Digitally Dazed

Rhode Island's been quick off the mark. When it comes to health IT, it's got a lot going for it. The governor, Donald Carcieri, doesn't...
by | May 31, 2007

Rhode Island's been quick off the mark. When it comes to health IT, it's got a lot going for it. The governor, Donald Carcieri, doesn't just give lip service to the idea. He's had his agencies harness their regulatory powers, make pacts with the private sector and dip into state funds to make such health IT touchstones as electronic health records and e-prescriptions happen. He's even offered to issue a revenue bond to fund part of some health IT projects -- if the private sector will commit to funding the other part.

And yet, as Carcieri and the officials who head up his various health agencies readily admit, Rhode Island has yet to fully weave health IT -- and its potential to save lives, improve care and lower costs -- into the state's health care system. "Medicine," notes David Gifford, the director of the state's health department, "is one of the few industries that has not gone to the electronic world."

It's the cry heard 'round the country: Most of the technology exists to create a health IT system -- starting with the basics of setting up electronic health records for patients that can be shared across provider sites and an e-prescription system that can link physicians with pharmacies. But the obstacles are formidable and include a need for national standards for the underlying technology, a means to pay for the start-up infrastructure and a policy to address patient concerns over privacy. The resolution of most of these issues will likely depend on federal action, which could, for instance, help set a national standard for an EHR system that is accessible to physicians throughout the country. But a growing number of states -- Rhode Island among them -- are managing to inch forward by biting off bits and pieces of health IT and incorporating them, pilot by pilot, into their existing health care systems. "It's more important to start," says John Young, Carcieri's deputy director of health services, "than to think about finishing."


EHRs are, in effect, a digitized version of the manila folders that line the shelves and fill the file drawers in doctors' offices. An EHR system goes one key step further. It makes those "folders" accessible electronically to whoever needs them, wherever and whenever they need to look at them. In other words, an EHR system could connect an emergency room physician to the medical records of a patient who, say, arrives in the E.R. suffering from severe chest pains. With the patient's record in hand, the physician would know what medications that patient has been taking, what underlying health problems he or she has and what diagnostic tests have been run.

Such a seamless system is a long way off. But a handful of states are getting started by encouraging physicians, hospitals and other providers to convert their manila folders into electronic files. Even if the EHRs, which are also known as EMRs or electronic medical records, aren't interoperable -- for instance, the orthopedist down the street can't see the MRI results that are in files in a doctor's office two buildings away -- there are still advantages to having them. The digital folders bring efficiencies to the medical setting, making it easier for physicians to file insurance claims as well as remember to provide preventive therapies. But the key, of course, is that the conversion of manila folders to EHRs creates the building blocks for a full-fledged system.

All of which may be an esoteric concern, depending on who's paying the bill for the underlying equipment. A good number of hospitals are finding the investment worthwhile -- they are big enough as institutions to absorb the cost and benefit directly from the efficiencies. However, for physician practices, which are, in effect, small businesses, the price of admission may be too high. The average initial cost for EHRs for small group practices is $44,000 per physician or nurse practitioner, with ongoing annual costs of $8,400 per physician, according to researchers at the University of California, San Francisco. It is not clear that, at least in the short run, a physician practice would even reap any financial return on that investment. "There's a potential longer term reward for it," says Rhode Island's Young, "but depending on the size of the practice, they may not have the luxury of time to invest in IT."

To bring physicians into the fold, Rhode Island is, Young says, "pushing and promoting, as opposed to compelling." That means pressing various regulatory buttons to create incentives that will encourage physicians and other providers to invest in or extend their use of the technology. One investment carrot for physicians is an offer of higher reimbursement for Medicaid patients -- if the practice converts to EHRs.

Another carrot is less direct: It starts with the certificate-of-need process that controls whether hospitals win approval for expansions. There are always conditions attached to an approval, and Rhode Island is, where appropriate, tying in EHRs. Recently, for instance, a Rhode Island hospital applied for a certificate of need to set up a cardiac catheterization lab. The state approved the expansion, but one of the conditions was that the hospital agree to fund the implementation of EHRs in 10 nearby physician offices; another was that it deliver the results on patient catheterizations to physicians electronically.

There have been other pushes and promotions, some of them coming from a public-private partnership, the Rhode Island Quality Institute, which has a board made up of representatives from provider, insurer, payer and consumer groups as well as the state. Recently a clinical leadership committee got together to define a high-quality electronic medical record for those medical offices seeking to go paperless. "There are some crummy ones that just pave over the goat path and call it the highway of the future," says Laura Adams, president and CEO of the institute. The hope is that, with underlying criteria in hand, individual offices won't hard-wire in incompatible variations that could impede a future linking-up of facilities.

In the past few weeks, several states have taken even more aggressive steps to get EHRs in place in physician offices. New York State, for instance, is offering free patient-record software to high-volume Medicaid providers. State officials estimate that the software, which will include billing and scheduling features, will go to 1,500 medical practices.


The holy grail is the interoperable system -- the one that connects offices, labs, hospitals and clinics all over the country so that all data about a patient has a home and can be pulled up effortlessly when needed. That endeavor is hugely complex and expensive -- estimates run to $400 billion to build a national health information network. It is several years away at the very least.

What progress is being made is taking place locally, through regional health information organizations. RHIOs are being set up in metropolitan areas and regions all over the country -- in small states such as Rhode Island and Delaware, the whole state might be in one RHIO. But the RHIOs work independently of each other, and their approaches are shaped by the local health care market and business style. Indiana, for instance, has moved forward with its RHIO, Indiana Health Information Exchange, by starting out in 2004 with a simple service, a clinical messaging system, that was technologically easy and inexpensive enough to attract physician practices and hospitals. It has since added other services and counts many large hospitals and hospital systems as customers.

What works in Indiana, however, won't necessarily work in other states. California, which has struggled with finding successful regional approaches, had one of the most forward-looking RHIOs, launched in 1999 in Santa Barbara. But it shut down in March because of problems arising from privacy concerns over health records and funding for services. Those weren't the only issues: It was taking so long to work out a system that, one by one, health care operations that had agreed to participate started to drop out.

RHIO programs, in short, are evolving -- some more successfully than others -- but without a standard model that everyone accepts. Unfortunately, that could hamper an eventual national link up.

On the federal level, the Bush Administration has called for implementation of a nationwide EHR system by 2014 and has awarded six states federal grants to build health information exchanges. One of those states is Delaware, which used its $4.7 million grant, plus smaller contributions from the state and three hospitals, to pull together a statewide health information exchange with a small group of participants.

In the Delaware model, lab results and other medical records can be transferred from one provider to another. About a third of the state's physicians now use EHRs, but non-enabled physicians can still access the network's services -- such as digitized medical records -- with a computer and a high-speed connection. They would, however, end up printing out a record of, say, a lab test another physician ran on their patient and sticking it in their paper file for that patient.

It has hardly been smooth sailing for the new network. There have been difficulties stemming from variations in IT systems, business practices and organizational cultures. It is a work in progress -- but at least it's in progress.


Only slightly less complicated than putting up an EHR system is linking physicians and pharmacists with an e-prescribing network that allows them to exchange prescription information, review it and send it back and forth. The efficiencies could save money, paper and time but an even bigger reason for the push toward e-prescriptions is patient safety. According to a 2006 report from the Institute of Medicine, there are 1.5 million preventable medication errors a year -- an unhealthy number of them traceable to written prescriptions, which are often illegible. Thirty percent of calls from pharmacies to doctors' offices are about paper prescriptions that are either hard to read, wrong or for a medication that a patient has an allergy to or that will interact with another medication the patient is taking.

Clearly, e-prescriptions are fertile ground for improving the health care system. And Rhode Island has been one of the early leaders, thanks in part to its being chosen to be a national beta test for a system, SureScripts, developed under the auspices of the National Community Pharmacists Association and the National Association of Chain Drug Stores.

The state is trying a lot of other things to encourage health providers to get on board. The Rhode Island Board of Medical Licensure, for instance, put out a policy endorsing e-prescribing. The state has been sponsoring health IT fairs to bring together vendors of e-prescribing and electronic medical records and speakers who have adopted the technologies. Governor Carcieri gave a keynote address on the subject at one educational panel the state arranged. Rhode Island now is posting on the health department Web site the names of providers who are e-prescribing. "We're really promoting this as increasing the efficiency of the health care system," says Stephanie Kissam, chief of program development in the health department director's office. The measure of success, she says, will be if 75 percent of prescriptions are sent electronically.

So far, 90 percent of retail pharmacies in the state are currently capable of accepting electronic prescriptions and close to one-third of physicians are now able to write prescriptions within the system.

Physicians who've tried it say that instead of spending 10 minutes writing eight prescriptions for an elderly patient, they can click on items on a list of prescriptions in a few seconds. They can see immediately if the patient has allergies to a particular drug or whether it will interact with another one the patient is taking. If patients say they take the "purple pill" or the "green pill," physicians are able to look up which one they mean. All of this has helped to cut by more than one hour a day the time physicians and pharmacists spend talking to each other on the phone.

Meanwhile, the associations that back SureScripts are busy promoting e-prescriptions by giving annual awards to states with the best record -- the highest percentage of eligible prescriptions routed electronically. Rhode Island won the first Safe-Rx award last year, but this year it was edged into second place by Massachusetts. Nevada, Delaware and Maryland finished out this year's top five.

E-prescribing, of course, is just one aspect of the total health IT picture. And all states have a long way to go to make e-health a reality.