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Paperless Medicine?

Three challenges stand between Texas and the era of electronic medical records: convincing doctors to use them, figuing out how to safely share and protect them and finding a way to pay for them.

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Electronic medical records that follow patients from doctor to doctor. Hospitals with instantaneous online access to lab results and health histories. Disease researchers with a state’s worth of field data at their fingertips. It all hinges on a single question: Can Texas physicians go paperless?

Some doctors are embracing e-records technology on their own. Others are being brought around to it, through a combination of federal requirements and the promise of tens of thousands of stimulus dollars. They’ve got a powerful coalition of software and communications giants, insurance companies, and cancer researchers urging them on — and laying the foundation for an electronic superhighway for Texas medical records.

“Right now, baseball managers have more statistics, more data, on their players than doctors do about their patients,” says Nora Belcher, executive director of the Texas e-Health Alliance, the chief advocacy group for the Texas e-records initiative. “For performance, for quality, for efficiency, for research, the doctors, the labs, the hospitals need to be able to exchange information.”

But even the most ardent supporters acknowledge they face an uphill battle. Consumer rights advocates fear e-records could jeopardize patient privacy. Some health care providers aren’t convinced e-records benefit their practice — or their bottom line. And until recently, the only software on the market was clunky and complicated, fueling doctors’ skepticism.

“Those who have made the change to all electronic records would never go back to paper," says Dr. Joseph Schneider, the chief medical information officer at Dallas’ Baylor Health Care System and chair of the Texas Medical Association’s Health Information Technology Committee. “But the amount of energy required to get there is really huge.”

Health care professionals, insurance companies and even privacy advocates agree on the premise behind e-records: Patients don’t benefit when their paper medical records are scattered across dozens of different doctors’ offices. Hospitals are unaware of afflictions and allergies kept on file with particular doctors. Lab tests and x-rays performed by primary care physicians are unnecessarily repeated by specialists — an inefficient and expensive practice. Researchers are unable to track disease trends in real time or identify the treatments that are having the best outcomes.

“I can tell you what the debt of the Treasury Department is today, but I can’t tell you how many patients were diagnosed with cancer in the United States this year,” says Adam Clark, director of science and policy for the Lance Armstrong Foundation. “Once we change that, we can identify cancer clusters in the community. We can identify the public health interventions we need to be taking. Patients need to understand that this information will come back to help them.”

There’s progress being made. Nationwide, doctors who see Medicaid or Medicare patients must start using e-records by 2015 or risk having their reimbursements slashed. That stick comes with an enticing carrot: up to $44,000 in federal stimulus funding for physicians using e-records in their offices.

In Texas, plans for a statewide health information exchange have been underway since 2005; they’re largely conceptual, though stakeholders — from AT&T to Intel to the University of Texas — are joining forces to influence the exchange’s development. Last legislative session, lawmakers passed a bill to create an electronic health file for state Medicaid patients and children on state-subsidized health insurance. Meanwhile, so-called “regional extension centers” have cropped up across the state to help health care providers make the transition — and share some of their information — in local communities. 

“The goal is to establish an electronic health information infrastructure for Texas that can support improved quality, safety and efficiency in health care,” says Stephen Palmer, director of the state Office of e-Health Coordination.

Challenge No. 1 is convincing the overwhelming majority of Texas doctors who don’t use e-records that they should. Though the federal incentives will light a fire under doctors who accept Medicaid and Medicare patients, some — ranging from top-dollar specialists to low-income rural physicians — won’t qualify. Belcher, of the e-Health Alliance, said there’s always the possibility of tapping into foundation money or establishing a revolving loan fund to help these doctors make the leap. “Medicare and Medicaid tend to be the 800-pound gorilla,” she says. “Where they go, private pay tends to follow.”

Still, many physicians simply don’t see what’s in it for them. Schneider said doctors are quick to embrace new technology when they see tangible benefits — say, in the case of cutting-edge surgical devices. While there’s no doubt e-records can save lives and improve health care, Schneider said the reality is that they create “all kinds of new ways to make mistakes.” He cited one case where the electronic medical record of a 2-month-old admitted to the hospital showed the infant had denied being a smoker. “Most of the advantages don’t come back to me, the doctor,” Schneider said. “But a lot of the risk does.”

Once doctors are routinely collecting medical records electronically, challenge No. 2 is how to share them. Today, the fax machine and the scanner are the physician’s best friend. Tomorrow? Software vendors and telecommunications companies have the technology to trade data over broadband — and stand to make a fortune doing it.

The jury’s still out on who will pay for Texas’ transition away from paper. So far, there aren’t even estimates of how much the effort will cost. Industry experts don’t expect state lawmakers to foot the whole bill. Some suggest the big software or telecommunications companies should invest in the infrastructure because they have the most to gain. Others say insurance companies could someday pay for the service through e-record transaction fees.   

And then there’s the question of whom health care providers share the records with — and what details they share. Consumer privacy advocates say that without the proper safeguards and patient consent policies, e-records will be easily hacked, or leaked to potential employers or profit-hungry pharmaceutical firms. If someone breaks into your bank account and steals your money, they say, the bank can make you whole. If your electronic medical record — everything from mental illness to sexually transmitted diseases — is inadvertently made public, there’s no way to get the cat back in the bag.

“The health and financial information that goes along with being treated in a hospital or a doctor’s office is incredibly valuable,” says Deborah Peel, founder and chair of the Austin-based nonprofit Patient Privacy Rights. “Once your sensitive health information is sold or lost, you can’t ever make that information private again.”

The privacy protectors may face some tough battles at the Legislature next session. Advocates for e-records have identified some state privacy laws they say must be revised to facilitate data transmission. Lawmakers say they hope to strike a balance between protecting patient privacy and expanding a practice that could reduce medical errors and health care costs.

“We still need to be very cautious that we protect the most sensitive medical information, and that the patient’s health record not be blasted into cyberspace,” says state Sen. Jane Nelson, R-Flower Mound, who chairs the Senate committee charged with holding hearings on electronic medical records. “But do some laws need to be changed? Probably.”

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