Electronic health records (EHRs) have become a primary tool in improving the delivery of health care to military service members and veterans in the past decade. Now, from the moment a new recruit is sworn in, the Department of Defense (DoD) EHR will contain every medical treatment, check-up, or notation for that individual for as long as he or she is in uniform – active duty, Reserve, or Guard. Upon leaving the service and moving to VA health care, the DoD EHR is transferred and the total record of all health-related information is continued to the grave.
With these encrypted records available to authorized caregivers wherever a service member or veteran may be, getting emergency care, seeing a new doctor, filling a prescription, etc., have become far easier and faster. It also provides a valuable safety factor. When Hurricane Katrina destroyed VA facilities and records in New Orleans, La., for example, veterans only had to go to the nearest unaffected VA center, where their EHRs could be accessed immediately.
“We have made an effort to combine with the VA to create a single EHR, a lifetime virtual record, so from the point of entry into the military through their veteran status, that information can be shared between the military and VA and the private sector,” according to Dr. Jonathan Woodson, assistant secretary of Defense for Health Affairs and director of the TRICARE Management Activity.
The private-sector component is the next major step in the evolution and universal adoption of EHRs.
“We have to put patients first,” U.S. Surgeon General Regina M. Benjamin said. “It is so important that we get our records in electronic format.”
The Obama administration’s 2009 stimulus law included a provision calling for full adoption of EHRs by all health care providers by 2014 – a goal also set by his predecessor. Whether that constitutes a government mandate, however, or even requires sharing all patient records remains somewhat uncertain.
In an October 2010 email response to a query from CBS News, for example, a spokesperson for the Office of the National Coordinator for Health Information Technology, a division of the Department of Health and Human Services (HHS), wrote: “Providers will treat health information the same in the electronic world as they have in the paper world. They will record the information necessary to treat the patient in the electronic medical record [EMR].
“HHS’s rules for doctors to receive payments for meaningfully using health information do not require the recording of any particular test result or procedure. The rule does not require a doctor to include a cancer diagnosis, abortion, or HIV/AIDS diagnosis in an EHR. What is recorded in an electronic medical record remains largely a matter between the physician and the patient.”
Many private practice doctors, while adopting EHRs, have done so reluctantly and with considerable criticism of what most consider to be a government requirement. Converting from paper to digital records can be expensive and time-consuming, as is training staff – and doctors – to use laptops or electronic tablets/pads instead of the paper charts and patient records they traditionally carry into an appointment.
A 2010 study by the University of California-Davis, involving about 100 internal medicine, pediatrics, and family care physicians through a four-year period, found a significant – but anticipated – drop in doctor productivity, down 25 to 33 percent following initial implementation of an EHR system. Within a month, most internists had returned to pre-EHR levels or slightly better, while pediatricians and family doctors continued to show some degree of reduced productivity.
As a result, Hemant Bhargava, associate dean and professor of management and computer science at the UC-Davis Graduate School of Management, concluded: “Our research suggests that a ‘one-size-fits-all’ design does not work – the ideal technology design should vary by physicians’ requirements and workflow demands.”
Indeed, some doctors print out the EHR, put it in a file folder and take it into the examination room, making handwritten notes on the paper record, which is then handed over to a staff “scribe” to be transcribed into the patient’s EHR. Others have been so caught up with hunt-and-peck typing to fill out the digital forms that patients have complained they are being ignored.
A $27 billion federal earmark was created to help some private practice doctors pay for the conversion to EHRs – but only up to $44,000 each.
At the 2011 annual meeting of the National Association of Medical Directors of Respiratory Care, the group’s president – Dr. Steve G. Peters, a Mayo Clinic pulmonologist – said even his clinic’s substantial resources, including a pre-existing system-wide EHR platform, found compliance with the universal EHR law difficult, at best.
“It sounds easy, but it’s not. It’s very tricky and it differs from measure to measure,” he said, creating a major IT challenge. “We have 85 percent of it there, but the last 15 percent is hard.”
With many doctors predicting the government funds will cover less than a quarter of the actual costs of converting to EHRs, Peters issued a dire forecast to his association: “Many predicted what you’re experiencing, that this incentive will not buy much. No one will admit it, but there is de facto pressure that there won’t be private practice in the future. Everyone will need to report measures on hundreds of patients [and] will need to be part of an organization [to afford it].”
In various medical publications and websites, comments from private practice doctors across the nation tend to echo common concerns and frustrations – along with some with a more positive view:
- “We are not adopting EMR because we think it will enhance our productivity, reduce costs or improve the quality of care we provide … [but] solely to satisfy the desires of our federal and state governments.”
- “We do not adopt EMR with great enthusiasm for the benefits it will provide us or our patients, but with great anxiety, fear and trepidation.”
- “There’s clearly a future [in EHRs], but I don’t believe any of the systems in their current form are where they ought to be and where they need to be.”
- “At the end of the day, the good overtakes the not so good. Change is not always easy. There will be days when things don’t go well. It’s a transition. Educate, educate, educate – and in the case of some physicians, educate again.”
- “I think IT can and will improve quality of health care if used effectively at point-of-care.”
- “The idea that [some providers] would willingly exchange health information and thereby give competitors access to their patients’ longstanding health information and thereby make it easier for competition to woo away their patients strikes a lot of CFOs as totally crazy.”
- “Most providers say after they use [EHRs] for six months, they would never go back.”
Woodson is among those who believe universal EHRs not only are the future of medical record-keeping, but key to the future health of military service members, veterans, and civilians.
“The Military Health System – and more importantly, the TRICARE insurance program – serves more than 1 million beneficiaries. And many of those actually will be served in the private sector. So it is extremely important for us, if we are to monitor access quality and improve care, to communicate with the private sector,” he said.
“Our efforts, combined with the VA, are to look at how we build EHRs that can effectively communicate with the civilian health sector. We look at what kind of common applications and standardization will allow those EHRs to talk to each other going forward into the future.”
As part of that effort, in September 2011 the VA announced an expansion of its pilot Virtual Lifetime Electronic Record (VLER) program for sharing of veterans’ health records.
“The expansion of the VLER pilot program will allow more veterans and facilities to participate in this exciting new technology,” predicted VA Secretary Eric K. Shinseki, a retired general and Army Chief of Staff. “It will keep health care providers informed, improve continuity and timeliness of care, and eliminate gaps in health care information.”
Basically, VLER employs a portfolio of health, benefits, personnel, and administrative information to share VA, DoD, and selected private health care facility data across the secure Nationwide Health Information Network. Starting with a base of 50,000 signed authorizations from veterans, the health information exchange is now available at 11 VA medical centers, along with partnered DoD and private health care entities.
More than 900,000 text-based documents pour into the VA network every day, a number that would increase substantially with implementation of universal EHR sharing.
The next step for the VA may help reduce private physician reluctance – a technology called “natural language processing” (NLP) that scans the complete text in medical records, including doctors’ notes, performing a Google-like search for anything that might indicate an unrecognized problem. The process is considered especially useful in detecting possible post-surgery complications.
According to the Journal of the American Medical Association (JAMA), a scan of the 1999-2006 records of 3,000 VA patients would have provided early detection of such post-surgical complications as acute renal failure, deep vein thrombosis, sepsis, and pneumonia.
“The excellent care VA provides to our nation’s veterans relies, in part, on our electronic health records,” Dr. Robert Petzel, VA’s under secretary for health, told JAMA. “This latest study shows how we can continue to improve the usefulness of our electronic medical records.”
In its September 2011 issue, the VA newsletter “Research Currents” reported the NLP software used to scan physician-written progress notes, imaging reports, discharge summaries, etc., not only was more sensitive than other methods – including reviews by experienced surgical nurses – but detected some complications other methods did not. However, it also was considered to be less “specific” than other methods and produced some false alarms, but only slightly more than others.
“Moreover, the researchers suggest that NLP has advantages … because search queries can be easily customized and refined to do an even more accurate job of finding problems,” according to “Research Currents.” “Another plus, say the researchers, is that NLP can potentially be used while a patient is still in the hospital to help doctors catch adverse events – something that would be less practical with the automated method that uses billing data.”
NLP is part of the VA’s Consortium for Healthcare Informatics Research (CHIR), designed to find ways to get the greatest possible value out of VA EHRs for use by researchers, clinicians, managers, and even veterans themselves.
“If you can convert narrative text into structured data, you can improve your measurement of quality, improve surveillance of infectious diseases and adverse drug events, create new decision-support systems, and help clinicians improve documentation of problems in the medical record. There are a huge number of applications,” according to Dr. Matthew Samore, a clinician and epidemiologist at the Salt Lake City VA Medical Center who serves as lead investigator for CHIR.
The VA’s EHRs were designed with large open blocks doctors can use for “free text” documentation of patient care, providing significantly more detail than checkboxes or pull-down menus.
“There’s a real limitation to asking clinicians to input only structured data when they are evaluating patients, recording those evaluations, describing what’s happening with the patient, documenting their decisions,” Samore continued. “There’s a richness to free text, a communication benefit. It allows people to express themselves.”
To protect patient privacy for NLP applications outside immediate care, CHIR also is looking for the best approaches to “de-identify” patient charts, enabling researchers to access clinically relevant data without incorporating patient names or other means of identification.
In the past, the VA’s 1,400-plus care sites across the United States have consolidated information only at the regional level. But EHRs are part of a VA umbrella system called the Veterans Health Information Systems and Technology Architecture. As of the end of 2009, VISTA housed more than 1.3 billion clinical text documents (with nearly 1 million more added each workday), 1.4 billion images (1.7 million new daily) and 1.6 billion vital-sign measurements (again, nearly 1 million new records added each workday).
Another new initiative – Veterans’ Informatics, Information and Computing Infrastructure (VINCI) – will pull EHR data from all those sites into a single secure, centralized repository. CHIR projects then will make that data useful to researchers trying to determine if doctors’ free text notes, for example, could shed new light on the symptomology and progression of post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), heart disease, cancer, and even “super-bugs” that are resistant to current infection-control methods.
That collective database also means veterans who go to medical centers that are not part of a research program can be included in future research, providing a far more representative sampling of veterans nationwide. Eventually, that will include expanded new research covering decades of unbroken EHR patient data.
Efforts also are under way to merge VISTA data with DoD’s Armed Forces Health Longitudinal Technology Application (AHLTA) as part of the creation of a common EHR system to improve health care to 7.8 million VA and more than 9 million DoD patients. A March 31, 2011, report by the Government Accountability Office (GAO) stated incompatibilities between the existing VA and DoD systems were hindering a continuance of care for injured combat personnel and veterans.
In testimony before a Senate Appropriations Committee subcommittee on Veterans Affairs that same month, Shinseki said a joint VA/DoD EHR system would fix reported problems with AHLTA and improve the overall capabilities of both departments: “We [VA] have a terrific electronic health record, but again, it’s about 20 years in being. So we’re going to have to adjust also to ensure the sustainability of that system. It’s a great opportunity for both of us to put our heads together.”
In FY 2012 budget hearings testimony before the House Committee on Veteran’s Affairs, Shinseki reported on the VA’s digital data efforts.
“The effective use of information technology is critical to achieving efficient health care and benefits delivery systems for veterans … IT is not a supplementary function – it is key to the delivery of efficient, modern health care,” he told lawmakers. “Our health informatics initiative is a foundational component for VA’s transition from a medical model to a patient-centered model of care.
“The delivery of health care will be better tailored to the individual veteran, yet utilize treatment regimens validated through population studies. Veterans will receive fewer unnecessary tests and procedures and more standardized care based on best practices and empirical data.”
Another VA effort to improve EHR maintenance and acceptance is the Transformation Twenty-One Total Technology (T4) program. T4, subject of a five-year, $12 billion series of 15 contracts, is intended to modernize VA health care services “through transformational capabilities, systems engineering and other solutions that span the entire range of lifecycle-based IT, including cyber security, LAN/WAN management, and technical facilities support.”
“T4 is a major tool in the transformation of VA into a 21st century organization,” Shinseki said. “These contracts will enable VA to acquire services for information technology programs that will help ensure timely delivery of health care and benefits to our veterans.”
However, the July 2011 T4 contract awards brought an immediate flurry of protests from a wide range of the 75 or so contractors who failed to make the cut, including IBM and General Dynamics. While temporarily suspending contracting activities after the IBM protest was filed in August, the VA soon reversed itself, citing an “urgent and compelling” need to move ahead rather than wait for a ruling from the GAO, which already had denied a number of protests.
Elements of the T4 modernization plan not only will affect the VA side of EHR implementation, but may have subsequent impact on its interface with – and the implementation of – civilian EHRs.
The rapidly growing VA population will mean sharing facilities and physicians with both DoD and civilian hospitals and clinics and private practice doctors. Along with more complete and accurate lifelong tracking of patient health and care, that is a primary driver behind the development of a universal EHR system.
Whether mandatory – with serious penalties for non-compliance – or voluntary, EHRs must overcome not only current opposition from private practice doctors, but also patient concerns about the privacy of their medical records. With computer hackers increasingly gaining access to presumably secure private information, from Social Security and credit card numbers to shopping habits and financial records, many people are reticent about opening their medical records to similar cyber attacks.
That concern was heightened in September 2011 when some 4.9 million military clinic and hospital patient EHR back-up tapes – including Social Security numbers, personal addresses, and phone numbers – spanning 20 years were stolen from a contractor’s car. That followed an independent research report claiming four out of five medical IT specialists admit their facilities had at least one data breach in the previous year.
While many of those involved electronic records, the survey also reported a majority of civilian hospital administrators believe full implementation of EHRs compatible with DoD and VA systems will improve security.
In the end, according to a report by research firm Frost & Sullivan, the transition to a universal system of electronic health records will be achieved and physician concerns about costs, security, impaired efficiencies, etc., will be addressed, even if not fully resolved. But an important element that has not been a priority to date also must be brought to the forefront, noted senior industry analyst Nancy Fabozzi.
“Branding and outreach must extend beyond physicians to include non-physician health care providers, as well as health care consumers. Both should be directly engaged as advocates for the use of health information technology,” she concluded. “Patients need to understand the role EHRs play in driving quality improvements and care coordination among all of their [physician and non-physician] providers.”
This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.