The momentum to move to a nationwide e-health network that includes electronic medical records and secure transmission of information between stakeholders is being fueled by entities of all sizes and influence-from grass roots-oriented non-profits to major health insurers to the federal government. This momentum is putting mounting pressure on the faction that may stand the most to gain yet seems most reluctant to participate-the health care provider.No one questions the fact that the e-health market is still in a state of relative infancy, in spite of the support being offered by the government, insurance, standards and vendor communities.

President George Bush has called for a system of universal health records by year 2015, yet the path to a universal health network is byzantine at best. At the larger network level, the federal government has been methodically plugging along, and in June asked for proposals to conduct trial implementations of the National Health Information Network (NHIN).

The NHIN has grass roots support from a variety of public-private e-health communities that want to make sure the momentum continues. In early June, a sustainable e-health data exchange model debuted, the capstone to four years of federally-supported work on a community electronic health information exchange (HIE) that is hoped by many to be the key to building the NHIN from the ground up. The effort is supported by the eHealth Initiative Foundation, a non-profit group comprised of affiliated organizations that want to drive improvements in the quality, safety and efficiency of health care through information and information technology.

In June, the Office of the National Coordinator for Health Information Technology in the Department of Health and Human Services published a request for proposals for health data exchanges of various types. The exchanges will cooperate to ensure they can implement an interoperable "network of networks" over the Internet.

The RFP follows work in the past year on prototype NHIN architectures by a federally contracted consortia comprising CSC, Columbia, S.C., IBM, Armonk, N.Y., Bermuda-based Accenture and Los Angeles-based Northrop Grumman.

REGIONAL SUPPORT

The success of the NHIN will largely depend on regional health information organizations (RHIO) in all communities. Three community HIEs (Indiana Health Information Exchange, HealthBridge in Cincinnati and Taconic Health Information Network, Fishkill, N.Y.) participated in the development of the model's tools, including a way to evaluate market readiness, a tool that estimates the value created by the HIE network, and a risk estimator for investors.

CareSpark, an RHIO in Tennessee, recently conducted an annual survey of RHIO and health information exchanges on behalf of the eHealth Initiative, which revealed that only 150 similar organizations were in various stages of development, Liesa Jenkins, CareSpark's Executive Director, told INN.

Some RHIOs serve their entire state; others serve a specific area that may be large or small. "Most RHIOs seem to be defined either by a political entity (state) or by the health care market," she says.

Spurred by the federal government, the health care community also wants to help establish standards that help streamline the use of electronic transactions between plans and providers. For example, the vendor community is creating systems that make the best possible use of standards in order to anticipate the growing needs of users.

"The Medicare Modernization Act of 2003 proved that online communications is the way things are going," says Maggie O'Hara, group vice president, marketing and customer operations, IVANS Inc., a provider of communications services to insurance and health care companies. "In many ways, real-time eligibility checking came out of the government's public opinion concerning the fact that they no longer wanted to accept paper." Vendors such as IVANS, which counts United Health, Wellpoint and Aetna among its customers, are focused on creating a number of transaction-based services for providers, payers and insurers over a safe and secure network.

Finally, the Council for Affordable Quality Healthcare (CAQH), a nonprofit healthcare alliance that provides solutions to promote interactions between plans, providers and other stakeholders, says more than 484,731 physicians currently use CAQH's credentialing database, and up to 12,000 providers register each month. In June, Georgetown University Hospital, Washington D.C., the first hospital in the country to participate in the Universal Credentialing Datasource service, said it now electronically collects all information required for provider credentialing and other business processes. More than 350 health plans, hospitals and managed care organizations are now using the CAQH service. And although most hospitals and group practices are using some form of EMR/EHR systems, individual doctors' offices are slower to implement.

In fact, most individual providers have yet to hear about CAQH's Committee on Operating Rules for Information Exchange (CORE) initiative, which develops operating rules that build on existing standards, such as HIPAA, to make electronic healthcare administration transactions more efficient, predictable and consistent, regardless of the technology. Of the more than 800 nationwide providers that participated in a survey conducted by IVANS, more than 84% were unaware of the initiative.

TRANSMISSION ISSUES

Although health insurers recognize the value of offering networked communications, some are still concerned about the challenges surrounding safe transmission of communication.

In a June 2007 Insurance Networking News online survey, 58% of insurer respondents identified privacy and security issues with payers and providers as their biggest e-health challenge.

Many carriers, such as Aetna and Blue Cross Blue Shield, have created their own networks. In 2005 Hartford, Conn.-based Aetna acquired ActiveHealth, a New York technology firm that provides personal health records (PHR) services for more than 14 million users. The acquisition enables the company to take clinical information from available administrative data, aggregate it for each member, and apply rules drawn from the medical literature to identify members whose care could be improved.

Jerry Wollscheid, managing director of BluesNet, a private data communications network operated for its member plans by Chicago-based Blue Cross Blue Shield Association (BCBSA), says his company has a similar worldview.

"We started down the electronic connection road a long time ago," he says. Wollscheid says the directives for electronic communications come from the top down, and are discussed regularly during board meetings. "This isn't taken on lightly," he says. A BCBS board committee that focuses on "emerging issues" is presented with all types of opportunities, and spends most of its time evaluating the ones it believes are most valuable, explains Wollscheid.

BCBSA president and CEO Scott Serota lives the company's commitment by serving on various committees of the CAQH, and Harry Reynolds, vice president of BCBS North Carolina, serves as chair of CAQH's CORE initiative.

BCBSA, meanwhile, has established physician and employer advisory groups to further enhance the market development of its Blue Health Intelligence (BHI) initiative, a national healthcare database comprised of de-identified claims information from up to 80 million lives.

Serota says the goal of the BHI is to provide sharper insight into healthcare trends, delivery and best clinical practices, and information about the efficacy of treatments and new medical technologies.

SO WHERE ARE PROVIDERS?

The support coming from the government, insurer and vendor communities for a health network, coupled with the number of providers using electronic credentialing services seem insignificant to the number of providers-especially those with smaller practices-signing up to use EMR/EHRs. In fact, sources interviewed for this story agreed that not much has changed since April 2004, when President Bush noted, "on the research side, we're the best, but on the providers' side, we are kind of still in the buggy era."

The benefits of EMR/EHR systems are known: At the patient level, they have been shown to help reduce adverse patient events and costs associated with duplicate testing and unnecessary diagnostic procedures. At the business level, EMR/EHRs also improve communication between health providers and the community in which they serve, including insurers. And although more than 75% of providers in the IVANS study currently employ some type of electronic eligibility verification technology, according to a study conducted by Bermuda-based Accenture, only 10% of physicians use modern EMR/EHR systems.

IVANS' O'Hara believes that the tough sell to doctors may have little to do with technology. "It's really a cultural thing," she says.

Insurers agree. According to a May 2007 Insurance Networking News online survey, 47% of insurers identified culture shift as the biggest hindrance to physicians' adoption of electronic health records, followed by "no clear value proposition," "cost," and "security."

"Some physicians think they'll get new patients anyway," says BCBS's Wollscheid. "But using EMR/EHRs is a huge change to the way they have conducted business in the past, and they've already been challenged by Medicare and Medicaid. Intuitively, providers know the most important benefits: more healthy patients and the right care to the right patient at the right time."

But, stresses Wollscheid, they also need to see the business benefits-will they make money? Get more patients in the door? Lessen the costs?

"No one has sold them yet," he says.

Regulatory compliance with HIPAA and frustrations with Medicare and Medicaid claims may also be contributing to a lack of provider participation in EMR/EHR systems.

"Careful consideration needs to be paid to the vendor of choice," says David Bailey, EDI operations manager for Blue Cross Blue Shield Arkansas (BCBSAR). "Not all vendors' practice management software has the technology in place to make physicians compliant with the various levels of HIPAA transactions."

Bailey advises "providers who use a 3rd party transaction service to verify that all transactions are in production with that entity and with all of the payers that the provider uses."

"Many docs use a clearinghouse," he says, "and clearinghouses and billing services are not covered under the HIPAA law. The 3rd party may promise support for 837 (institution claims) transactions, but many have not implemented 270 (beneficiary eligibility inquiries/replies) transactions, so the physician gets caught in the middle."

SOME SUCCESS STORIES

While the statistics may bear out a lack of provider momentum, there are a number of healthcare providers successfully embracing EMR/EHR systems.

Denise Hayes, office manager at Women's Health Specialists, (WHS) a Grayslake, Ill., obstetrics, gynecology and infertility clinic, reports that the concern at their practice, which employs a seven-member provider staff and a full-time nurse practitioner, is less about the larger network issues, and more about being providing efficient, safe patient care.

One year after implementation of the PrimeSuite and PrimeChart Web-based integrated practice management, EMR/EHR and managed care solution from Greenway Medical Technologies Inc., Carrollton, Ga., the WHS staff is fully up to speed-but not without some bumps along the road.

"It does take awhile, and there is a learning curve," she says. "Our physicians have come a long way; we've seen some that picked it up right away, some that still struggle."

WHS provider Joseph Capezio, M.D., described learning the new system as a "pain," but admitted that it's because he's used to writing, not tapping on a wireless PDA in his lap. "I came to this kicking and screaming, but I now see great value in using it," he said.

"The physicians do have to do their own typing," says Hayes, "but the system has allowed our practice to grow, and we've eliminated costs associated with transcribing dictation, purchasing paper such as charts, stickers, etc., and dealing with eligibility, such as the receptionist copying the patient's member ID card and calling the carrier to confirm coverage, and claims transactions with our carriers."

The staff now scans insurance cards into the system, and patients are asked to sign an EMR/EHR release form and are photographed for identification purposes. "All patients have responded positively," says Hayes.

Another major benefit is in the discounts the practice receives from its malpractice carrier, confirmed Hayes.

Some carriers are encouraging their provider members in other ways. BCBSAR's Bailey believes that by making education and training available to providers, the likelihood of buy-in increases.

The company's "Advance Health Information Network" (AHIN) gives providers access to patient eligibility as well as the ability to conduct electronic remits, and correct claims that have been rejected due to front-end edits-for free. The system processes HIPAA 270 eligibility requests electronically-once a 270 or 276 request is submitted into the AHIN system, a response is forwarded back to the provider within three seconds.

"We have 94% of providers in Arkansas using our AHIN system-given a choice, providers would rather use it than go through customer service, so it's working very well," reports Bailey. "We offer onsite training, and when providers see how easy the system is to use, and realize that they can use the system to retrieve information and actually fix errors, it really helps reduce problems and it saves everyone time."

And there are still other benefits to using EMR/EHRs, adds Bailey. "In the smaller offices, doctors often times hire family members to perform all the administrative tasks," he says.

"For example, we all know the importance of getting billing right the first time. When you consider the fact that one person trains the next-based on their own, oftentimes limited knowledge of their billing system-there is no real opportunity for enhanced training. We've tried to remove the barriers to this."

THE FUTURE

IVANS' O'Hara believes that, with the best intentions, challenges still reside with all stakeholders, including hospitals, which are notorious for having silos of data.

"There are challenges even at the insurer level. Often times, eligibility is tracked in one system, claims in another," she says.

And much needs to occur before grass roots exchanges will be able to ensure they can implement an interoperable healthcare "network of networks" over the Internet. But soon, recognizing the current state of patient demographics, the question to providers still on the fence about using EMR/EHR systems will no longer be "if" but "when," say sources interviewed for this story.

"We are operating in an increasingly consumer-driven health care market comprised of more and more younger patients who want it now, and want it digital," says IVANS' O'Hara."

For the consumer/patient, that digital world includes a personal health record (PHR), which gleans data from the EMR, and could include pharmacy, claims, and health-related data actually entered by the patient, into a password-protected format.

Bailey agrees. In an effort to provide value to its providers and members, BCBSAR is evaluating making PHRs available on members' cell phones.

"Imagine being rushed to the hospital...doctors don't have access to your health information or pre-existing condition, so the patient pulls out a cell phone, logs on using a user name and password, and retrieves his/her PHR," he says.

BCBS's Wollscheid takes a philosophical view. "None of this is going away," he says. "No matter how hesitant providers might be, we aren't stopping. We continue to view the value of the use of information generated by technology, and because information is power, we'll continue to use it to benefit the healthcare consumer. It's up to the provider to decide how best to manage patient care."

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