Presented by
George Arges
Senior Director
Health
Data Management Group
American Hospital Association
Members of the National Committee on Vital Health Statistics, I am George Arges, senior director of the Health Data Management Group of the American Hospital Association (AHA). The AHA represents nearly 5,000 hospitals and health systems, networks, and other providers of care. We appreciate this opportunity to present our views on the development of a patient medical record system and its electronic transmission.
Hospitals and health systems have a strong interest in this area, particularly since their patient records are at the heart of this information system development. The AHA is supportive of a well planned, adequately financed, and incremental approach for the development, adoption and use of computerized patient record systems. As many of you are aware, in November of 1991, the AHA assembled a work group to identify practical steps toward the implementation of computer-based patient records. In April of 1993, the work group issued its report to the Secretary of Health and Human Services. The report mentioned ways that the patient record could improve the quality and efficiency of patient care. It further explained how computers can be used to manage patient information across time and place and how they can be linked to practice guidelines and other decision support tools. To do so requires a health information infrastructure composed of several important components: a computerized patient record; standard definitions, codes, and formats; and, high-speed communication highways.
Since the issuance of that report, we have seen vast improvements in computer processing, storage, and communication capabilities. The good news is that these advancements occurred with a corresponding decrease in the cost for acquiring this technology. Despite these improvements, providers are generally finding it difficult to obtain the necessary financing in order to undertake such a major information system investment. Another factor influencing their decisions is that the corresponding benefits remain relatively small.
Because of the passage of the Health Insurance Portability and Accountability Act of 1996, (HIPAA) providers will soon have to implement the new administrative simplification provisions. These changes will impose additional costs on institutional providers to upgrade their information systems without corresponding benefits for the provider sector.
Interpretation of Congressional Intent of the administrative simplification provisions means to reduce administrative costs through the adoption of standards involving the nine routine financial and administrative transactions exchanged between providers and payers.
Factors preventing or delaying the development and widespread implementation of uniform standards for patient medical record information and its electronic transmission.
One of the primary factors preventing or delaying more widespread implementation of the computerized patient medical record is the lack of universally accepted standards for defining, coding, storing, and transmitting medical data. Another important reason for the delay is the cost to implement such system changes is enormous. Today there is still little scientific evidence that implementation of such a system will reduce costs. Or, whether such a system will always lead to better quality and/or management of patient care.
Is the private sector able to address these problems satisfactorily? What is the role of government for assisting the private sector in the guidance, development, coordination, and implementation of standards for patient medical record data and their electronic transmission? How might the government help to improve the standards processes?
It is important for the private sector to define the patient medical record in terms that are more concrete. The primary purpose for the medical record is to document the course of a patient’s illness and the treatment received. Consequently, the patient, physician, and health care institution are the primary beneficiaries of its development. Others also find the patient record as a useful reimbursement supplement. These varied uses challenge us to define what additional information should be documented for inclusion in the record and what can be maintained at the departmental level. Today providers are faced with the challenge of how to design an information infrastructure that can utilize the patient medical records for purposes other than what was originally intended. We believe that it is important for the entire private sector to come to agreement on the type and amount of data and documentation that is necessary to include in a patient record of any kind. Such an activity would be a good starting point for further computerization of the patient’s medical record. Doing so requires not only the financial commitment from these organizations but also a willingness to work through a lengthy process. Ultimately, the process should produce a national model that clearly defines the content and documentation to be routinely maintained in the patient medical record.
The government has several important roles. First, government health programs, like Medicare and Medicaid, should be actively engaged in helping to define a core set of data standards pertaining to the patient record. Secondly, it is important for the government to establish a fundamental framework for the creation of a safe and secure national electronic infrastructure. This must include development of national standards protecting the confidentiality of patient information along with adequate security provisions that will protect the storage and authenticity of each electronic patient health record. There must be a national approach, which preempts state laws and can impose severe penalties for violation or misuse of patient medical record information.
The goals outlined in the 1993 report, Toward a National Health Information Infrastructure, indicated that the time needed to create a viable computerized patient record is a long one. It also laid-out a series of incremental goals that include an estimate of the costs needed to complete each of these goals along with a brief description of the benefits associated with its implementation. When making nationwide changes we must be clear about how the changes would affect an organization’s resources. The examination should include an assessment of the job skills, management commitment, and other hurdles or obstacles that may lay ahead. Such an examination should apply more scientific rigor to the analysis and provide a blueprint of the steps that one followed.
Which standards related to patient medical information and its electronic transmission would:
A) Add the most value for improving the quality and efficiency of health care for the nation? Why?
B) Be most important to the business or goals of your organization? Why?
C) What is the business case for more rapid standards development and implementation?
Clearly, the content standards that describe information about the patient’s care are extremely important. Earlier this year, a notice of proposed rulemaking concerning the HIPAA transactions called for the migration to ICD-10-CM for diagnoses coding of disease and illness, along with the adoption of a new procedure classification system. Additionally, a corresponding effort to train staff on the proper application of the new classification system will be necessary. These changes alone will require providers to make large investments in their clinical information systems.
Today, the Internet is changing the way our nation exchanges information. As we look to enhance communications and promote continuity of care among physicians and other care professionals, we need to look at the new electronic standards that should apply and the availability of a secure high-speed electronic network. Otherwise, the full benefits of establishing an electronic based patient record will be lost.
Finally, the NCVHS should keep in mind the price tag associated with the implementation of such a massive undertaking. Already the fix to the Y2K problem will impose a larger price than what many of our health care organizations are capable of absorbing. Upcoming changes to the clinical code sets will further strain a provider’s financial operations. We need to be sensitive on how these massive information changes are affecting the delivery of patient care. Today, financial resources that would be earmarked for patient services have to be diverted to solve Y2K problems. Providers and others must be certain that plans that call for the implementation of an electronic patient record are the right ones. Moreover, it is important that the NCVHS give thoughtful considered before any massive nationwide deployment takes place. In the meantime, establishing a fundamental framework for the future infrastructure needs to begin, but one that allows providers the flexibility to gauge when their operations should move in this arena.
We look forward to working with the NCVHS on this important endeavor.
Thank You.