State to shift to electronic medical records

BYLINE: Don Harris

Imagine being able to actually decipher a prescription your doctor writes for you. Impossible? Not if Arizona manages to shift from paper to electronic medication prescribing and medical recordkeeping under a proposal being championed by Governor Napolitano. The target date for implementing Arizona Health-e Connection is 2010, and a considerable effort has been put into drawing up a roadmap to get the state's medical community there. The idea is to prevent errors that occur most often in hospitals, nursing homes and rehabilitation facilities where patients are prescribed multiple medications.

Chris Cummiskey, director of the Government Information Technology Agency (GITA) and chief information officer for the state, says Arizona Health-e Connection is a follow-up to President Bush's executive order in 2004 establishing a health-information technology office in the U.S. Department of Health and Human Services. "The notion is to encourage e-recordkeeping at the federal level within ten years," Mr. Cummiskey says. Ms. Napolitano launched Arizona's effort on Aug. 30, 2005, through an executive order of her own that led to the roadmap, a product of some 300 public and private sector participants who focused on five specific areas - clinical, financial, technical, legal and governance. The premise is that "a statewide infrastructure to exchange health information electronically will improve the quality and reduce the cost of health care in Arizona. " Patt Rehn, executive director of the Arizona Nurses Association, agrees. Ms. Rehn, one of the roadmap participants, says electronic prescribing and recordkeeping is an important factor in helping nurses enhance patient safety. "A computer system minimizes the possibility of a mistake," she says. "Clearly we recognize that to provide safe care to patients we have to have some continuity of records and medical information. " Although each hospital might have an electronic history of a patient while that person is in the hospital, those records might not be available to other medical practitioners. Prescriptions written in hospitals often go electronically to the in-house pharmacy. Handwritten prescriptions can be a problem But if the prescription is handwritten, that's when there is the potential for problems. "Now, when we look at the doctor's handwriting, it's not always clear what medication is being prescribed," Ms. Rehn says. "That leads to a lot of phone calls to the doctor from the nurse practitioner or the pharmacist. " The Arizona Health-e Connection roadmap says shifting to an electronic, paperless system would: * Ensure that health information is available at the point of care for all patients. * Reduce medical errors to improve patient safety. * Avoid duplicative medical procedures. * Improve coordination of care between hospitals, physicians and other health care professionals. * Further health care research. * Enhance public health and disease surveillance efforts. * Encourage greater consumer participation in their personal health care decisions. * Enhance the business environment for small and large employers and reduce state expenditures by controlling health care costs. Mr. Cummiskey says the roadmap ensures that the needs of rural communities and small physician practices are accommodated. "Physicians in rural area offices and clinics who participate would be able to connect to a statewide infrastructure, making it possible for service delivery to move throughout the system," he says. Although the roadmap is a statewide plan, some initiatives will be implemented in regions, or so-called medical trading areas, which generally is defined as an area where groups of physicians, hospitals, labs and other providers work together to serve consumers. Patient privacy an issue A key element of shifting to an electronic system is protecting patient privacy. "We need to be mindful of the need to protect the privacy of a patient's information," Ms. Rehn says. Mr. Cummiskey emphasizes the security factor. Doctors could ship prescriptions electronically to a local pharmacist "once we work out the security issues," he says. "It would be transmitted to all partners, all pharmacies, through a secure gateway. " A patient's medical history, if based on someone's memory or recollection, might not be all that accurate, especially in an emergency, Ms. Rehn says. A patient or relative might not be able to tell a doctor or nurse which blood pressure pill he or she is taking. "Patients have expectations that we will provide the safest and best health care, and this is an avenue and method for a health care provider to access accurate information," Ms. Rehn says. Currents records: 'Sea of paper' How are medical records kept now? Ms. Rehn says, "Some offices have electronic records and some hospitals have them. Some orders are written in computers and some are done in part by hand. It's not consistent across the board in every hospital. Sometimes the expense precludes going to electronic records, either in rural or metropolitan areas. " Mr. Cummiskey says, "It's a sea of paper piled up over decades of faxing things back and forth. " The next step is to set up an infrastructure so health care practitioners can get connected in a cost-competitive fashion, Mr. Cummiskey says. "The first purpose of the roadmap is to build ownership through the stakeholders, not by government," he says. "It will be owned by private associations that coordinate discussion and provide a clear sense of where we're headed. " One of the strategies is to partner with organizations already involved in health care information technology, which is utilized in a doctor's office, a lab or hospital for such things as keeping track of medical records and billing. Other strategies include providing guidance, direction, education and incentives. Some Arizona health providers, including the Southern Arizona VA Health Care System, previously known as the Tucson VA Medical Center, and the University Medical Center and its outpatient clinics, have led the way in reducing medication errors by replacing medical charts and prescription pads with electronic prescribing and patient records. "The next task is health information exchange, and what Arizona will have to do in the next four or five years to set up the infrastructure," Mr. Cummiskey says. Health information exchange is the necessary infrastructure that would include a central Web site, health care terminology translation tools, a master patient index, and an authorization system. Strategies focus on leveraging existing projects and databases and developing key statewide resources for data access and sharing. "All states are getting into the process, and Arizona has catapulted ahead of the pile," Mr. Cummiskey says. In 2005 and 2006, 38 state legislatures introduced 121 bills that specifically focused on health care information technology. "We are in a partnership with e-health initiatives in Washington," Mr. Cummiskey says. "We hired a consultant close to Health and Human Services who worked on the roadmap. We went to other states, including Florida, Texas and Michigan. " Planning has been funded by St. Luke's Health Initiatives and BHHS Legacy Foundation, and other grants, including one for $350,000 from the National Governors Association, to explore the privacy and security issues, how to come up with the best practices and how to handle those factors at the local level, Mr. Cummiskey says. BHHS Legacy Foundation is an Arizona non-profit dedicated to improving community health and access to health care for Arizona children, families and seniors. Since its inception in 2001, the Foundation has invested more than $20 million into local communities through grants to non-profit organizations, programs and projects. "We're also working with ASU and private law firms that specialize in privacy in health issues," Mr. Cummiskey says. "The grant concludes next April, and we will share our information with other states, hopefully to benefit them. "The Legislature appropriated $1.5 million from the General Fund for planning in rural areas and to help encourage what's going on in Tucson with a regional health information organization. " The Arizona Health-e Connection is in a transition period, during which a non-profit organization will be set up, as Mr. Cummiskey puts it, "to take a handoff from the government committee by the end of the year. " It will have a private board of directors, and the state will play a role, but will not be the catalyst. "A lot of folks will be at the table," Mr. Cummiskey says. "It will go in incremental steps. The first step is to establish a statewide portal for statewide messaging. If doctors don't want to subscribe to e-prescriptions initially because of the cost, they can take some steps to be part of it through a secure system. " The National Governors Association grant is being used to determine a litany of changes required, including what protections are needed and any regulatory concerns, Mr. Cummiskey says. "The only way it will work is if the public has confidence in the system," he says. "Down the road, citizens will become empowered to manage their own prescriptions, what's going on with their own health and be able to look at their own medical history, with proper safeguards. " Ms. Rehn of the Nurses Association sees a potential problem regarding medical history. "How far back do you go, where do you start, and how much do you include?" she says. "Every page from a hospitalization is not needed. Maybe a summary of what the doctor dictates would be sufficient. Especially in the development stage, you don't want to include too much information or it will be overwhelming. People won't use it. "