February 2, 2009

President Obama’s $819 billion Economic Stimulus package calls for a $20 billion investment in health information technology. Approved 248-188 by the House of Representatives on January 28, the American Recovery and Reinvestment Act of 2009 (H.R. 1) awaits adoption of the corresponding bill in the Senate. On January 27, both the Senate Finance and the Senate Appropriations Committees approved provisions within their respective jurisdictions. The Finance Committee proposed an estimated $17.9 billion for investing in HIT. The Appropriations Committee’s measure would provide $5 billion for incentives to adopt electronic health records.

To create incentives for the adoption of Medicare-certified HIT systems, the Finance Committee’s proposal would establish temporary bonus payments beginning in 2010 for providers who adopt such systems. Later Medicare would penalize providers who fail to implement qualifying HIT through reduced Medicare payments.

Many readers are already aware of the incentives for HIT in the Physician Quality Reporting Initiative (PQRI). Measure # 124 may be reported by clinicians who have adopted and are using certified/qualified health information technology. Under a new program spun off from former PQRI Measure # 125, physicians who successfully report the e-prescribing quality measure under the E-prescribing Incentive Program will be eligible for a 2% bonus in 2009 and 2010. (The e-prescribing system used must be “qualified” and the physician must report the measure on at least 50% of eligible cases.)

The value of HIT was described thus by Finance Committee Chair Sen. Max Baucus (D-MT) in his “Call to Action” White Paper issued on November 12, 2008:

Health information technology (IT) can put comparative effectiveness research and other clinical decision-support tools at providers’ fingertips in real time, as well as improve the delivery of care across settings and help providers to better coordinate patient care. Health IT can also facilitate initiatives to improve quality performance and data collection and aggregation. Senator Baucus has stated that billions of dollars in funding for HIT should create many new jobs and reduce medical errors, as is demonstrated by a growing number of studies. According to the Congressional Budget Office, implementation of HIT as proposed would cut healthcare costs by about 0.3% from 2011-2019.

One of the latest studies appeared in the January 26 issue of the Archives of Internal Medicine. The authors obtained outcomes information from 41 urban hospitals in Texas and measured automation through questionnaires administered to both surgeons and primary care physicians. They found that hospitals with computerized notes and records, order entry and clinical decision support had fewer complications, lower mortality rates and lower costs. Amarasingham R. et al., Clinical Information Technologies and Inpatient Outcomes. Arch Intern Med. 2009;169(2):108-114

Will the economic stimulus incentives lead to a greater number of anesthesiology departments using anesthesia information management systems, or AIMS? The installed base of AIMS was somewhere between about 7% and 10% by the end of 2006. The three hurdles that AIMS will have to pass before they are widely adopted are the following:

• Improve upon pen and paper from the anesthesiologist’s point of view. The learning curve cannot be steep and the electronic interface cannot be slower than the paper record;
• Satisfy the profession that the electronic record will not increase liability, and
• Demonstrate a significant return on investment, i.e., to the hospital administrator who is likely to be purchasing the AIMS and its integration with the Operating Room Management System.

These factors are identified in the Introduction to Anesthesia Informatics, the comprehensive new book edited by Jerry Stonemetz, M.D. and Keith Ruskin, M.D. (Springer, 2008). Some overlapping barriers to entry were described in a study entitled “Electronic Health Records in Ambulatory Care – A National Survey of Physicians” by DesRoches et al. (N Engl J Med 2008; 359:50-60). In the DesRoches survey, only 4% of responding office-based physicians reported having a fully-functional electronic record. Capital cost, uncertain return on investment, concerns about liability, fear of loss of productivity during transition and the difficulty of find an EHR system to meet one’s needs were the principal reasons given. Yet the level of satisfaction with their EHRs was high among the small minority of physicians who had adopted systems.

Doctors Stonemetz and Ruskin demonstrate that there are too many advantages to be gained by the adoption of AIMS for the technology to fail to develop: nonfinancial returns on investment such as improved patient care with decreased effort in delivering that care; outcomes analysis and performance improvement; compliance with Joint Commission standards; documentation required for the Maintenance of Certification in Anesthesiology; readiness to participate in pay-for-performance initiatives; better patient preparation; reduction of errors, improved charge capture and operating room efficiency.

While integration with a hospital system is ultimately necessary for every fully-functional EMR or EHR, interoperability is less urgent for office-based practices. That is why EMRs that increase patient safety, productivity and charge capture may become available for pain medicine before they truly spread their roots in surgical anesthesia. ABC is currently exploring such EMRs.

The combination of federal economic incentives to spur the adoption of HIT and the growing need for the electronic clinical reporting systems that will allow anesthesiology to maintain its eminence as a six-sigma specialty in the domain of patient safety and quality care will likely accelerate the development of anesthesia EMRs over the next few years. Anticipating the growing interest in AIMS and anesthesia EMRs, we planned for future integration with such systems when we designed our proprietary F1RSTAnesthesia™ software on the Oracle platform. We are now discussing interfaces with several of the larger companies that have created the current generation of AIMS – knowing that the pace of evolution in this field is about to increase sharply.