Seeking cure for e-records
By Judith Messina
Published: October 19, 2008
In Brooklyn, when a nurse from the Visiting Nurse Service of New York first enters the home of a patient, she often finds herself faced with a dilemma: a medicine chest filled with medications, none of them the drugs the patient was supposed to take home from the hospital.
“It's a common event,” says a frustrated Pamela Brier, chief executive of Brooklyn's Maimonides Medical Center. “How do you deal with that and coordinate care?”
It's a scenario fraught with potential for harm, and it happens all too frequently in New York's fragmented health care system. Medical records are mostly on paper and follow a patient sporadically, if at all, from doctor to hospital to nursing home to home care. The result is that patients often get drugs from multiple providers, none of whom knows what the others are prescribing.
It's also a scenario that Maimonides, VNSNY and numerous other health care providers in Brooklyn are working to reform. They are poised to turn the key on the Brooklyn Health Information Exchange, a network that electronically transmits medical data between providers, so when a patient arrives home from the hospital, the VNSNY nurse no longer has to guess what drugs he should be taking.
Using an electronic tablet and a wireless Internet connection, the nurse (with permission) will be able to tap into a patient's hospital records on the spot, use software that warns of harmful drug interactions and, eventually, see the records of other providers.
“It's really important that we bring medical care into the information age,” says Dr. Thomas Frieden, New York City commissioner of health. “It's tragic that you have more fail-safe mechanisms buying a can of soup in a supermarket than you do getting medical care that can save your life or kill you.”
Statewide effort
Due to go live next month, BHIX is one of 26 regional networks that are part of an effort to digitize patient medical records and link providers in the new Statewide Health Information Network, or SHIN-NY. The goal is to improve quality, reduce errors and make a dent in the state's outsize health care bill.
At least, that's the plan. Similar networks around the country have stalled or died, victims of the low rate of automation in the small physician practices that in New York make up the largest portion of the primary care capacity. Some providers are also reluctant to share patient data with competitors. More discouraging, New York's nascent health care networks have yet to figure out how to pay the bills after public seed money runs out in a couple of years.
A national study of 145 regional health information organizations by Harvard's School of Public Health last year said that a quarter were defunct; only 20 were operating at even a modest level. While data this year show more networks in operation, few have achieved a working model.
“How to keep an organization going, keep everyone happy within it and get the funding—it's not there at this point,” says Peter Waegemann, chief executive of the Electronic Medical Records Institute, an education and research organization.
Indeed, health care has lagged virtually every other industry in making use of technology to cut costs and improve quality. Despite delivering uneven outcomes, the nation's health care system consumes a staggering 16% of the gross domestic product. The price tag is continuing to rise and is driving efforts to digitize information as a solution to spiraling costs and inconsistent quality.
“We frequently don't have the information we need,” says New York state Commissioner of Health Dr. Richard Daines. “It is driving a lot of cost, duplication, poor quality and the inability to shift resources where they're most effective.”
President George W. Bush has set a goal of 2014 to have a nationwide electronic medical network in place. Among the states, New York has committed the most money to the effort, nearly $160 million so far, under the 2005 Health Care Efficiency and Affordability Law, or HEAL NY.
The bulk of the funding has gone to build regional information networks. In New York City and Long Island, dozens of hospitals, nursing homes, community clinics and home care agencies are participating in 16 networks and projects. All participants agree to use compatible software and hardware and adhere to a set of privacy and security standards.
They all have one basic goal: to speed up the handoff of accurate and up-to-date medical information when a patient moves into a facility or between facilities. In Long Island and Manhattan, the new networks are starting by making hospital patient data available to emergency departments. That means that when a patient shows up with chest pain and an abnormal but inconclusive EKG, the ER doctor will be able to check previous EKGs and potentially avoid more invasive, costly and risky tests.
In the Bronx and Brooklyn, patient transfers pose the biggest risks. Large numbers of elderly and chronically ill patients shuttle constantly between hospitals, nursing homes and home care.
More information needed
While they wait for the paperwork to catch up, doctors and other providers often have no idea what tests or procedures were done in other facilities, making it almost impossible to continue appropriate care. Many medical errors, in fact, happen soon after a patient's arrival at a new venue.
“A lot [of error] is related to not having enough information,” says Dr. Benjamin Stein, an emergency care physician and director of the Long Island Patient Information eXchange. “Assumptions are made that are not correct.”
Ultimately, the networks will be able to interact, say, to transmit information on a patient transferring from a hospital in Manhattan to a nursing home on Long Island.
The payoff for all this activity is years in the future, making public funding critical to getting such projects off the ground. Some argue that health networks, like highways, are a public good and that their cost should be built into Medicare, Medicaid and commercial insurance reimbursements. How soon that might happen remains a question, given the state's already huge Medicaid tab and its severe and growing deficit.
In the meantime, networks are working to find ways to pay for themselves, such as charging fees to participants or acting as a service bureau for small physicians who can't afford the $10,000 to $30,000 price tag for an EMR system.
“The state funding made other people feel secure in investing and willing to make a bet,” says Rachel Block, director of the eHealth Collaborative, which is coordinating HEAL NY technology efforts around the state. “Even so, it is more of a short-term solution.”
GETTING CONNECTED
Key regional health information organizations in the New York area (followed by HEAL NY funding and selected stakeholders)
Brooklyn Health Information Exchange $16.8 million; Maimonides, Kingsbrook Jewish Medical Center, Metropolitan Jewish Geriatric Center, VNSNY
Long Island Patient Information eXchange (Nassau, Suffolk, Queens) $14.2 million; North Shore-LIJ, Nassau Health Care Corp., Cold Spring Hills nursing home
Bronx Regional Health Information Organization $14.1 million; Montefiore, Bronx-Lebanon, James J. Peters VA, St. Barnabas, Bronx Community Health Network, Jewish Home and Hospital
Primary Care Information Project $10.8 million; NYC Department of Health and Mental Hygiene, 171 community health centers
Interboro RHIO (Queens, Brooklyn) $9.7 million; New York Hospital Queens, Jamaica Hospital, Flushing Hospital, HHC Health and Home Care
New York Clinical Information Exchange $2.3 million; Beth Israel, NY-Presbyterian, Memorial Sloan-Kettering, Mount Sinai, Bellevue, NYU, Institute for Urban Family Health
Sources: State Department of Health, NY eHealth Collaborative
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