Legislation in Congress boosts healthcare IT profile

It's that time again. With the 2004 presidential campaigns kicking into high gear, election trail promises are flowing fast and furiously. While both Republicans and Democrats tackle issues from the occupation in Iraq to the economy and gay marriage, healthcare remains at the top of many agendas. Even radiology may see some goodies in the campaign bag this year.

Legislation has emerged proposing everything from voluntary national information technology infrastructure standards to hundreds of millions of dollars in funding. The response from many radiologists to these legislative moves has been mixed. The refrain from radiology experts in imaging informatics is typically, "It's about time, and will it be enough?"

"The recent government proposals to invest in healthcare IT are a welcome, if not overdue, attack on a huge problem in the U.S.," said Dr. David Channin, chief of imaging informatics at Northwestern University. "We generate huge amounts of medical data and information, only a small percentage of which can be used when and where necessary for medical decision support. This leads to unsafe, low-quality healthcare practices, while increasing cost, inefficiency, and liability."

For many, the response has been one of relief, since any money and support is better than none. And radiologists working in informatics say the focus on healthcare IT will enable hospitals to provide better care to their patients.

"I believe that more investment in IT is the single most important quality and productivity initiative that can be taken in healthcare," said Dr. James Thrall, radiologist-in-chief at Massachusetts General Hospital. "Further improvements in quality of care will come from better systems, not by exhorting people to learn more and do better."

Thrall said that most preventable medical errors arise from flawed systems used in the care process, including verbal communication of orders and care instructions; handwritten documentation of the care process; and ad hoc visual identification of patients, drugs, and devices.

"This should be a huge boost to the healthcare IT industry. Even when legislation does not pass, it often makes people more aware of the issues. This kind of publicity is priceless. If legislation passes, so much the better," he said.

A CALL FOR STANDARDS

Even before the presidential campaigns got under way, legislators were priming the pump with several proposals aimed at bolstering the nation's healthcare information infrastructure. In July 2003, Rep. Nancy Johnson (R-CT) proposed the National Health Information Infrastructure Act (HR 2915).

"The information systems that securely give you 24/7 access to your bank account can be adapted to transform American healthcare into a 21st century system," said Johnson, chair of the House Ways and Means Committee's subcommittee on health, in a news release.

Such a system has not already been implemented because it is being blocked by a lack of comprehensive architectural standards to ensure interoperability, she said.

The legislation would designate a national health information officer who would work under the Secretary of Health and Human Services. This officer would work with both public and private healthcare entities to facilitate the adoption of voluntary national communications and data standards.

Also tackling the issue of system interoperability standards is a proposal by Sen. Hillary Clinton (D-NY). In December, Clinton sponsored a bill (S 2003) that would amend the Public Health Service Act, adding provisions to strengthen health information and information infrastructure, as well setting standards for the use of health information by both providers and patients.

"In the 1990s, many industries transformed through the use of information technology. Healthcare has not done so but can and should," Clinton said in a news release. "Information, in the hands of the right people, at the right time, drives quality and value."

The bill proposes a standardized reporting system for U.S. hospitals so patients could compare the quality of facilities. It would provide government assistance to hospitals seeking to improve and update their computerized communications systems. Tied to this goal is language in the bill advocating voluntary interoperability standards designed to enable various systems from different institutions to communicate with each other.

HIPAA contradictions

This call for national interoperability standards may sound good on paper, but many radiologists believe the task will be much more complex than the legislative proposals suggest. It becomes even more complicated when Health Insurance Portability and Accountability Act regulations are taken into account.

"Interoperability is a neat concept, but how can they ask for such systems on the one hand and then say on the other hand that you can't interoperate with other physicians?" asked Dr. Gary Wendt, vice chair of informatics at the University of Wisconsin.

The biggest problem with the call for national interoperability standards is that it may fail to consider the impact of HIPAA. While HIPAA was well intentioned, it was written by people with no experience or basis in healthcare who didn't realize the implications that restricting physician-to-physician communication would have on healthcare research, Wendt said.

HIPAA regulations did not consider that in the past research tended to be anecdotal, with researchers stumbling upon ideas and then sharing those ideas with colleagues as they went about fleshing them out.

"Now, that's impossible," Wendt said. "You can't just scratch your head and look under stones for information, because for every stone you turn you need to get a consent form. They want the systems to talk to each other freely, but HIPAA says that physicians can't freely talk to each other. The right hand and the left hand aren't doing the same thing."

Other radiologists note that while trying to achieve interoperability may be difficult, it is necessary. The way radiologists send images, using different types of image and data files, is just too slow for some physicians.

"Things like DICOM take too long. Interoperability is important, and users haven't pushed hard enough in this arena," said Dr. Osman Ratib, vice chair of information systems at the University of California, Los Angeles. "We have to stop providing lip service by saying, I can send the images, and then not being able to because the systems can't interoperate."

Neither of the two bills provides details on how exactly to achieve nationwide system interoperability. Ratib suggests the interoperability issue may be solved by open source technologies. In addition to developing and distributing open source tools, by debundling the code, users may be able to force a shift toward national standards. With HIPAA regulations to keep in mind, however, some constraints to using open source technology will remain, especially with regard to security.

"We must, of course, still protect the patient. There has to be a balance between the restriction of regulation and the convenience of openness," Ratib said. "What is useful for patient care should prevail. With open source, you can still protect the data. In fact, the best data protection encryption was developed by the open source community."

HOW MUCH IS ENOUGH?

Recent regulation hasn't all been about the technical nitty-gritty of promoting healthcare information technology. It has also been about money. From either side of the aisle, politicians are promising to throw more money at national healthcare information technology.

In October 2003, Sen. Bob Graham (D-FL) and Sen. Olympia Snowe (R-ME) introduced the Medication Errors Reduction Act of 2003 (S 1729), a bill that sets out to establish an informatics grant program for hospitals.

"Medication errors are preventable tragedies. With the right technology and training, hospitals can create near-error-proof systems for the protection of their patients and medical staff," Graham said in a press release.

The bill would offer both hospitals and nursing homes $97.5 million in grants every year from 2004 through 2013.

Also promising to improve the quality of healthcare by giving more money to the nation's hospitals, President Bush highlighted the importance of healthcare IT in his 2004 State of the Union address.

"By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care," he said.

In a radio address in January, Bush said his budget for the upcoming year would double current spending to $100 million for projects that use promising health information technology. For fiscal year 2005, the administration is proposing $84 million for the Agency for Healthcare Research and Quality. Of this, $50 million will fund grants to further develop and promote information technology.

But how much will $100 million here and $50 million there really do for the U.S. healthcare IT infrastructure? And how does this compare with what hospitals are already spending to enter the digital age? The University of California, San Francisco Medical Center will spend $50 million over the next two years to upgrade its clinical information system. The Fremont Area Medical Center in Fremont, NE, announced that it will implement a $6.5 million clinical information system, and the University Medical Center in Tucson, AZ, has implemented a $10 million clinical information system in three of its pediatric units.

"These recent (federal) proposals are a pound shy and a dollar short," said Dr. Howard Forman, a health economist and associate professor of diagnostic radiology and management at Yale University. "They are very limited. The government is putting forth that they are budgeting this amount of money, but they haven't necessarily even allocated the money yet. I'm concerned that this may be more symbolic and political then real."

Forman attributed the longstanding underinvestment in healthcare IT both at the macro and micro levels to the lack of a clear business case. The benefits that flow from improvements wrought by IT don't have an immediate, direct impact on the purchaser of that IT infrastructure. Indirect savings may occur from less paper and better access to information, for example, and the hospital may see improvement in overall healthcare quality through fewer medical errors. These positive externalities, as Forman calls them, may not mean more revenue, but they do result in a better quality of life.

"Because of positive externalities, because of the positive effects that are not related directly to the market transaction, there is a role for government," he said. "The overall benefits help society as a whole. But you only see the benefits over the long run, so it's very hard even for people in Congress to see the benefits of investing in this area."

Radiologists must do their part to make sure they get their piece of the pie. Even though radiology has led the medical industry in the use of IT, experts advise that radiologists remain vocal in pursuing some of the proposed grant money for their own departments. They will benefit the most if radiologists, at the local level, are very aggressive about informing their own hospitals how best to use these types of grants, according to Forman.

"This is healthcare IT's 15 minutes in the spotlight," Channin said. "We have the opportunity to revolutionize how healthcare IT is used and developed for the next decade in this country. This is an opportunity to radically change the way healthcare is practiced. It is a key juncture in time. If we mess up this opportunity, it will be a long time before we get another chance."