Dr. Solberg is Professor of Medicine in the Department of Hematology/Oncology at the Mayo Clinic in Jacksonville, FL. Dr. Solberg is also Chair of the ASH Committee on Practice.
Subduction zones arise where geological tectonic plates collide — a reasonable metaphor for the collision of health information technology (HIT), finances, and medical practice. The adoption of electronic health records (EHRs) into general medical practice has been slow but is likely to accelerate in part due to its potential to improve patient safety and to promote evidence-based medicine. A recent survey of 5,000 physicians randomly selected from an AMA physician database by DesRoches, et al. (N Engl J Med. 2008:359:50-60) revealed that only 4 percent of the respondents have access to what an expert panel determined would be a fully functional electronic-based system, and only 13 percent had access to even a basic system. Why has there been such a slow roll-out despite the near universal acceptance by experts in quality improvement that HIT improves quality of care? Perhaps the answer lies in inherent conflicts at the subduction zone. For the HIT experts whose world revolves around large scale health-care systems and their economics, the critical issues are the concepts of "functionality," "interoperability," "security," "reliability," "financial incentives for adoption," "harmonization of standards," and "measuring performance and errors." The community practicing physician has other concerns related to more direct personal engagement (i.e., cost of acquisition and maintenance, steepness of learning curve, ability to help in cost-effective practice management, and communication with other providers relevant to that practice).
In hematology, the subduction zone landscape has two predominant features. In large health-care systems, HIT environments often include enterprise-wide EHR applications or collections of applications utilized to support medical practice and research. These systems may have fewer customized features supporting the chemotherapy-ordering functionality. In selecting an EHR, the hematologist practicing in a community setting has to carefully weigh a different set of financial implications, medication management incentives, administrative gains and costs, and oncology-specific features. "The Oncology Electronic Health Record Field Guide" published by the American Society of Clinical Oncology is a good resource to guide practices in selecting oncology EHRs. While this resource is helpful for the limited purpose of identifying a system that can handle oncology information, you may want to purchase an electronic system that will not have to be upgraded or replaced if you want it to interact with systems outside of your office.
Since many physicians have concerns about the viability of an electronic record, it is not surprising that an accrediting agency has emerged that is designed to validate the utility of various systems. That agency is the Certification Commission for Healthcare Information Technology (CCHIT). CCHIT is an independent, non-profit, federally authorized certification body for EHR products. Having a certifying authority, free of conflict of interest, to help assure hematologists that the EHR system they use or purchase has necessary functionality, security, reliability, and interoperability is a commendable goal. Additional impetus for CCHIT certification comes from national HIT policies. In 2006, the Department of Health and Human Services began to spur universal adoption of EHRs by creating a safe harbor for entities such as hospitals to assist small practices in acquiring systems. The safe harbor allows participants to cooperate without violating federal anti-kickback statutes or the Physician Self-Referral Law (Stark Law). A requirement of this safe harbor exception was that any such software had to be certified as being interoperable by a certifying body, such as CCHIT. On June 10, 2008, the HHS secretary announced 12 communities that have been selected to advance the use of EHRs in the first-ever national demonstration project estimated to affect 3.6 million patients. Embedded in this pilot is an offer of bonus payments to physician practices that adopt a certified EHR and use it to measure and improve quality.
Does this mean that hematologist/oncologists should buy a CCHIT-certified product? No. Most hematology-oncology applications, including some of the largest and most widely used, have not been submitted for certification and, as CCHIT declares on its Web site, "Purchasers should not interpret a lack of CCHIT certification as being of significance for specialties and domains not yet addressed by CCHIT criteria." CCHIT has not yet established an oncology-specific work group, even in its 2009 activities, but in time is expected to do so. It is prudent, however, for hematologists engaged in evaluating or purchasing EHRs to be familiar with this evolving certification story.
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