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zoom RSS 医療記録電子化への疑問/米国医療事情 オバマ政権

<<   作成日時 : 2009/03/27 19:50   >>

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 連邦政府が医療記録のコンピュータ化を促進するために190億ドルを投入する計画が決定した。
 NEMJの最新の2つの論文が、医療記録の電子化を医療改善と医療費抑制という目標達成のために使用することには問題が大きいとしている。
 一つ目の論文は、約3,000病院の調査によるもので、電子化はわずか9%にすぎず、政府研究では利用が極めて低レベルであることを示した。研究では患者記録のデジタル化のみを調査し、院外の専門医やクリニックとの効果的な通信に使用されたかどうかを調べていない。
 二つ目の論文は、ボストン小児病院の専門家が、既存医療記録ソフトの採用に連邦予算を何十億ドルも使用することは大きな方針ミスであると断言している。アップグレードや改良が高価でベンダの切り替えが困難な専有技術を使った前インターネット時代のソフトウエアを提供しているとしている。このようなソフトウエアの使用を刺激するのではなく、革新的な電子医療記録アプリケーションをオープンなソフトウエアプラットフォームで開発促進するような規則を設定指導する立場を政府は取るべきであると言っている。
 Mandl-Kohane モデルでは、ソフト開発業者は薬剤アレルギー警告や治療ガイドラインといった医療記録様式の新しいアイデアを持ってアプリケーション開発を行い機能を追加したり代用したりできる。
 こうしたアプローチが、競争・柔軟性・低コストへと道を開き、長期的に医療改善に結びつく。現在のテクノロジーを固めるために政府の資金が使われることは医療改革の進行を妨げることになる。税金を投入するからには、どのようにテクノロジーを医療改善に役立てるかを中心に考える必要がある
 景気刺激パッケージの一部であるオバマ政権の医療テクノロジー計画は、医師1人あたり40,000ドル以上、病院あたり数百万ドルまで(several million dollars)医療電子記録採用を誘発するための支出を含む。支給は数年間なされ、議会が定義を保健福祉省に任せたけれども、「保証された」記録に対して「有意義な使用」した場合を基準とする。
 業界専門家は、利用誘導のための財政支給は、医療電子記録の普及を促進するのに十分であると言う。病院の最新調査では、デジタル医療記録システム採用への最も大きい障害の一つはコストである。
 ハーバード・メディカル・スクールの教授Dr. David Blumenthalは、先週オバマ政権の医療情報技術コーディネータに指名されたが、医療改革のために、医療記録電子化はツールであり、メディケアとメディケイドへの給付をより良い治療結果にたいし支払うかたちにシフトし、品質と効率をゴールとする、としている。
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富裕層への増税で医療費捻出/米国医療事情 オバマ政権
http://kurie.at.webry.info/200902/article_44.html
医療記録の電子化と個人情報保護の戦い/米国医療事情 オバマ政権
http://kurie.at.webry.info/200902/article_33.html
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Doctors Raise Doubts on Digital Health Data
http://www.nytimes.com/2009/03/26/business/26health.html
By STEVE LOHR
Published: March 25, 2009

Now that the federal government plans to spend $19 billion to spur the use of computerized patient records, the challenge of adopting the technology widely and wisely is becoming increasingly apparent.

Two articles, to be published on Thursday in the New England Journal of Medicine, point to the formidable obstacles to achieving the policy goal of not only installing electronic health records, but also using them to improve care and curb costs.

One article reports that only 9 percent of the nation’s hospitals have electronic health records, based on a survey of nearly 3,000 hospitals. The study, financed by the federal government and the Robert Wood Johnson Foundation, is the most definitive measure to date of the use of computerized patient records by hospitals. The government-backed study found a far lower level of use than some earlier, less rigorous surveys.

The study, the authors said, measured only the adoption of digital patient records. The survey did not ask whether the electronic records were used to advance the health policy goals of the federal plan, like tracking the quality of care and communicating effectively with outside specialists and clinics to coordinate a patient’s care.

“We have a long way to go,” said Dr. Ashish K. Jha, an assistant professor at the Harvard School of Public Health who was the article’s lead author. “And we did not measure effective use. Even if a hospital does have electronic health records, it does not mean it is sharing information with other hospitals and doctors down the road.”

In a second article in the journal, two experts in health information technology at Children’s Hospital Boston assert that spending billions of dollars of federal funds to stimulate the adoption of existing forms of health record software would be a costly policy mistake.

In the article, identified as a “perspective,” Dr. Kenneth D. Mandl and Dr. Isaac S. Kohane portray the current health record suppliers as offering pre-Internet era software ― costly and wedded to proprietary technology standards that make it difficult for customers to switch vendors and for outside programmers to make upgrades and improvements.

Instead of stimulating use of such software, they say, the government should be a rule-setting referee to encourage the development of an open software platform on which innovators could write electronic health record applications. As analogies, they point to other such software platforms ― whether the Web or Apple’s iPhone software, which the company has opened to outside developers.

In the Mandl-Kohane model, a software developer with a new idea for health record features like drug allergy alerts or care guidelines could write an application, and those could be added or substituted for a similar feature.

Such an approach, they say, would open the door to competition, flexibility and lower costs ― and thus, better health care in the long run. “If the government’s money goes to cement the current technology in place,” Dr. Mandl said in an interview, “we will have a very hard time innovating in health care reform.”

To justify spending taxpayers’ money, the government program must expand digital records beyond routine tasks like billing to focus on “how the technology will be used to improve clinical performance,” said Herbert S. Lin, a senior scientist the National Academy of Sciences, an advisory group to the government.

The Obama administration’s health technology plan, which is part of the economic recovery package, includes incentive payments for adopting electronic health records ― more than $40,000 per physician and up to several million dollars for hospitals. The payments are spread over a few years and are based on “meaningful use” of “certified” records, although Congress left defining those terms to the Department of Health and Human Services.

The incentive payments, industry experts say, are enough to greatly accelerate the adoption of electronic health records. In the new survey of hospitals, the cost of digital record systems was cited as the single largest obstacle to adoption.

Dr. David Blumenthal, a professor at the Harvard Medical School, oversaw the hospital study. Last week he was named the national coordinator for health information technology in the Obama administration. In a conference call to discuss the study, Dr. Blumenthal declined to talk about his plans in detail.

But clearly, he sees electronic health records as a tool to reform health care, and the Obama administration intends to shift Medicare and Medicaid reimbursement toward paying for better health outcomes, which will be measured and monitored using technology.

“The goals are quality and efficiency, instead of just putting machinery in offices,” Dr. Blumenthal said. “If we encourage better performance, then physicians are going to find ways to improve performance. And health information technology is one crucial way to do that.”

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Published at www.nejm.org March 25, 2009 (10.1056/NEJMsa0900592)

Use of Electronic Health Records in U.S. Hospitals
Ashish K. Jha, M.D., M.P.H., Catherine M. DesRoches, Dr.Ph., Eric G. Campbell, Ph.D., Karen Donelan, Sc.D., Sowmya R. Rao, Ph.D., Timothy G. Ferris, M.D., M.P.H., Alexandra Shields, Ph.D., Sara Rosenbaum, J.D., and David Blumenthal, M.D., M.P.P.

ABSTRACT

Background Despite a consensus that the use of health information technology should lead to more efficient, safer, and higher-quality care, there are no reliable estimates of the prevalence of adoption of electronic health records in U.S. hospitals.

Methods We surveyed all acute care hospitals that are members of the American Hospital Association for the presence of specific electronic-record functionalities. Using a definition of electronic health records based on expert consensus, we determined the proportion of hospitals that had such systems in their clinical areas. We also examined the relationship of adoption of electronic health records to specific hospital characteristics and factors that were reported to be barriers to or facilitators of adoption.

Results On the basis of responses from 63.1% of hospitals surveyed, only 1.5% of U.S. hospitals have a comprehensive electronic-records system (i.e., present in all clinical units), and an additional 7.6% have a basic system (i.e., present in at least one clinical unit). Computerized provider-order entry for medications has been implemented in only 17% of hospitals. Larger hospitals, those located in urban areas, and teaching hospitals were more likely to have electronic-records systems. Respondents cited capital requirements and high maintenance costs as the primary barriers to implementation, although hospitals with electronic-records systems were less likely to cite these barriers than hospitals without such systems.

Conclusions The very low levels of adoption of electronic health records in U.S. hospitals suggest that policymakers face substantial obstacles to the achievement of health care performance goals that depend on health information technology. A policy strategy focused on financial support, interoperability, and training of technical support staff may be necessary to spur adoption of electronic-records systems in U.S. hospitals.

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Published at www.nejm.org March 25, 2009 (10.1056/NEJMp0901592)

Stimulating the Adoption of Health Information Technology
David Blumenthal, M.D., M.P.P.

The recently enacted stimulus bill ― the American Recovery and Reinvestment Act of 2009 (ARRA) ― touches almost every aspect of the U.S. economy. Health care is no exception. In fact, the ARRA is historic health care legislation of the type rarely produced by our famously incremental federal government. The law prevents dramatic state cuts in Medicaid, expands funding for preventive health care services and health care research, and helps the unemployed buy health insurance. But perhaps its most profound effect on doctors and patients will result from its unprecedented $19 billion program to promote the adoption and use of health information technology (HIT) and especially electronic health records (EHRs).

The HIT components of the stimulus package ― collectively labeled HITECH in the law ― reflect a shared conviction among the fledgling Obama administration, the Congress, and many health care experts that electronic information systems are essential to improving the health and health care of Americans. However, proponents of HIT expansion face substantial problems. Few U.S. doctors or hospitals ― perhaps 17% and 10%, respectively ― have even basic EHRs, and there are significant barriers to their adoption and use: their substantial cost, the perceived lack of financial return from investing in them, the technical and logistic challenges involved in installing, maintaining, and updating them, and consumers' and physicians' concerns about the privacy and security of electronic health information. HITECH addresses these obstacles head on, but huge challenges await efforts to implement the law and fulfill President Barack Obama's promise that every American will have the benefit of an EHR by 2014.

One of HITECH's most important features is its clarity of purpose. Congress apparently sees HIT ― computers, software, Internet connection, telemedicine ― not as an end in itself but as a means of improving the quality of health care, the health of populations, and the efficiency of health care systems. Under the pressure to show results, it will be tempting to measure HITECH's payoff from the $787 billion stimulus package in narrow terms ― for example, the numbers of computers newly deployed in doctors' offices and hospital nursing stations. But that does not seem to be Congress's intent. It wants improvements in health and health care through the use of HIT.

To achieve this goal, the law takes several approaches. It starts by creating a leadership structure to guide federal HIT policy: the Office of the National Coordinator of Health Information Technology (ONCHIT) within the Department of Health and Human Services (DHHS). ONCHIT currently exists under executive authority, but HITECH enshrines it in statute and greatly expands its resources. One of the national coordinator's first responsibilities will be to create a strategic plan for a nationwide interoperable health information system, a plan that must be updated annually. Two statutory committees will advise the coordinator: a Health Information Policy Committee and a Health Information Standards Committee.

From the standpoint of physicians, the legislation's most important provision may be $17 billion in financial incentives intended to get doctors and hospitals to adopt and use EHRs. Starting in 2011, physicians can receive extra Medicare payments for the "meaningful use" of a "certified" EHR that can exchange data with other parts of the health care system. These payments can total as much as $18,000 in the first year in the case of physicians who adopt in 2011 or 2012, with at least $15,000 for physicians who adopt in 2013 and a slightly lower amount for those who do so in 2014; incentives are gradually reduced and then ended in 2016. Thus, physicians demonstrating meaningful use starting in 2011 could collect $44,000 over 5 years. Waiting until 2013 would result in a maximum bonus of $27,000 over 3 years. Experts estimate the cost of purchasing, installing, and implementing an electronic-records system in a medical office at about $40,000.

For physicians with high volumes of Medicaid patients (30% or higher), the law provides subsidies through the Medicaid program as well. Doctors must choose whether to participate in the Medicaid or Medicare bonus program ― they cannot receive awards from both. Hospitals participating in Medicare also stand to benefit. Meaningful use of EHRs in 2011 will earn hospitals a one-time bonus payment of $2 million plus an add-on to the Medicare fee based on the diagnosis-related group (DRG). The add-on, which would phase out over a 4-year period, would apply to every admission up to a (yet-to-be-designated) maximum amount. Children's hospitals and other hospitals with a high volume of Medicaid patients can participate in a Medicaid incentive program instead.

HITECH also threatens financial penalties to spur adoption. Physicians who are not using EHRs meaningfully by 2015 will lose 1% of their Medicare fees, then 2% in 2016, and 3% in 2017. Hospitals, too, face penalties for nonadoption as of 2015 ― in their case, taking the form of cuts in their annual updates under the DRG system.

Spurring the adoption of EHRs and other HIT will probably require more than financial carrots and sticks. Many physicians and hospitals will need technical help to keep their systems working and to update them as technology improves. HITECH provides $2 billion for ONCHIT to begin putting such support systems in place and authorizes a variety of tools for building the requisite infrastructure. It sets aside $300 million to support the development of health information exchange capabilities at the regional and state levels. The law also authorizes grants to create regional technology extension centers to help providers install EHRs, funds to train a workforce to assist with HIT implementation, educational programs for medical students, and grants and loans to states to assist with adoption and interoperability.

Mindful of concerns about privacy and the security of electronic-records systems, HITECH strengthens protections of health care information as well. It extends the privacy and security regulations of the Health Insurance Portability and Accountability Act to health information vendors not previously covered by the law, including businesses such as Google and Microsoft, when they partner with health care providers to create personal health records for patients. It requires health care organizations to promptly notify patients when personal health data have been compromised, and it limits the commercial use of such information.

All this constitutes a substantial down payment on the financial and human resources needed to wire the U.S. health care system. Still, major hurdles remain. First, the DHHS and ONCHIT are operating on a very tight schedule. The infrastructure to support HIT adoption should be in place well before 2011 if physicians and hospitals are to be prepared to benefit from the most generous Medicare and Medicaid bonuses. Meeting this deadline will be challenging. It takes time to develop and implement innovative federal programs, and it will take even more time to create the local institutions needed to support HIT implementation.

Second, much will depend on the federal government's skill in defining two critical terms: "certified EHR" and "meaningful use." ONCHIT currently contracts with a private organization, the Certification Commission for Health Information Technology, to certify EHRs as having the basic capabilities the federal government believes they need. But many certified EHRs are neither user-friendly nor designed to meet HITECH's ambitious goal of improving quality and efficiency in the health care system. Tightening the certification process is a critical early challenge for ONCHIT. Similarly, if EHRs are to catalyze quality improvement and cost control, physicians and hospitals will have to use them effectively. That means taking advantage of embedded clinical decision supports that help physicians take better care of their patients. By tying Medicare and Medicaid financial incentives to "meaningful use," Congress has given the administration an important tool for motivating providers to take full advantage of EHRs, but if the requirements are set too high, many physicians and hospitals may rebel ― petitioning Congress to change the law or just resigning themselves to forgoing incentives and accepting penalties. Finally, realizing the full potential of HIT depends in no small measure on changing the health care system's overall payment incentives so that providers benefit from improving the quality and efficiency of the services they provide. Only then will they be motivated to take full advantage of the power of EHRs.

The nation's economic woes have given birth to an unprecedented federal effort to modernize the information systems of a troubled health care system. It is now up to the government and the nation's health care professionals and facilities to turn this opportunity into real improvements in the health and health care of Americans.

Dr. Blumenthal reports receiving grant support from GE Corporate Healthcare, the Macy Foundation, and the Office of the National Coordinator for Health Information Technology in the Department of Health and Human Services and speaking fees from the FOJP Service Corporation and serving as an adviser to the presidential campaign of Barack Obama. No other potential conflict of interest relevant to this article was reported.

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医療記録電子化への疑問/米国医療事情 オバマ政権 医師の一分/BIGLOBEウェブリブログ
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