Americans bank online. Americans file taxes online. Yet, if a child gets sick it could take hours or days for doctors to get current and necessary medical records, especially if a child has multiple health care providers. In a country that invented the Internet, there is no reason why medical records can't be online as well.

The much ballyhooed proposed economic stimulus package of President Obama appears to be the largest public infrastructure project since the 1950s and promises hope for millions of Americans. Yet the most overlooked aspect of this plan could be one of the most meaningful aspects: the promise to upgrade the country’s HIT infrastructure.

While rightfully much has been made about new green-collar jobs, the extension of broadband access and improving the nation’s educational system, building a HIT infrastructure is as important and critical as the economic, educational and environmental considerations. We saw first-hand what happened when medical records were destroyed by Hurricane Katrina and patients and health care providers were left with no information on medications and past medical history.

But in order to really make HIT work, President Obama must mandate interoperability. There are numerous HIT operating systems and the new administration should bite the bullet and set standards over the objections of the industry. This would promote open data exchanges among vendors, and compatible systems would speed reform activities along.

Of course, health IT vendors and even hospitals will object and say we run the risk of compromising patient privacy (or that patients will be lost to competitors), but this is something that needs to be done and the safeguards can be put in place. If these systems talk to one another, it lead us to better quality of care and it’s certainly a much better approach than some in Congress who have suggested withholding Medicare payments for doctors who refuse to adopt HIT. Providing loans for health IT also does not get us to the adoption phase. President Obama and Congress must make the business case for doctors to adopt this technology.

Study after study has shown that electronic medical records and e-prescriptions save time, money and lives. As the President pointed out in recent remarks, e-prescribing has been proven to help reduce medical errors:

• A 2007 Dana-Farber Cancer Institute study of an e-prescription pilot program showed the program helped prevent 724 bad drug interactions or drug allergy issues.
• A Harvard Medical School study, e-prescribing could save $845,000 a year for every 100,000 people filling prescriptions.
• The Medical Group Management Association (MGMA) found that e-prescribing with pharmacy interoperability can significantly reduce the $10,000 spent annually per physician on phone calls with pharmacies related to prescription refills.

To not use a basic and available technology to protect patients and potentially drive down the cost of health care is a mistake. We must encourage the medical community to invest in this infrastructure through incentives and credit programs. We must work to ensure that it is affordable for doctors to have access to the most up-to-date technology.

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Nancy Brown, CEO of the American Heart Association, advocates a "significant federal investment" in HIT. Here's what she has to say:

"We should not hesitate in making a strong and sustained investment in health information technology

(HIT), particularly clinical decision support. HIT is a building block for health reform and a significant federal investment is needed to stimulate provider adoption of HIT and fully achieve the promise of HIT to prevent medical errors, improve quality of care, reduce health disparities and stimulate a sluggish economy. In the scheme of things, it’s a small price to pay for a maximum return on investment. According to a recent RAND Corporation study, patients with coronary heart disease received only about 60 percent of recommended care. Although women and minorities are more likely to experience health disparities, the RAND study found that all adults in the United States are at risk for receiving poor care. Health IT can help translate scientific advances into the improved treatment of all patients including those with certain cardiovascular diseases. The American Heart Association has proven HIT’s effectiveness in improving the quality of care that patients receive through its Get With the Guidelines clinical support program. Get With the Guidelines are in use by more than 1,400 hospitals and has collected more than one million patient records in the program’s database. But many more healthcare providers and their patients could benefit from the use of these types of tools."

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It’s impossible to deny that quick access to health IT guides better diagnostics and treatment decisions and can improve the quality, efficiency and safety of patient care. It’s also impossible to say how much money it will take to adopt a nationwide health IT system. What we do know is that doing nothing will be far more expensive.

Congress is taking important steps to help integrate health IT into routine care processes in all health care settings through H.R. 598, the HITECH Act. While not perfect, H.R. 598 confirms the government’s commitment to lead—it requires the federal government to develop standards for an interoperable IT system by a specific date.

The move to an interoperable health IT system will be an expensive one for the nation’s health care providers. The HITECH Act also confirms government’s commitment to funding—it provides meaningful and significant financial incentives for hospitals and doctors to move to these new technologies.

Financial resources, while critical, are one of many challenges in the development of a nationwide health IT system. The HITECH Act recognizes this, and in addition to providing funding, also creates a health IT research center to help disseminate best practices and lessons learned from existing IT efforts.

An immediate investment in health IT is critical to the sustainability and efficiency of our nation’s health care system. This notion has been emphasized repeatedly by President Obama, and we stand ready to work with Congress and the Administration to encourage the adoption and use of health IT to help providers deliver timely, high quality care.

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Across the board, everyone seems to agree that investing in HIT is a great idea. We can make our health care system more affordable while simultaneously increasing quality and patient safety. What's not to like?

As usual, the devil is in the details. Congress tried to pass HIT legislation in the 110th Congress, but many provisions were controversial, and there were serious disagreements between the House and Senate. Worse, in the 109th Congress, HIT legislation was debated ad nauseum, and eventually passed in both the House and the Senate... but the two bills were never reconciled, so no final law was enacted.

Does this sound like an issue that we should jam through Congress in a stimulus package that is being rushed through and not debated at great length?

Many in the business community are committed to funding investment in HIT, including codifying the Office of the National Coordinator of HIT, funding grants and loans, developing national standards, and more. But there is a very real concern that the current legislation, as proposed, may do more to hinder the adoption of HIT than to promote it. The bill is full of dangerous, onerous "privacy" provisions that would make it hard for doctors, hospitals, and pharmacies to use HIT - creating new criminal penalties for them, and probably causing them to hire more lawyers, negating much of the savings we hope to see from HIT.

Do we really want to pass a HIT bill that might scare health care providers away from HIT? And isn't this obviously an issue that is important enough to spend some time working through until we have a compromise everyone can support?

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The economic recovery package currently being discussed contains funding for broader adoption of health information technology (health IT) across the nation. Creating a nationwide health IT infrastructure—which includes health records exchange and e-prescribing—is essential to improving health care quality and care coordination. The draft House bills appear to be on the right track, but some questions will need to be answered in the next several weeks to clarify the role states will play in helping build out the infrastructure that would allow for exchange of medical records.

There are two primary reasons why states should serve as the chief organizing entity and essential partner with the federal government in this effort. First, states play a critical role in protecting consumer privacy and ensuring the security of medical information storage and transmission. Expansions of health IT must conform to current state privacy and security requirements, and states will need to enforce these and other consumer protections. The current House bills seem to recognize this vital function of states.

Second, states represent the most appropriate level of government that can work with key stakeholders—including providers, hospitals, and public clinics—to establish a practical business model for a health information exchange and oversee its construction and operation. States can work with their stakeholders to negotiate what technologies to use, how data will be stored and exchanged, how start-up costs will be funded and distributed, and what rates will be charged. Furthermore, states can use their role in the health care marketplace (i.e., state employee health plans and Medicaid) and regulatory authority to ensure that providers purchase interoperable systems, connect to an exchange, and use the system.

The current House bills encourage states to engage in planning the build out of health IT infrastructure and include a provision for planning grants. The bills also include substantial incentive funds for providers to adopt health IT. What is unclear in the bills, however, are start-up funds and a process to create the exchange or “highway” that connects the providers and sustains its operations (i.e., a business model). We believe states should be in the forefront—with their stakeholders—of crafting the business model for the exchange, helping build the infrastructure, and setting rules to sustain its operation. We hope final versions of the recovery package will clarify these roles.

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Can We Actually Spend the Money that Fast?

The biggest problem we will have with the economic stimulus package in general is spending the money fast enough to make a difference. It won’t be easy to give away $20.0 billion over two years for HIT as proposed in the economic recovery package. Existing HIT grants processes are inadequate to handle this much money. The Agency for Healthcare Research and Quality (AHRQ) currently provides about $166.0 million for HIT research and 17 states currently provide $124.7 million in funding for HIT implementation (National Conference of State Legislatures). The best way to distribute this much money quickly is as an add-on to Medicare payments for providers who adopt certified systems. But this alone is not enough to assure that the money is wisely spent.

For example, we must be sure that existing standards and certification processes assure that these systems are genuinely interoperable and can be used to measure and improve health care quality. It may be less costly and more appropriate to our long term objectives to support web-based systems rather than the stand-alone systems now in use by individual providers. We also need to identify those entities that are eligible and decide upon eligible uses of funds such as software, hardware, ongoing maintenance, and training. By the time standards are set and criteria are established, the economy could be on the mend.

Regardless of the recession, investing in HIT makes sense only if it is done right. Our own analysis of president Obama’s health care plan during the campaign is that his HIT proposal would reduce health spending by about $111.0 billion over ten years, with potentially significant health benefits. However, even these modest savings are in jeopardy if funding is ill directed. If we are going to add this much to the national debt that our children must pay off, we should take care to leave them with something that works.

Updated Jan. 26 at 9:55 a.m.

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To fix our economy we have to fix health care – the system is literally crushing our chances for economic recovery that can last. It’s why we absolutely need to invest in healthcare information technology now as part of the recovery package. It’s not controversial – and it will let us start getting the building blocks in place for a healthcare system that lowers costs while providing higher quality and covering everyone.

Improving health IT will help eliminate redundant tests and treatments. It will give patients, businesses, and other healthcare purchasers access to cost and quality reports. And it will reward innovation by doctors and nurses – plus create good jobs.

Over a million members of our union work on the front lines of health care every day. From their experience we know that a few steps will be key to making the change to better health IT a success:

– Involving health care workers as new technology is introduced and providing good training.

– Providing strong security and privacy protections so patients trust that health IT serves their needs.

– Offering financial rewards and creating IT standards that push hospitals, doctors, and other providers to make the upfront investment.

SEIU members also have broad experience working in the healthcare safety net, delivering care to low-income and underserved communities. These safety net providers will need extra federal help to be able to invest in health IT – and it’s the communities they serve that can benefit the most from the information tools and care practices that come with better technology.

Our advice to Congress is simple: include investment in health care information technology in the economic recovery, give the Department of Health and Human Services the authority to work out the details and patient protections through a transparent and inclusive process, and hold all of the stakeholders who receive funding accountable for results that deliver for patients.

The longer we wait to fix health care the worse it gets. Health IT is a step we can, and should, take right now.

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I'd like to echo Karen Davis's point about the savings we can reap in the long term with Health IT investment now.

The consulting firm Deloitte LLP released a report last week saying e-prescriptions combined with putting comparative effectiveness research to use would save a whopping $530 billion over 10 years. For the up-front investment of $10 billion, we can in effect multiply our money by a factor of 10.

With that kind of potential return, it's hard to understand why anyone wouldn't want this as part of President Obama's economic recovery package.

Last week, a key Senate Democrat, Sen. Barbara Mikulski, D-Md., expressed concern about moving too quickly on health information technology. Here's what CongressDaily reported Jan. 15:

Lawmakers working to spur the adoption of electronic medical records should not rush the process, a key Senate Democrat said today. As she chaired a Senate Health, Education, Labor and Pensions Committee hearing on health IT, Sen. Barbara Mikulski, D-Md., said that she will work with colleagues and President-elect Obama to craft a sound bill but cautioned against moving too quickly. "I've seen where we've ... thrown a lot of money at stuff, and ended up with a boondoggle," said Mikulski, who chairs the Senate Commerce-Justice-Science Appropriations Subcommittee as well as the HELP Aging Subcommittee. "We can't afford to waste time on a fool's journey." Mikulski predicted an Appropriations Committee markup of the stimulus bill would occur before February, but after the hearing she declined to say whether the Senate version would contain the $20 billion for health IT that House Democrats included in the $825 billion stimulus package they unveiled today.

MONEY, YES… BUT A WHOLE LOT MORE

Until recently, I had the honor of serving for several years with one of the most dedicated groups of individuals I’ve ever known—the National Committee for Vital and Health Statistics (NCVHS), which is dedicated to clearing the way for a health information system for the future, including electronic health records.

The Committee saw and dreamed of endless possibilities and opportunities. Patients could access their records when they moved. Back-up systems would be in place in case of a disaster such as a hurricane. Duplication of services could be avoided, and drug and treatment interactions better monitored. And perhaps most importantly, the Centers for Disease Control (CDC) and researchers elsewhere could have in place better early warning systems, as well as better data with which to track or solve problems such as increased incidence of cancer in a region or growth nationally in prevalence of Alzheimer’s disease or autism.

But the complications are also many: privacy concerns and the related unwillingness of some to recognize that there are only safer, but not fail-safe systems; evolving standards for both software and clinical terms; and perhaps most significantly, limited incentives among insurers, doctors, and government workers themselves.

More information at times can even be a threat. As my own doctor said to me, electronic health records only give the insurers more information with which to badger him. Another doctor complained of the extra time it would take him to type in (and check) input on each patient, as well as the fear of buying the wrong software. Insurers, in turn, have limited incentives in an open-ended, cost-plus system, since at times, inefficiency can actually increase profits. Moreover, many standards cannot be set by government, just as government doesn’t want to determine what software we should use on our computers.

How can we change this broken system of incentives? Well, the government can and should continue to increase its funding of information technology and electronic health record experiments, as it has done for a number of years already. But I think more is required. All government insurance systems such as Medicare need to pay more for e-prescribed drugs, less for those not e-prescribed; and more for lab tests maintained electronically and sent to the CDC when appropriate, less for those not maintained or sent. The government needs to put a lot more money and effort into its statistical systems and clinical trials and break down the extraordinary barriers to sharing and merging data across agencies. Government workers need to be rewarded not just for limiting bad publicity but for the number of valuable health research projects they foster both internally and through outside researchers (who currently have limited access to data that might be developed with electronic health records).

Perhaps most importantly, doctors and insurers, as well as other providers and intermediaries, are not going to drive reform—it must be consumer-driven. With enough consumer demand for the protections that an expanded system of electronic health records could provide, doctors, insurers and hospitals finally will have the incentives to make it happen despite all the obstacles.

How can that demand be generated? Among other means, I have suggested that the Secretary of Health and Human Services ought to help stir up this demand by nothing less than going around the country telling people that for their own protection and well-being, they ought to demand that electronic health records be maintained by their providers.

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Those of us who regularly attend health-care conferences have come to appreciate that the U.S. appears to be lagging many other developed nations in the application of health information technology (HIT), even though American entrepreneursdevelop much of the hadrware and software of first-rate HIT systems.

What can explain this paradox.

One explanation is that our health system has not been spending enough on HIT overall. It often is the stepchild in the budgeting process of hospitals and medical practices. Government has a role to play here by mandating the use of certain types of HIT, but also to help fund it. There have been too many unfunded mandates on the health system. Government support for IT can be justified by the fact that a good part of it is in the nature of a public good.

A second reason for our lagging in HIT is that, by the very nature of our pluralistic health system and the equally pluralistic HIT industry, we have produced a veritable HIT Tower of Babel. The manner in which hospitals code what they have delivered is not always understood by insurers who have to pay for it, which has given rise to an industry of interpreters in between. This is inefficient.

A third reason for our lagging in HIT is that there have been too many fly-by-night outfits in this industry, often elaving their clients in the lurch over the longer run. HIT applications must be serviced reliably, over the long haul. Many users have been sorely disappointed in that area in the past.

Like Mao Tse Tung was right about the virtue in letting thousand flowers bloom, so is John Goodman when he worries about too heavy a hand of government on the HIT industry. In principle, letting thousand flowers bloom outght to bring out the best in technology development. But in HIT, there IS great virtue in imposing certain commonalities on the industry -- a comon nomenclature and system-wide interoperability. The HIT industry has had close to three decades to develop such commonalities on its own. It has failed. So now it is time for government to impose these commonalities at long last, along with public subsidies for its implementation.

Left to ist own devices, the HIT would continue the balkanization of its software, just as the cell-phone industry has not so far succeeded in agreeing on as simple a thing as common portals for charging the devices or plugging in earphones. In fact, the cellphone industry is a good metaphor of what a high tech industry left to its own devices can beget: a mishegaz.

A federal allocation of $10 billion a year for 5 years seems a reasonable support level for a first rate American HIT system. The industry has had three decades to demnonstrate that we will never get there without the strong hand of government, just as we wouold not get there if government ran the whole show.

But I hope that we shalll be taught again in the next decade that there are wasy for government and the private, entrepreneurial sector to work together, without corruption, to work for the common good.

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Investment in national health information technology (IT) infrastructure is a crucial component of the upcoming economic stimulus package--one that will expand employment in the health sector in the short-term and facilitate improvements in the quality of care, gains in efficiency, and lower costs over the long run.

Recent analysis of the 2006 Commonwealth Fund Survey of Primary Care Physicians confirms that advances in IT are making it easier for physicians to provide coordinated, high-quality care by streamlining many crucial tasks, including sending patient reminders, creating disease registries, prescribing and refilling medications, and viewing lab results. Meanwhile, several Commonwealth Fund-supported studies have suggested that a business case can be made for the adoption of health IT, both nationally and at the individual facility level. The Commonwealth Fund report “Bending the Curve” put the aggregate savings of promoting health IT investment at $88 billion over 10 years.

Despite the promise of improved quality and lower costs, utilization of health IT in the United States is substantially lower than it is in many other industrialized nations. The 2006 Commonwealth Fund Survey of Primary Care Physicians highlighted a particularly stark contrast between the United States and the Netherlands, with 98 percent of Dutch primary care physicians reporting the use of electronic medical records compared with only 28 percent of their American counterparts. Further Commonwealth Fund work has shown that upwards of 99 percent of Danish primary care physicians now use electronic health records. This pattern persists when examining the prevalence of other IT functions such as electronic prescribing, decision support, and computerized access to test results.

It is important to note, however, that health IT in isolation is not a panacea for all that ails U.S. health care. Data from high performance health systems within the United States and throughout the broader international community show that investments in health IT must be made alongside equally strong commitments to performance improvement activities and performance-based culture. Experience also shows that government support is needed to ensure high levels of adoption and improved outcomes. Not only are common definitions and protocols required to enable the efficient exchange of information, government funding is needed for the creation of health information networks or portals, accreditation of vendor systems, and the development of incentives for health IT.

It's high time that U.S. health care take advantage of the gains made in technology over the last decade by including health IT investments in the stimulus package. The development of a national health information network will bring much-needed benefits and savings to the nation in years ahead.

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I’m afraid that any bill that passes Congress is likely to do more harm than good. Why? Peter Neupert (Microsoft) knows more about health IT than just about anyone. This is from his testimony last Thursday:

Congress … should take care not to mandate or prescribe any particular technology or development model. Doing so could deprive healthcare providers of the best available solutions, exclude scores of American companies and workers from competing to supply these solutions, and weaken incentives for further private-sector investment and R&D—just when we as a nation should be trying to strengthen these incentives.

Health Information Technology (HIT) is infrastructure just like roads and bridges. We have neglected to invest in both for far too long. The impediments to HIT spending are formidable -- doctors are reluctant to take the time to adopt HIT, we lack the ability (but not the technology) to exchange data, and privacy concerns still threaten to derail legislation. Yet, we are now in a position to overcome them. A few successful public and private HIT programs are creating a greater awareness of what HIT can accomplish and we now have the political leadership necessary to disseminate these models and re-create their success across the country.

So, what are our first steps? To lay the foundation for utilizing health information technology, I recommend the following:

1. Make broadband access in rural areas possible ASAP.

2. Announce that we are moving to electronic medical records and that additional privacy protections will be implemented simultaneously, including mandatory notification of breaches by HIPAA-covered entities and vendors of Personal Health Records, and strengthening HIPAA's rules on marketing and business associates' use of Protected Health Information.

3. Offer time-limited incentive payments for purchasing and implementing health IT systems / software packages that meet certain functional requirements (e.g., interoperability), privacy protections, and are designed to achieve quality of care improvement goals (e.g., point-of-service decision support tools, managing chronic conditions). A certifying entity like CCHIT should be charged with blessing these systems.

4. Offer incentives to providers who acquire a new and approved electronic records system that includes decision support. Incentives could take the form of grants, partial loan forgiveness for primary care clinicians, etc. and could be awarded in reverse proportion to provider group size (the smaller the group, the more money per doctor). Incentives should include support for skilled personnel to train clinicians and staff in use of electronic information system, convert paper records, and eventually to help maintain electronic records systems. A timeframe should also be established whereby physicians must have an HIT system operational to continue to receive Medicare payments.

5. Reward states that are utilizing HIT systems to control their Medicaid costs and improve care (e.g., chronic care management that has both medical and behavioral care components), and provide additional incentives for states that move their state employees into a similar system.

6. Offer grants to states or regions that organize and operate health information exchanges to offer private, secure access to the new data.

7. Create and fund webinar and conference presentations by physicians from those who have successfully implemented HIT systems (e.g., Kaiser Permanente, the VA, and the Billings Clinic) to teach the country's reticent physicians that HIT is a good thing. Provide financial incentives (e.g., free CME credit) to encourage physician attendance.

Much like roads and bridges, interoperable HIT is necessary to make all other aspects of a quality, affordable health system possible. Bringing 21st century information tools to our health system is an investment worth making, but it is also an investment that will take some time to fully mature. We cannot restore the health of our economy without fixing our health care system, and we cannot fix our health system without bold initiatives to encourage HIT.

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