MC: PAeHI is a broad-based public-private partnership seeking to further the adoption of electronic medical records in Pennsylvania and the adoption of electronic health interchange. Just having an EMR within an individual provider site isn’t enough – it’s connecting those EMRs so that clinical patient data can be available at the point of care, no matter who the provider is. There are about 160 different organizations that are represented in the membership, including hospital providers, physicians, provider association representatives and various agencies of state government.

MC: The report is the culmination of the two-year history of PAeHI, which began in concept in March of 2005, when the Pennsylvania Medical Society, Quality Insights of Pennsylvania, and the Hospital and Healthsystem Association of Pennsylvania were looking for movement toward creating personal health records for all citizens within 10 years, based on the pronouncement of President Bush in spring of 2004. The PAeHI report offers a better understanding of where we currently are in Pennsylvania and how we need to mobilize consumers, providers, payers and government to work cooperatively toward furthering the adoption of electronic health records and health information exchange at a local level.

MC: Our report describes a four-phase approach to connecting Pennsylvanians for better health: get electronic information, exchange it among provider EMRs in an electronic fashion, assemble a core data set of critical health information about the population, and give the individual patient control over a personal health record. The first piece that we need is digital data, so we need to encourage more providers to implement electronic medical records. We’re far from having universal adoption of electronic medical records in Pennsylvania, at the individual physician and hospital levels. We then need those digital records to be standards-based, so they can be interoperable with other providers and can be exchanged with a common syntax across installations of electronic medical records. Once we get more data to be electronic at individual provider sites, we’re working toward being able to encourage the exchange of that information across related providers and across unrelated providers. There are many health systems in Pennsylvania that are implementing electronic medical records and exchanging information with physicians who are employed by that health system, as well as related providers – physicians who are members of the medical staff. We need to work toward the exchange of information between unrelated providers. In the central part of the state we have a good example of this: the Geisinger Health System is exchanging clinical information with the ED physicians at Shamokin Hospital, Bloomsburg Hospital and the Geisinger Medical Center in Danville. Those three unrelated organizations are now able to have the physician in the emergency department query, not only their own EMR about patients they’re seeing, but also the other two unrelated facilities’ EMRs.

Having that exchange enabled at the local level is the first step of the evolution of health information exchange. What we need to be able to do beyond that is have one part of the state be able to share data with a health information exchange in a different part of the state. Ultimately, we need to be able to plug in to what is being called the nationwide health information network, which is going to be a conglomeration of local exchanges – either statewide exchanges for smaller states or multiple local exchanges that exist in individual states.

MC: Educating consumers and providers about the need to implement digital clinical data in an electronic medical record is probably the biggest hurdle facing us right now. We need to work toward eliminating the obstacle of patients not wanting to have their information exchanged or maintained in electronic format. We’ve got to educate patients that this is in their best interest – to have good, trusted clinical information available for use by their standard practitioner and also available in the case of an emergency whenever they’re seeing a physician in a different town. PAeHI is working with a national organization called the eHealth Initiative to use what they’ve learned through focus groups to help educate consumers in Pennsylvania about the merits of participating in a electronic medical record and health information exchange. We’re working on a consumer brochure that talks about those merits.

We also have to help providers understand that it’s in their best interest to implement an electronic medical record and to participate in a health information exchange. An individual physician has to make an upfront financial investment in a system that may or may not have a financial return on investment. It may have a detrimental impact on productivity during the early implementation of the system. We need to demonstrate that physicians who have gone through that process, while they might not be able to point to financial savings, they can point to quality of life savings for their own practice and for improved quality of patient care.

Some providers view patient data in their medical records as a way to maintain their market share or their patient population. We’ve got to get beyond individual providers trying to keep too close a hold of their individual patient data, and have them recognize that providers are ultimately going to need to be able to share clinical information about patients. How they’re going to compete in the marketplace is going to depend on how they use that information. In five years it wouldn’t surprise me if an individual patient who is looking for a physician examines whether a physician has an electronic medical record, whether they have access to information in that medical record, and whether that physician is participating in a health information exchange – so that whenever the patient shows up at an emergency room, the emergency room doctor has access to the patient’s electronic medical record. Ultimately, the physician will compete in the marketplace because they have the information technology and they use information, not only from their own practice but also from other sources, to appropriately manage patients in their care.

MC: One critical question is, will the investment an individual practice makes in an EMR be able to be used in the future? Two years ago, if an individual physician was looking to implement an electronic medical record, there was really no sort of good housekeeping seal of approval on any of the hundreds of different versions of commercial electronic medical record software available. The industry needs to give individual providers some sense that they’re not going to be throwing their money away if they make an investment in an electronic medical record. At the national level, the industry has created standards for data and interoperability that need to be built in to every EMR system, and has created the Certification Commission for Healthcare Information Technology (CCHIT) which has certified over 80 specific electronic medical record applications for physician practices as meeting the evolving standards for content and interoperability. So, giving the physician some sense of stability and usefulness into the future of the system they implement was a key obstacle, and we’re overcoming that. During 2007 CCHIT is implementing a similar certification process for the electronic medical record systems that would be used by a hospital. We’ll have a better sense, over the coming year, of which systems have stepped up and built in all of the standards.

In terms of helping physicians or hospitals pay for electronic medical record systems, there have been a couple of initiatives in Pennsylvania. Payers are recognizing that it is a value to their insureds whenever their physicians have an electronic medical record, and a variety of pay-for-performance programs award points to a physician practice if they have an EMR. The Highmark Foundation has earmarked $26 million to be used for subsidizing physician implementation of e-prescribing and electronic medical record systems. Under that program, they would pay up to $7,000 per physician to help offset the cost of implementing an e-prescribing system. Almost immediately they were over-subscribed for the amount of physicians that they could fund through that initiative, and the mechanism that they created to funnel that money to individual providers is still awaiting 501(c)(3) recognition from the Internal Revenue Service. The IRS recently issued a memorandum that essentially said that a 501(c)(3) organization would not be in violation of their charitable status if they assist community physicians with implementing health information technology. Health information exchanges are in that same situation: PAeHI is incorporated as a not-for-profit in Pennsylvania, and is awaiting 501(c)(3) certification from the IRS, which makes a huge difference in terms of the avenues we can pursue for funding – both for operations as well as for pilot projects that PAeHI might sponsor.

MC: Yes there are. For example, the Utah Health Information Network, created about 10 years ago, is being used by all providers and payers in Utah as a clearinghouse for administrative transactions – electronic claims, eligibility queries, prior authorizations – for essentially all care that’s being provided in Utah. There is a per-transaction fee, as well as subscription fees for all providers that are participating, and that’s what supports the network’s infrastructure. Utah is looking to expand the network to include clinical transactions, like pushing lab results from a lab to the provider who ordered it, or to the multiple providers who are supposed to be getting results from that specific test, and charging a small transaction fee to sustain that additional traffic on their network. As another example, Inland Northwest Health Systems began in Spokane Washington about ten years ago as a way for hospitals in that community to get some economies by agreeing on a single health information management system. Essentially, they now have a single IT shop for 39 hospitals across Washington, Idaho, Montana, Oregon, and some hospitals in California.

MC: The Health Insurance Portability and Accountability Act had within it a series of provisions to help enable health information technology for administrative transactions and we’re now working on implementing a national provider identifier in those transactions. HIPAA also called for a universal patient identifier which, if we had it today, the matching of records across individual providers’ EMRs would be relatively simple. At this point, the federal government has decided not to implement that provision of the HIPAA legislation. Because we don’t have a universal patient identifier, the matching of records across EMRs is a very difficult process and each community is faced with having to implement a patient enumeration system that relies on as many as 5, 10, or 15 different key demographic facts about the patient to ensure that they’re identifying the same patient. That’s a huge hurdle that each local exchange has to figure out how to deal with, and there really isn’t good guidance on how to get there. There are a number of commercial software vendors that do this matching with different degrees of reliability, but you still have to have manual intervention whenever there’s not a 100 percent match.

Data privacy and security concerns also have to be addressed. There are a variety of ways to ensure that the data is secure in transmission. A patient privacy notice has to be given for each person, as per HIPAA. A similar kind of authorization needs to be given for patients to opt into health information exchanges. There are different models for how you implement a health information exchange: one would be to assume everybody is included and people would opt out; another would assume that everybody has to opt into the system. In either case there are privacy notices that have to be given and policies that have to be followed across all providers and participants in that exchange. PAeHI hopes to contribute some standard policies and standard language that can be adopted across the exchanges in Pennsylvania.

MC: I think the jury is still out on whether or not there’s increased or decreased exposure. We hope that care will improve as a result of having a complete, trusted clinical database about the patient that you’re treating available to the physician at the point of care, and that there will be less chance of having adverse drug interactions if the physician knows right up front that their patient has an allergy to a specific drug or is currently taking three other drugs and one is contraindicated. Ultimately, an improvement in the quality and process of care ought to diminish incidents in which patients are inclined to bring actions against individual providers.

MC: There are three different applications being administered through state government today to begin the process of collecting electronic data relative to patient condition. One is the Statewide Immunization Information System (SIIS), an electronic immunization registry that individual providers opt into voluntarily, which ultimately could serve as the authoritative immunization data bank for all Pennsylvanians. It is being supported through the state Department of Health and we hope to expose that project to more providers to get them to participate more willingly, and hopefully to create interfaces with electronic medical record systems that physicians have put in place in their offices so they can automatically populate that statewide registry. Similarly, the state has a Real-time Outbreak and Disease Surveillance System (RODS) that looks at descriptions of emergency department encounters for patterns of disease outbreaks. If there were a TB hotspot in the state, they would see it very quickly by using this system. There is also a National Electronic Disease Surveillance System (NEDSS) in which health care providers report data in electronic format so that the state can quickly identify public health concerns and easily backtrack and get to the root of an outbreak, for example.

If we’ve got a predominance of physicians and hospitals in Pa. that are participating in SIIS, for example, that system has a patient identifier that could be used as the identifier across unrelated providers in a local community. That’s one way that we could leverage a specific infrastructure that exists in Pennsylvania to enable other exchanges at the local level. Another way they can be used is for a local exchange to have electronic links into the state immunization registry, so it would not have to maintain or populate its own, separately.

MC: That is what’s envisioned by Governor Rendell’s Prescription for Pennsylvania. As I understand it, there is an executive order under development within state government to create a health information technology commission that, among other things, will be tasked with identifying specific standards for e-prescribing and electronic medical records, and would require physicians and hospitals to have installed, or have a plan for installing, an electronic medical record system that meets those standards in the not-too-distant future. That commission has not been formed yet. The specific timeframe for issuing the executive order, for creating the commission, and for setting a deadline for the commission’s work is not clear at this point.