ePrescribing, drug safety increases. But how does a patient know that these functionalities exist, let alone, that they are benefitting their health? If a provider cannot access an aggregated EHR at the point of care, again, what is the point?

Great strides have been made in integrating communities of care with electronic health information. Through the Patient Protection and Affordable Care Act, the Center for Medicare and Medicaid Innovation (CMMI) has been tasked with defining and creating Accountable Care Organizations. These organizations will likely be based off of the Geisinger/Kaiser model and pay based on a capitated system. But what is more important than their payment structure and commitment to provide comprehensive care is their continual commitment to innovation.
This commitment to innovation is exhibited by CMMI’s reception to mobile health technologies. The ability of EHRs to interface with remote medical devices will be groundbreaking. Take, for instance, a diabetic. Currently, a diabetic takes a blood glucose reading and records it by hand. These logs are often illegible and physicians do not have the time to page through them to identify trends. Currently the technology exists to link glucose meter readings to patient records electronically. This link ensures that readings are recorded correctly and allows for physicians to passively monitor a patient’s blood glucose, enabling them to take immediate action when levels fall outside a predetermined range. Furthermore, the system can remind a patient to check their blood sugar and allows the patient to track their progress via an online portal. This application is a prime example of how technology enables effortless patient communication and provider accountability. Pilot studies show that this kind of application is effective; indeed, it is correlated to a reduction of 5 points in blood glucose readings and a 1% reduction in HbA1c readings over a three-month period.

But this level of innovation is not possible so long as we believe that EHRs are simply static repositories of information. Until there is an open flow of information between providers and patients, this level of innovation will remain but a dream. Indeed, patients and providers alike must demand this kind of functionality be reimbursed by payors by proving the tool’s value through consistent utilization and better outcomes. I believe that we can move beyond this dysfunctional Health IT system and into one that is truly patient centered. Have I been drinking the proverbial kool-aid? Probably. But if that’s what gets me to think outside of the “EHR as savior” box and vocalize the need for the engaged exchange of medical information across the continuum of care, pour me another glass. Cheers.



Note: With this essay I won the distinction of being the 2011 NCHE Graduate Scholar.

Before I went to the reception I sent this picture to a friend telling them that I couldn't wear the "hooker heels" UNLESS I won. If you win you get to wear whatever non-totally-business appropriate shoes you want!

Hooker Shoes

This is a covert shot I took as soon as  I won and sent to my Grandma. Grandmas like images like that. Covert Shot



Works Cited:
“About ONC.” http://healthit.hhs.gov/portal/server.pt?open=512&objID=1200&mode=2.
Medical Records Privacy Rights. http://www.privacyrights.org/fs/fs8-med.htm
Beacon Partners. Healthcare Leaders Speak up on Where THey are in the EHR Adoption Process. http://www.beaconpartners.com/ehradoption/BeaconPartners_EHR_AdoptionStudy.pdf
NAMCS Data. Accessed May 2010. http://www.cdc.gov/nchs/data/hestat/emr_ehr/emr_ehr.pdf
Jha et al., 2009, NEJM. Accessed May 2010.
NAMCS Data. Accessed May 2010. http://www.cdc.gov/nchs/data/hestat/emr_ehr/emr_ehr.pdf
Yu, Wil. Ambulatory Adoption. July 2010. Office of the National Coordinator for Health Information Technology.
Simon et. Al.” Correlates of Electronic Health Record Adoption in Office Practices: A Statewide Survey.” JAMA. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2215070/
Electronic Health Records and Meaningful Use. http://healthit.hhs.gov/portal/server.pt?open=512&objID=2996&mode=2
HIT Regional Extension Centers. http://www.regionalextensioncenters.com/
Community College Consortia to Educate Health Information Technology Professionals in Health Care Program. http://healthit.hhs.gov/portal/server.pt?open=512&objID=1804&parentname=CommunityPage&parentid=14&mode=2&in_hi_userid=11673&cached=true
Beacon Community Program. http://healthit.hhs.gov/portal/server.pt?open=512&objID=1805&parentname=CommunityPage&parentid=2&mode=2&cached=true
Fact Sheet: Medicare Meaningful Use http://www.cms.gov/apps/media/press/factsheet.asp?Counter=3792&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date
Hunt et al. JAMA. Effects of Computer-Based Clinical Decision Support Systems on Physician Performance and Patient Outcomes. http://jama.ama-assn.org/cgi/content/abstract/280/15/1339
Lee et. Al. Creating Accountable Care Organizations. NEJM. http://www.nejm.org/doi/full/10.1056/NEJMp1009040
$10B CMS Innovation Center to pilot eCare. http://mobihealthnews.com/7587/10b-cms-innovation-center-to-pilot-ecare/
Bluetooth Blood Glucose Meter Now Interoperable With Nokia Phones. http://www.medgadget.com/archives/2010/04/bluetooth_blood_glucose_meter_now_interoperable_with_nokia_phones.html
Watson et al. “Diabetes Connected Health: A Pilot Study of a Patient- and Provider-Shared Glucose Monitoring Web Application” Journal of Diabetes Science and Technology, March 2009, Volume 3, Issue 2: Page 345-352. http://www.connected-health.org/programs/diabetes/research-materials--external-resources/diabetes-connected-health-a-pilot-study-of-a-patient--and-provider-shared-glucose-monitoring-web-application.aspx

2009 Graduate Scholar (Second Runner Up)

Unlike most twenty-three-year-old sorority alumnae, I receive my monthly subscription of Cosmo with a side of insurance rejections: such is the life of a coed who lost the genetic lottery. Thankfully, I earned an undergraduate degree in Health Administration and specialize in reminding health care organizations of their contractual obligations. Unfortunately the majority of Americans have not had this training while the red tape surrounding the insurance system is dense and misleading (1). But that’s to be expected; even the laws put in place to protect patient rights are incomprehensible. A Journal of General Internal Medicine report found that legislation set to protect patient rights is comprehensible to people with a reading level equivalent to that of an Associate Degree (2). To put this in perspective, approximately 70% of the United States population over the age of 25 can’t understand the laws which protect their health care rights (3). This ambiguity has created a market of confused individuals who are easily melded into padding the bottom line for both insurance companies and for-profit health care advocates.

According to the California Nurses Association, 1 in 5 claims are rejected by private insurance companies each year (4). These rejections can occur before or after care is received and come in two classes: quantitative and subjective. The first genre consists of clerical errors and miscoding issues, both of which are easily corrected to the subscribers benefit (so long as the subscriber catches the error, knows their benefits, and appeals the rejection in a timely manner).  The second groups of denials are difficult to negotiate as they result the insurance companies definition of preexisting conditions, medical necessity and experimental procedures (5).

Comedian Stephen Colbert illustrated the satirical nature of this licensure in his October 29, 2009 introduction in which he asked “What qualifies as a preexisting condition? … If you have to ask, you probably have one! (6)” Take for example Stephanie, a 24 year old from Oakland, California, who opted into a single-payer insurance policy while she was studying for her MCATs. She went to the doctor for an annual exam and was diagnosed with bronchitis. This diagnosis led her insurance company to do a five-year review of her medical records in which they found evidence of a past chest infection, providing them with grounds to refuse payment for her care. She never thought that her former chest cold could be a preexisting condition, yet due to her insurance company’s interpretation, she was forced to pay out of pocket (7). Obviously the insurance industry has to stack the deck in their favor; they are for-profit companies and deserve to be compensated for their sizeable gamble on individuals, but the high profits which result from rising premiums and unclear coverage denials is unethical (8).

This no-man’s land between insurers and individuals has led to a job market in patient advocacy. Many advocacy groups are either non-profit or governmental agencies; indeed, most states have patient advocacy bureaus to help their residents navigate the difficult legislature governing their care (9). Unfortunately these bureaus, like most social service sectors, are overworked and underpaid, forcing states to mandate who qualifies for advocacy (10). This urges patients with financial means to employ private, for-profit advocacy agencies to help them navigate the intricacies of the health care system, adding additional cost to their health care. Furthermore, the for-profit nature of these companies caters to healthy individuals, and some refuse to work for people with preexisting conditions, leaving those who desperately need support without recourse (11).

Einstein once said “make everything as simple as it has to be, but no simpler.” If this principle governed the success of Time’s “Person of the Century,” perhaps we should consider applying his wisdom to our current health care crisis (13). Simplicity is indeed the key to our success. Currently, health care reform bills have provisions to subsidize and reward the utilization of electronic medical records. Unfortunately, these electronic medical records are not currently at a developmental level which would supply security or uniformity. Yet these systems have great promise, indeed, if they are streamlined, continuity and accuracy of care would be vastly improved (14). A standardized record system would incite uniform regulations across insurers, helping to hold the insurance system accountable in a laissez-faire manner which increases its political viability. Furthermore, the clarity this system provides would help subscribers to understand the reasoning behind decisions which were formerly illogical. Unfortunately this goal is several years in the offing and we cannot wait to provide culturally relevant data to patients.

I recently attended a Comparative Effectiveness Research seminar in which Dr. Robert Epstein was panel member; I recognized his name, but couldn’t immediately place him (12). Halfway through the panel, it hit me - Epstein’s signature is affixed to letters I receive from Medco Health Solutions when my prescription drug coverage changes. In my world, Epstein is the prescription-drug-coverage-devil. But as I sat listening to his speech on personalized medicine, his congenial nature and “carpe diem” philosophy made me realize that the man behind the signature is human and truly cares for his subscriber’s futures.

Insurance companies are made up of educated people who, like Epstein, want what’s best for their subscribers. Admittedly, the more effective treatments are, the less they have to pay in the future. Yet these companies are woefully unsuccessful and demonized by the lay public in their attempts at efficiency. Likewise, the current push for health care reform is misunderstood and chaos abounds. If you want proof that a number of Americans do not understand the goals of health reform, look no further than “end of life counseling” being touted as “death panels.” Something has been lost in translation. If our goal is efficient, culturally competent care, the information delivery system must be clarified and translated via an appropriate advocate.

Note: For this piece I was recognized in NCHE's Annual Scholarship competition.

NCHE Year One

Works Cited:

1. Kaiser Family Foundation. Confusing Insurance Jargon Prompts Call For Reform. Kaiser Health News. [Online] September 21, 2009. [Cited: October 31, 2009.] http://www.kaiserhealthnews.org/Daily-Reports/2009/September/21/2khnstory.aspx?referrer=search.

2. Gardner, Amanda. Patient's Bill of Rights Too Tough to Read. U.S. News & World Report. [Online] March 27, 2009. [Cited: October 31, 2009.] http://health.usnews.com/articles/health/healthday/2009/03/27/patients-bill-of-rights-too-tough-to-read.html.

3. United States Census Bureau. Educational Attainment: 2000. census.gov. [Online] August 2003. [Cited: October 2009, 30.] http://www.census.gov/prod/2003pubs/c2kbr-24.pdf.

4. California Nurses Association. California's Real Death Panels: Insurers Deny 21% of Claims. National Nurses Organizing Committee. [Online] September 2, 2009. [Cited: October 30, 2009.] http://www.calnurses.org/media-center/press-releases/2009/september/california-s-real-death-panels-insurers-deny-21-of-claims.html.

5. Vogin, Gary. Dealing With Rejection. MedicineNet.com. [Online] WebMD, March 22, 2002. [Cited: October 30, 2009.] http://www.medicinenet.com/script/main/art.asp?articlekey=51313.

6. Wednesday, October 28, 2009. Comedy Central, New York : Stephen Colbert, October 28, 2009.

7. X., Stephanie. Personal Interview. October 2009, 28.

8. FactCheck.org. Insurance Co. Profits: Good, But Not Breaking Records. FactCheck.org. [Online] August 5, 2009. [Cited: October 31, 2009.] http://www.factcheck.org/2009/08/insurance-co-profits-good-but-not-breaking-records/.

9. Patient Advocate Foundation. The National Financial Resources Guidebook for Patients. Patient Advocate Foundation. [Online] [Cited: October 30, 2009.] http://www.patientadvocate.org/report.php.

10. R, S. Personal Interview. June 2009. Mr. R is a CNA employed by Tenderloin Health in their case management and health advocacy departments.

11. HealthCare Advocates, Inc. The Consumer Price Plan. HealthCare Advocates, Inc. [Online] 2009. [Cited: October 31, 2009.] http://www.healthcareadvocates.com/priceplan.html.

12. Personalized Medicine Coalition/National Pharmaceutical Council. Comparative Effectiveness Research and Personalized Medicine: Policy, Science, and Business. Arlington, VA : Personalized Medicine Coalition/National Pharmaceutical Council, October 28, 2009.

13. Golden, Frederic. Person of the Century: Albert Einstein. Time. [Online] Time, Inc. , January 3, 2000. [Cited: October 31, 2009.] http://www.time.com/time/time100/poc/magazine/albert_einstein5a.html.

14. Huslin, Anita. Online Health Data in Remission. The Washington Post. [Online] February 16, 2009. [Cited: October 30, 2009.] http://www.washingtonpost.com/wp-dyn/content/article/2009/02/15/AR2009021501284.html.