In April 2004, President Bush set a 10-year goal of equipping most Americans with electronic medical files and prescription drug records.
The ambitious initiative promises to improve the safety, quality and efficiency of health care nationwide, but it also faces major hurdles: chiefly, the enormous upfront costs involved and the need to radically transform the paper processes used in medical care today.
Heading up the monumental task is Dr. David Brailer, a medical doctor and researcher who has devoted much of his professional career to expanding the use of technology in health care. Brailer was working for a nonprofit research group in San Francisco when he was hired by the White House in August 2003 as a consultant to develop policy options for equipping all Americans with electronic health care records. The following May, he was appointed by the secretary of the Health and Human Services Department as the first national coordinator for health information technology where he will execute policies he helped create and encourage doctors and hospitals to embrace greater use of information technologies.
Although Brailer’s immediate staff is small — growing from 15 to 40 in the next year — hundreds of employees from 35 federal agencies are working on the initiative. Brailer’s not sure how long he’ll be overseeing the effort — for the past two years, he has been commuting to Washington every week from San Francisco, where his wife and 5-year-old son live. But he says he won’t leave until he’s sure his team is well on its way to fulfilling the president’s mandate.
Brailer discussed with Federal Times the benefits and challenges of the project, including his frustrations at working in a federal bureaucracy:
Q: What’s driving the need for this?
Brailer: A few things. First, we now for the first time really know how bad medical errors are. Secondly, there’s huge cost pressure. And finally, we have a consumer that’s becoming more and more sophisticated.
Q: How bad are the medical errors?
Brailer: They’re significant. At least 50,000 people die every year in a hospital from medical errors. At least 2 million Americans are injured every year from outpatient drug prescribing, and thousands of people die from that. So it’s big, it’s huge.
Q: How will information technology help reduce those errors?
Brailer: If the doctor prescribes a drug, the first thing [the technology] does is validate that it’s the right patient. The next thing it does is check the allergies, and it won’t allow the doctor to continue if the patient has an allergy. If the patient is taking a drug that has a dangerous interaction, it stops the doctor. Plus there’s no handwriting. The order gets transmitted right to the pharmacy. They don’t have to read the doctor’s writing to figure out what he or she meant. When [the medication] goes to the [hospital] nurse, they can bar-code scan the patient [identification] to make sure they’re giving it to the right patient. It fixes the whole system.
Q: How prevalent is the use of this type of technology now?
Brailer: Most of the surveys are kind of patchy and narrow. But our estimate from all the various patchwork studies is around 10 percent.
Q: What are the main barriers to expanding its use?
Brailer: Two big ones. One is cost. In health care we pay by the piece. If you were my patient, I would be paid for seeing you, depending on how long I saw you, and I would be paid the same amount if I made a mistake or if I didn’t. There’s no incentive for quality or incentive for efficiency. Health IT increases quality and efficiency, but it doesn’t increase the doctor’s bottom line.
The other one is know-how. These systems are complicated, not just technically. They’re about changing the way practices operate, changing the culture of practice, changing the way people communicate, the way decisions get made, the role of the patient. And that requires a lot of change management and organizational re-engineering know-how.
Q: So, what are some of your ideas for getting over those barriers?
Brailer: First, one single set of information standards, so information always means the same thing regardless of the doctor’s hospital, the clinic, the laboratory, the pharmacy. Secondly, we’re going to start certifying electronic health records [systems], so the doctor can have a lot more certainty and comfort that they’re buying the right product. Also, we’re working on developing new advances in privacy and security. This is ultimately about the consumer’s data, and we want to make sure their data’s protected.
Q: What will this mean ultimately for the consumer?
Brailer: They should have no worries that when they show up to their doctor’s office that their data won’t be there. If they’re evacuated from New Orleans or from the next place that has a catastrophe, their data goes with them. We learned with Hurricane Katrina that people were being saved from New Orleans and dying in shelters because the doctors there didn’t know what drugs they were taking. So we created in seven days a database that had all the drug data for most of the evacuees, and it saved a lot of lives.
Q: How much is it going to cost, and who’s going to pay it?
Brailer: It is expensive. There have been estimates of the cost of this ranging from $100 billion to $200 billion. But all the estimates of cost also are paired with an estimate of savings, and they show that over a decade it might cost $200 billion but the savings will be more like $700 billion or $800 billion. Every time somebody has a medical error, besides the fact that they could die — which is horrible in its own right — they lose their productivity. People don’t just die; they die after a month in the hospital. It costs us a fortune.
Q: How might the Federal Employees Health Benefits Program (FEHBP) serve as a model?
Brailer: It’s already started. In April, the first page of the Office of Personnel Management’s letter [to insurance companies] explaining what the government was looking for was about health IT and how important it was that health plans support local adoption of health IT among their doctors and hospitals. And that’s had a huge response. Every health plan’s paying attention to it. They’re all looking at their own programs, they’re gearing up to do things, they’re adding new programs, new efforts, they’re assessing what’s going on in their own markets. We’ll do another turn of that [next April] to be able to say . . . here’s some of the criteria you should judge this [expansion of IT] with. I think FEHBP is going to be a big driver of this.
Q: Are some federal programs already forerunners of this?
Brailer: The Veterans Affairs Department has been using a fully automated paperless record in its hospitals and clinics for 10 years. They were one of the early movers. Once people go into the VA, basically, the VA bears the cost of their care from then to the end of time. Therefore it’s in the VA’s interest to put in investments to lower costs. But if you look at the typical hospital, that’s not how it works. They just get paid when someone comes through the door, so it’s in their interest to have people come more often.
Q: How has your experience been working in a bureaucracy like this? What surprised you about it, either good or bad?
Brailer: I’ve really been impressed with how good federal people are just across the board. Whenever I want a specialist on some kind of large-scale security architecture, I can find some of the best in the world working for the federal government. Negative surprises are — the list is so large we could spend a lot of time on it. In health care, the government only has one purpose in general, which is to regulate the market, create mandates. I find that to be one of the real problems with health care. I came in to drive a market-based agenda and I’ve been fighting uphill because it’s just a regulatory environment. If you go around this building, people, when they think of doing something with health care, they think of a regulation. If we want to have a freer market, it has to start with the government . . . starting to free up the stranglehold of regulations on the market that keep it from having innovation.
Q: This is a 10-year effort the president outlined. Do you expect to be here for the long haul?
Brailer: No. I never came in to do the long haul. I’m frankly shocked I’m still here. Not because I’m not having a good time, not because I don’t think it’s important, not because I frankly don’t love the people I’m working with. I just viewed myself as someone who would come in, get it set up, get the strategy worked out, get the team in place.
Q: How will you know you’ve done enough so the momentum will continue?
Brailer: I’ve got several criteria for that — when there’s a leadership team in place here in the federal government that can really drive it forward; when we have all of our external infrastructure in place, with the key drivers, the contractors, the entities who can do this on the outside; and when there is a really broad recognition that this is inevitable and it has to keep going.