Health Information Technology Advances Health Care Delivery and Enhances Research

The fields of health management and health information technology (HIT), health informatics inclusive, are intertwined; one cannot distinguish where one field begins and the other ends. There are no areas in health care management currently being carried out without informatics support, especially those areas requiring the most advanced information technology and informatics innovations, such as electronic health records, clinical decision support systems, and health care data analytics.

Both HIT and health informatics hold promises of efficiency, cost reduction, and improved health care. A recent evaluation reported a median revenue increase of $49,916 per full-time physician after operating costs were attributed to EMR-associated efficiency gains from the elimination of paper charts, as well as transcription savings, better charge capturing, and reduced billing errors.¹ Numerous reports by the National Academy of Sciences have identified the transformative potential of information technology to control costs and improve outcomes in health care.^2,3,4,5

For all these reasons, the field of health informatics has grown steadily over the past fifteen years.⁶ Much of this growth can be attributed to the U.S. government. The first major incentive for health informatics development dates from 1996 with HIPAA, when the health care community was asked to embrace Health Information Technology (HIT) and required health plans, health care clearinghouses, and certain health care providers, including pharmacists, to create electronic data interchanges for electronic transactions (see Table 1). Another critical line of investment in IT was the passage of the Health Information Technology for Economic and Clinical Health (HITECH) provisions of the American Recovery and Reinvestment Act of 2009, which was to promote the widespread adoption and use of health IT, and ultimately improve the quality, safety, and efficiency of the U.S. health care system. HITECH included incentive payment programs and technical assistance for eligible health professionals and hospitals to adopt, implement, or upgrade certified electronic health records (EHRs) and to achieve the Meaningful Use (MU) of HIT.^7,8 Also, the massive investments required by HITECH and the Accountable Health Care Act (ACA) since 2009 further contributed to HIT growth. In 2009, the U.S. Department of Health and Human Services received congressional authorization to spend $27 billion to support implementation of HITECH, and in 2010, ACA budgeted nearly $20 billion over five years to support the widespread adoption of health information technology.^9,10

Table 1.

UNITED STATES GOVERNMENT INCENTIVES ELECTRONIC HEALTH RECORDS

Act or Law (Year)	Strategy	Strategy/Electronic Transaction
HIPAA (1996)	asked health-care community to embrace Health Information technology (HIT) in 1996 created an electronic data interchange that health plans, health-care clearinghouses, and certain health-care providers, including pharmacists, are required to use for electronic transactions	claims and encounter information payment and remittance advice claims status eligibility enrollment and disenrollment referrals and authorizations coordination of benefits premium payment
Tax Relief and Health Care Act of 2006 (TRHCA), CMS Physician Quality Reporting Initiative (now called Physician Quality Reporting System (PQRS)) (2006)	a voluntary physician electronic reporting program.	voluntary physician electronic reporting
Electronic Prescribing (eRx) Incentive Program, created under the Medicare Improvements for Patients and Providers Act (2008)	provides incentives for eligible physicians who e-prescribe Medicare Part D medications through a qualified system. this program converted to a penalty program last year for physicians who don’t use eRx.	e-prescribe Medicare Part D medications
HITECH Act (2009)	higher Medicare and Medicaid payments to physicians who adopt and “meaningfully use” EHRs – up to $44,000 under Medicare and $63,750 under Medicaid $30 billion in new Medicare and Medicaid incentive payments $500 million for states to develop health information exchanges (HIE) AHRQ has awarded $300 million in federal grant money to more than 200 projects in 48 states to promote access to and encourage HIT adoption. Over $150 million in Medicaid transformation grants awarded to three states and territories for HIT in the Medicaid program under the 2005 Deficit Reduction Act.	“Meaningfully use” EHRs HIEs
ACA (2010)	established uniform standards that HIT systems must meet	automatic reconciliation of electronic fund transfers and HIPAA payment and remittance improved claims payment process consistent methods of health plan enrollment and claim edits simplified and improved routing of health-care transactions electronic claims attachments.
ACA (2010)	voluntary PQRS electronic reporting program has become a mandate. Starting in 2015, Medicare payments will be reduced for nonparticipating physicians

DHSS has provided clear guidance to providers as to the expectations of the development in the adoption and implementation of EMR.¹¹ Meaningful use of certified electronic health record technology is expected to improve the quality, safety, and efficiency, as well as reduce health disparities. Other expected outcomes of meaningful use are the engagement of patients and family, greater level of care coordination, and population and public health.

Currently, it is estimated that at least 78.4% of medical practices, 59.4% of non-federal acute care hospitals, and 89% of critical-access hospitals in the United States have adopted some form of EMR.^12,13,14

The speed and magnitude of the EMR adoption has, however, been minimized by the slow pace at which services have been able to migrate from a basic level to a comprehensive system, as was expected in HITECH. A likely reason for this status quo is the time and cost of implementing changes in medical practice to accommodate EMR and related functions. It has been estimated that an average five-physician primary care clinic needs to invest about $162,000, with an additional $85,500 in maintenance expenses during the first year, to implement an EMR.¹⁵ Also, an average of 134 hours per physician is needed to prepare to use EMRs during patient visits. Another study of primary care practices found the cost to be “$32,409 per physician through the first 60 days after the EMR system was launched, with one-time costs for hardware of $25,000 per practice and an additional $7,000 per physician for personal computers, printers, and scanners. The annual cost of software and maintenance was approximately $17,100 per physician.”¹⁶

Furthermore, despite the large investments by the federal government and the continued growth of information technology (IT) and health informatics, many studies failed to demonstrate evidence for recommending the use of health informatics to improve quality of health care and reduce health care costs.^17,18,19,20 Moreover, others have identified that increased use of government mandated technology, IT inclusive, was associated with both increased costs of running medical practices and decreasing number of private practices, since many new physicians preferred to be employed versus owning an expensive practice.^21,22 Two recent surveys (2013 and 2014) have actually indicated diminished support for EMR use among physicians.^23,24 One of the surveys (2014) reported about 50% of respondents said “implementation of EMR systems has made the quality of patient care worse” while 69% said “coordination of care with hospitals has not improved”.²⁴

Nevertheless, all in all, there appears to be a positive balance of evidence in favor of adopting information technology for health care, and health care actors continue to invest in this sector. A 2012 report estimated that providers, payers, and physician groups will be spending over $69 billion on health care-related IT and telecommunications services over the next six years. This represents a compounded growth rate of 9.7% over the forecast period, increasing from $9.1 billion in 2012 to $14.4 billion in 2017.²⁵

Six manuscripts in this issue of Missouri Medicine address different aspects of health care management and informatics that should interest physicians who have a stake in managing the best health care possible to their patients.

Khatri’s is original research which describes IT capabilities essential for health care delivery and their relationship with the population-based mortality rate from heart attack.²⁶ In its background review, the article illustrates business organization and processes with examples ranging from specialties to hospitals to comprehensive academic medical centers. Its main finding underscores the interactive effects of IT capabilities, workers’ efforts, and flexibility on health outcomes.

Information technology-based health care data systems have been shown to increase the efficiency not only of health care delivery but also of health research studies. The article by Mosa et. al focuses on an academic medical center’s experience in creating online data capture and a research data repository for the purpose of translational research.²⁷

The ethical controversies about proper use of informatics in health care management are explored by Phillips’ article.²⁸ The principles of health care ethics are systematically reviewed for health informatics practices. In this essay, the difficulties in keeping a balance between ethics and the implementation of HIT faced by planners and practitioners in the field are discussed in four topics and eight sub-topics, ranging from confidentiality and privacy to patients’ portals.

Two articles cover distinct health evaluation and research methodologies highly dependent on IT capabilities. Boren’s and Moxley’s article provides a basis for and step-by-step processes of systematic review of the health literature.²⁹ Systematic reviews are the basis for evidence-based medicine and provide critical information for decision making at the management level. Therefore, it should be used as a tool not only by academic researchers but also by health care managers and practitioners. Alafaireet et. al describes the application of concept mapping (CM) for building clinical research strategies necessary to study mental health.³⁰ The study is useful for both health researchers and practitioners because it describes how concept mapping use can increase critical thinking and clinical preparedness of medical staff and patients to address recidivism of mental health patients.

Finally, the larger issue of change in the management and practice of health care is framed by Hicks and Bouras through the optics of past (early managed care) and new (health care reform) organizational and policy models.³¹ The authors’ conclusions and recommendations center on the physician-management relationship.

Biography

Eduardo Simoes, MD, MSC, MPH, is the chair and Health Management and Informatics Alumni Distinguished Professor at the University of Missouri school of Medicine.

Contact: simoese@health.missouri.edu