British EMR Failure Invites Comparisons to USA HITECH Program

American physical therapists may breathe a sigh of relief that the Office of the National Coordinator of Health Information Technology (ONC HIT) will be less likely now to impose "top down" mandates for the purchase and use of interoperable health information technology now that Great Britain has decided to dismantle their failed system.

On September 22, 2011, the National Health Service (NHS) issued a Press Release announced that it was discontinuing its 10-year, $18.5 billion dollar effort to collect, computerize and centralize all of its electronic medical records. Existing electronic systems in hospitals and clinics would continue to operate but would not be interoperable across all of England.

The announcement essentially killed what had been hailed as “the world’s biggest civil information technology program” at that time.

The NHS program began in 2002 and was described as “top-down engineering” that met substantial resistance from physicians and other users of the system. The Press Release announcing the end of the program cited the lack of local control as the prime reason for the failure of its interoperable system:

“In a modernised NHS, which puts patients and clinicians in the driving seat for achieving health outcomes amongst the best in the world, it is no longer appropriate for a centralised authority to make decisions on behalf of local organisations.”

Authorities in the United States were quick to assure providers that a similar information technology (IT) effort stimulated by Title XIII of the American Recovery and Reinvestment Act of 2009, called the Health Information Technology for Economic and Clinical Health Act (HITECH) would not fail.

Faith in American electronic medical records is largely voiced by policymakers who say they are collaborating with providers, such as hospitals and physicians, rather than mandating a top-down structure.

Authorities claim that Electronic Medical Records strategy, standards and outcomes are set by HITECH Meaningful Use criteria but implementation is being set at the local level by any of the 900 certified IT vendors that the providers may choose to use. However, providers complains that 900 choices is NO better than no choice at all.

Why should private practice physical therapists care?

Used to be, we could just hang a shingle, treat your patients and expect to make a decent living. Now, if you want to work for yourself and your patients, you need to comply with all sorts of regulations that may or may not improve your patient care or add to your patient's outcomes.

For example, the Physican Quality Reporting System (PQRS) is a quality measure reporting program that has, since 2007, paid physical therapists up to 2% extra for treating and reporting Medicare claims data. In 2014, this little "extra" will turn into a discount and the program will turn into a top down mandate.

Can authorities in the USA learn from the British disaster?

I hope that authorities will learn that physical therapists, acting at the local level can determine what is quality and that some of these local measures can be used in place of centrally-determined, top down quality mandates.

Quality Measures Physical Therapists can Use to Prepare for Meaningful Use

Physical therapists can begin using these quality indicators in their clinics, if you're not already:

Treatment of depression: ask "Are you depressed or have you felt sad or blue during the last 30 days".

Smoking cessation advice among smokers: I read this this on a pack of Camels... "Quitting smoking now can greatly reduce your risk of death from cancer, heart attack or stroke".

I usually ask the patient if any other medical provider has asked them to give up smoking. Over 80% say that their doctor has asked them - but, that means that up to 20% have not been asked to quit!

Diet advice in high-risk adults: I'm 175lbs, 42 years old and I still look good in a Speedo so I punt this one, "I know a registered dietitian who can help you cook tasty meals from your favorite foods and you won't have to give up desserts!"

Exercise advice in high-risk adults: "I'd like to show you some simple things to do at home to feel better and get stronger. Later, if you like, I can show you how you can start to do more things that you like to do".

I actually try not to use the word exercise until the patient has used that word, with me, at least once.

Diet advice in adolescents: same as with the adults, "I know a registered dietitian who can help you cook tasty meals from your favorite foods and you won't have to give up desserts!"

Exercise advice in adolescents: same as with the adults, "I'd like to show you some simple things to do at home to feel better and get stronger. Later, if you like, I can show you how you can start to do more things that you like to do".

I'll usually mention sports, or for the college bound, I'll mention the rigors of studying and computer use.

Blood pressure measurements: This is, by now I think, routine in most physical therapists offices and clinics but I could be wrong.

One point of discussion we haven't settled... Do you take blood pressure on EVERYBODY or just those you consider "high risk". Good resource allocation principles would indicate that your therapists' time is valuable and routine screening on everyone is wasteful.

The Impact of Quality

These measures come from the National Ambulatory Medical Care Survey (NAMCS) that has been collected on a sample of patient visits to non-federal employed office-based physicians who are primarily engaged in direct patient care since 1973.

A recent impact study in the Archives of Internal Medicine on the effectiveness of Electronic Medical Records (EMR) with Clinical Decision Support(CDS) prompting the use of these quality indicators in 255,402 physicians' practices found that only two of twenty possible indicators were improved with the use of the EMR/CDS.

This new study casts doubt on the wisdom of the $27 billion dollar HITECH investement for EMR showing meaningful use capabilities.

Many recent studies of electronic clinical decision support have found improvements in the process of care, like inappropriate antibiotic prescriptions, with the use of electronic aids at the clinic or the hospital level.

This study looked at visit data aggregated nationally to see if the same local trends persisted but they didn't.

Can Physical Therapists Move Forward?

Absolutely. The first step would be to adopt these quality measures - there is no controversy about quitting smoking. Its good for your patient and its within your skill set.

Don't rush out and buy yourself an electronic EMR/CDS just yet - 80% of physical therapists are still on paper.

Fax the paper to your referral sources and let them scan it into their new, government sponsored EMR.

I think the future will reward those of us who focus on quality.