By Lawrence A. Solberg Jr., MD, PhD
2009-01-01
Dr. Solberg is Professor of Medicine in the Department of
Hematology/Oncology at the Mayo Clinic in Jacksonville, FL. Dr. Solberg
is also Chair of the ASH Committee on Practice.
Subduction zones arise where geological tectonic plates collide — a
reasonable metaphor for the collision of health information technology
(HIT), finances, and medical practice. The adoption of electronic
health records (EHRs) into general medical practice has been slow but
is likely to accelerate in part due to its potential to improve patient
safety and to promote evidence-based medicine. A recent survey of 5,000
physicians randomly selected from an AMA physician database by
DesRoches, et al. (N Engl J Med. 2008:359:50-60) revealed that
only 4 percent of the respondents have access to what an expert panel
determined would be a fully functional electronic-based system, and
only 13 percent had access to even a basic system. Why has there been
such a slow roll-out despite the near universal acceptance by experts
in quality improvement that HIT improves quality of care? Perhaps the
answer lies in inherent conflicts at the subduction zone. For the HIT
experts whose world revolves around large scale health-care systems and
their economics, the critical issues are the concepts of
"functionality," "interoperability," "security," "reliability,"
"financial incentives for adoption," "harmonization of standards," and
"measuring performance and errors." The community practicing physician
has other concerns related to more direct personal engagement (i.e.,
cost of acquisition and maintenance, steepness of learning curve,
ability to help in cost-effective practice management, and
communication with other providers relevant to that practice).
In hematology, the subduction zone landscape has two predominant
features. In large health-care systems, HIT environments often include
enterprise-wide EHR applications or collections of applications
utilized to support medical practice and research. These systems may
have fewer customized features supporting the chemotherapy-ordering
functionality. In selecting an EHR, the hematologist practicing in a
community setting has to carefully weigh a different set of financial
implications, medication management incentives, administrative gains
and costs, and oncology-specific features. "The Oncology Electronic
Health Record Field Guide" published by the American Society of
Clinical Oncology is a good resource to guide practices in selecting
oncology EHRs. While this resource is helpful for the limited purpose
of identifying a system that can handle oncology information, you may
want to purchase an electronic system that will not have to be upgraded
or replaced if you want it to interact with systems outside of your
office.
Since many physicians have concerns about the viability of an
electronic record, it is not surprising that an accrediting agency has
emerged that is designed to validate the utility of various systems.
That agency is the Certification Commission for Healthcare Information
Technology (CCHIT). CCHIT is an independent, non-profit, federally
authorized certification body for EHR products. Having a certifying
authority, free of conflict of interest, to help assure hematologists
that the EHR system they use or purchase has necessary functionality,
security, reliability, and interoperability is a commendable goal.
Additional impetus for CCHIT certification comes from national HIT
policies. In 2006, the Department of Health and Human Services began to
spur universal adoption of EHRs by creating a safe harbor for entities
such as hospitals to assist small practices in acquiring systems. The
safe harbor allows participants to cooperate without violating federal
anti-kickback statutes or the Physician Self-Referral Law (Stark Law).
A requirement of this safe harbor exception was that any such software
had to be certified as being interoperable by a certifying body, such
as CCHIT. On June 10, 2008, the HHS secretary announced 12 communities
that have been selected to advance the use of EHRs in the first-ever
national demonstration project estimated to affect 3.6 million
patients. Embedded in this pilot is an offer of bonus payments to
physician practices that adopt a certified EHR and use it to measure
and improve quality.
Does this mean that hematologist/oncologists should buy a
CCHIT-certified product? No. Most hematology-oncology applications,
including some of the largest and most widely used, have not been
submitted for certification and, as CCHIT declares on its Web site,
"Purchasers should not interpret a lack of CCHIT certification as being
of significance for specialties and domains not yet addressed by CCHIT
criteria." CCHIT has not yet established an oncology-specific work
group, even in its 2009 activities, but in time is expected to do so.
It is prudent, however, for hematologists engaged in evaluating or
purchasing EHRs to be familiar with this evolving certification story.
For More Information:
Certification Commission for Healthcare Information Technology
Health and Human Services
American Society of Clinical Oncology
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