Sunday, March 9, 2008

HIT Helps Low Income Persons

Senator Whitehouse (D-RI) plus representatives from leading health organizations were all in agreement that HIT can effectively deliver much needed critical healthcare to low income persons. The Capitol Hill Steering Committee on Telehealth and Healthcare Informatics briefing met on March 5th to focus on the challenges that exist in providing healthcare to this important population in our society today.

Senator Sheldon Whitehouse told the attendees that he is excited to be working with the Steering Committee to move HIT forward. He emphasized that our broken healthcare system is resulting in a tidal wave of health care costs, the number of uninsured Americans is rapidly climbing and will soon hit 50 million, and as many as 100,000 Americans are killed each year by unnecessary and avoidable medical errors.

The Senator mentioned his involvement in HIT and that he has introduced major health IT legislation. In a recent action on March 6, 2008, the Senate Budget Committee resolution that passed included a bipartisan Health IT amendment sponsored by both Senator Stabenow and by Senator Whitehouse. The amendment emphasizes the need for Iraq and Afghanistan veterans to have integrated medical records and would create a reserve fund supporting widespread adoption of health IT. The measure also examines the efforts by DOD and the VA to create seamless, interoperable electronic health records for service members transitioning from active duty service to veteran status.

The Senator was pleased to introduce Marcia Montanaro, MSW, President and CEO, Thundermist Health Center, located in Woonsocket, Rhode Island. She has worked hard to bring health IT into the health center and the use of technology in the center is now helping many patients that have few economic resources.

Thundermist a private, non-profit community health center provides comprehensive healthcare services to 26,000 patients in three communities in the state. Most of the patients come from poverty stricken areas and are able to receive primary medical care, dental care, behavioral health visits, plus they have access to a full in-house pharmacy.

Montanaro reports that the Rhode Island Department of Health is in the process of building a statewide health information data system. To start the initiative, $5 million in grants came from AHRQ. However, AHRQ does not fund interfaces with EMRs, decision support functionality, the creation of a Clinical Data Repository, pilot test sites, web-based patient portals, secure clinical messaging, laboratory orders, and e-prescribing. In addition to the AHRQ funding, HISPC contributed $507, 214 with funding ending in 2007, but $200,000 was contributed in new funding. Also, RWJF contributed $96, 317 for one year ending in 2006, Medicaid Transfer supplied another $2.2 million, and the state legislation provided $20 million for IT upgrades.

Montanaro is excited that Thundermist now in the process of switching from a paper to an electronic health record will be completed this year. The HIT project will reduce staff, redirect costs by not chasing paper, increase care management, and enable physicians to better communicate with patients, and downstream, the use of technology will produce more primary care savings. To accomplish technology goals, quality has to be maintained, the problem of the uninsured and underserved populations has to be solved, the payment system needs to be realigned, and financing for HIT needs to be made available through HRSA 330 grants.

JoAnn Webster, Senior Director, Access Leadership, Ascension Health, St. Louis, Missouri reports that Ascension Health as a private safety net provider is the largest Catholic non-profit health system serving patients through a network of hospitals and related health facilities. The healthcare provided is patient-centered paying particular attention to the poor and vulnerable while providing for acute, long term, community health, psychiatric, and rehabilitation care and services.

According to Webster, the goal in 2020 is to have 100% access and coverage to all of the people served in the communities but in the meantime, specific actions need to be taken to develop a community wide formal infrastructure, fill community services gaps, design care models to improve healthcare, engage private physicians in the system, and obtain sustainable funding.

Webster explained how $4 million invested in technology in Austin Texas provides IT for enrollment software and for pharmacy assistance software. The IT system is used by the Southern Arizona HIE, Primary Care Action Group, Escambia Health Information Network, and Healthcare Access San Antonia.

The system in Austin Texas provides care for an indigent coalition, and has community safety net providers in three central Texas counties. Data is now collected in 60 localities, 16 hospitals, and from 45 clinics. The Austin healthcare program serves 600,000 patients, has maintained 3.1 million encounters, and has filled 531,000 prescriptions.

However, as Webster sees the situation, there are many challenges to sharing information among safety net providers. Many in this group have little or no experience with existing technology, the patient population is very mobile and moves in and out of the system, there is little data available from payers since the majority of patients are uninsured, and in general, there are scarce resources.

According to Susan Stuard, Director, Technology Policy Development, New York Presbyterian Hospital (NYP), the hospital with 5 main facilities is the largest private employer in New York City, with over 5 thousand physicians and residents. The healthcare system serves poverty populations in Washington Heights, and Central and East Harlem. Today, there is 20% poverty in Manhattan with 51% foreign born comprising 22% of Manhattan and this can be as high at 37%.

Stuard stressed the importance for an HIE to enable patients to have direct access to healthcare data on line and be able to use a PHR. However, in order to use the PHR effectively, NYP will have to address socioeconomic barriers such as language, access to computers, and privacy concerns.

The NYCareConnect Project with three domains includes community hospitals, home care and skilled nursing, and referring physicians. The system provides emergency department alerts, discharge alerts, and access to medical records. However alerts are sent via fax, since many physicians do not have EHRs.

Stuard mentioned that there are some key hurdles such as dealing with patient privacy but it is also difficult to obtain physician contact information. Obtaining this information is difficult because many patients don’t have a physician or they simply can’t remember their doctor’s name. It has also been extremely difficult not only to track data on community physicians but also to confirm the information.

Fortunately for the community, a diabetes web registry has been developed that draws from hospitals, health plans, and community doctors to create an integrated view of patient care. The registry also includes an assessment for depression because there is a high rate of individuals with diabetes and depression.

Feygete Jacobs, Chief Operating Officer, RCHN Community Health Foundation, New York, NY, explained that the Foundation as a not-for-profit supports community health centers nationally and is the only foundation in the country devoted exclusively to CHCs. Through strategic investments and partnerships in research, education, and advocacy the foundation sustains the CHCs.

The Foundation has only been in existence for two years, but the addresses three key program areas to include healthcare access and center stability, affordable prescription drugs, and health IT.

According to Jacobs, the CHCs have the same basic operating needs as other ambulatory healthcare organizations but developing technology can present problems. Sometimes the program requirements for federal funded programs and FQHC reimbursement requirements can add further complications. Unique state specific PPS implementation requirements can also be added to the mix of complications. In addition, limited financial resource for many health centers restrict adequate financing to support technology.

Jacobs wants to see technology activities include strategic investments, joint program initiatives, policy influences through research, needed financing in terms of loans and grants, and collaborations developed to search and find financing vehicles. For example, the Foundation is developing a strategic partnership with NACHC affiliates, Community Health Advocates, and Community Health Ventures, to further develop business opportunities for CHCs.

Gary E. Michael, MD, Clinch River Health Services, in the small town of Dungannon, Virginia, explained that health services are provided to 400 individuals and includes 3,500 active users serviced by 3 providers. As Dr. Michael pointed out it is very important to follow an Implementation Plan as the EHR is developed. Following their implementation plan resulted in greater efficiency, more understanding of how the system should and will work, and the system was able to be put into place much sooner.

The implementation plan that was used was divided into seven phases:

  • Phase 1 Strategic Planning—Develop a 5 year plan to improve performance. At the same time review finances and look at all funding opportunities
  • Phase 2 Partnerships—Use partnerships to see where they can help in develop the EHR
  • Phase 3 Staff Evaluations—Look at staff skills, organizational readiness, the process, patient flow, and then align personnel skills with what is needed
  • Phase 4 Define measurable outcomes—Examine costs, efficiency, productivity and satisfaction. Interview the staff for job functions and concerns
  • Phase 5 Review vendors—Select vendors, make purchases, and do on-site visits
  • Phase 6 EHR Implementation—Designate a supervisor or an onsite IT person to work closely with the vendors before the “go live” date. Examine policies in terms of requests, orders, password protection, and routine charting system upkeep. Conduct weekly team meetings to share lessons learned
  • Phase 7 Revisit the outcome measures—After one year reexamine all of the efforts to implement the plan and look for areas to improve

The EHR project captures more information, there are more total encounters, more daily recorded telephone messages, there is faster x-ray turnaround, and Rx refill time has been reduced. According to Dr. Michael, much of this is due to the implementation planning that was done beforehand resulting in an efficient EHR system.

Continuing Honorary Steering Committee Co-Chairs are Senators Kent Conrad (D-ND), Mike Crapo (R-ID), Sheldon Whitehouse (D-RI) and Representatives Eric Cantor (R- VA), Rick Boucher (D-VA), Bart Gordon (D-TN), David Wu (D-OR) and Phil English R-PA). The Steering Committee coordinates many activities with the House 21st Century Health Care Caucus, co-chaired by Representatives Patrick Kennedy (D-RI) and Tim Murphy (R-PA).

The next lunch briefing session to be held at noon on Wednesday April 2nd, 2008, will discuss “Training a HIT-Enabled Healthcare Workforce: Addressing Shortages.” The briefing will take place in the Rayburn House Office Building, Room B-340. For more information, contact Neal Neuberger, President, Health Tech Strategies LLC, at (703) 790-4933 or email