GHIT Notebook

November 5, 2007

Katrina Plus 2: Still starting over

By Nancy Ferris

Just days after Hurricane Katrina wiped out the medical histories of millions of people in Louisiana and Mississippi in August 2005, federal officials were touting the potential for raising a model health information system from the wreckage.

On Sept. 8, 2005, Dr. David Brailer, then national coordinator for health information technology at the Health and Human Services Department, said, “I want to see a digital health information infrastructure happen for the people of the Gulf Coast. We can deliver personal health records that move with [the patients] as they go through care.”

A regional health information exchange would demonstrate the value of health IT and “would make the lives of the people much safer,” Brailer added.

The storm wiped the slate clean. For example, by destroying the paper medical records of 1.2 million people, Katrina took with it the knowledge of what type of chemotherapy was being administered to cancer patients and how much insulin certain diabetics needed, Brailer said.

Moreover, physicians had to treat seriously ill patients they didn’t know and who couldn’t recall precisely what medications they were taking. Some of them were in no condition to speak with doctors. And some evacuees were moved three, four or more times, seeing new doctors and getting new treatments at each stop along the way.

Responding to those conditions, Brailer told the audience at the eHealth Initiative’s 2005 annual conference that Katrina demonstrated that “what we have been working on as a community is not an abstraction” because electronic health records (EHRs) can mitigate medical problems in real-world situations.

HHS Secretary Mike Leavitt told the same audience, “If there was ever a case for [EHRs], this disaster underscores the need.”

Two months later, he announced that two organizations — the Louisiana Department of Health and Hospitals and the Southern Governors’ Association — would get about $3.7 million to plan for and promote the use of EHRs in the areas damaged by hurricanes Katrina and Rita.

Today, New Orleans and its health system have begun to show signs of recovering from the devastation, yet health IT has not made much progress, according to many officials who have been on the scene since 2005. And what progress has occurred seems due mostly to the persistence of committed Louisianans rather than to the federal government’s support.

Building IT into the new system Even with a rosier federal forecast, not everyone was singing in health IT harmony. Scott Wallace, president and chief executive officer of the National Alliance for Health IT, visited New Orleans to assess the potential for the technology soon after the storm. He characterized his team’s assessment this way: “They need a health care system before they can worry about health care IT. They need buildings, they need nurses, and they need physicians. We’re about 19 steps away from putting IT in down there. What we first have to think about is how we do health care delivery.”

“The IT aspiration is a wonderful thing to think about, but you have to calibrate a little bit off of where they are right now,” Wallace said. “They don’t have anything. How are they going to have IT?”

To help answer that question, Leavitt pushed state and city officials to develop a plan for rebuilding the New Orleans health system. He attended a ceremony in the city in July 2006 to launch the Louisiana Health Care Redesign Collaborative. The collaborative was an HHS-inspired effort to get the competing factions in the state and city to work together to build a new and better health system, one that would include health IT as a key element of its infrastructure.

“There may never be a ‘green field moment’ quite like this again,” Leavitt said at the time. “There is wide agreement that the old system may have served well in a former day, but that day has passed.”

Although the health care system might have been washed away, old rivalries, factions and suspicions live on. “There are extremely entrenched interests all over the place,” Wallace said. Many of those conflicts have nothing to do with health IT, but the technology can’t be developed in a vacuum, he added.

Home improvements EHRs became an intrinsic element of the collaborative’s plan to create medical homes — clinics that would keep track of patients’ medical histories and provide primary care using a team-based approach. Among other services, they schedule regular preventive care, such as immunizations and diagnostic tests.

The medical homes would replace the previous health care system in which 90 percent of uninsured New Orleans residents visited the old Charity Hospital for their care. Whether they needed a flu shot, cancer treatment, a broken bone repaired or a baby delivered, residents often entered the hospital through the emergency room. As a result, the wait for emergency care often was 24 hours. Furthermore, some inappropriate and duplicate care was delivered, and the cost was high.

Louisiana State University, which operated Charity Hospital, wants the government to rebuild it, as do many New Orleans residents with fond memories of the only hospital they’ve ever known. In a history-minded city, they revere its record of caring for Louisianans since 1736.

But proponents of the medical-homes plan argue that their approach would provide higher-quality care at lower cost than the city’s former hospital-based system, which HHS officials described in a press release as “among the most expensive and least effective in the nation.” Financing questions have kept the plan from moving ahead rapidly.

If HHS approves the state’s request for expanded Medicaid eligibility, the medical-homes plan will get started next spring, said Dr. Roxane Townsend, secretary of the Louisiana Department of Health and Hospitals.

Last May, HHS rewarded the state and New Orleans for the collaborative’s work by releasing about $160 million in grants for primary care clinics in an effort to attract health care professionals back to the state. That brought total HHS grants to Louisiana for Katrina recovery to more than $1.4 billion. Some of the new money can be used for health IT, and state officials predict that the clinic-operating subsidies will free some funds for installing EHR systems in clinics.

“The physicians down there have expressed a big interest in going ahead and adopting EHRs as they bring their practices back up” in newly opened or rebuilt community clinics, Townsend said. In addition, the clinics agreed on a single system they would all use, which will facilitate information sharing. They are installing back-office modules of the CareRevolution system from EHS, a Birmingham, Ala., company, and will later add a clinical component, she said.

As part of the Katrina recovery efforts, HHS’ Office of the National Coordinator for Health IT extended an existing contract with the state to support development of the Louisiana Health Information Exchange. LaHIE is a public/private partnership that includes the state Department of Health and Hospitals, the state Medicaid program, Blue Cross and Blue Shield of Louisiana — the state’s largest private insurer — and hospital systems.

Before the $3.7 million in federal funding for LaHIE expired in March, the organization established policies and demonstrated that it could transmit health records among providers in New Orleans and Baton Rouge.

The plan for LaHIE is to use claims data from the state Blue Cross affiliate and Medicaid as the foundation for a data repository with a hybrid architecture that would also let providers retrieve records from their peers through a record-locator service.

“It worked well from a technical standpoint,” said Ob Soonthornsima, senior vice president and chief information officer at Blue Cross and Blue Shield of Louisiana.

Like other similar organizations, LaHIE has had trouble finding a business model that would help it become self-sustaining. Soonthornsima said the organization is trying to attract more participants while seeking solutions to the revenue issue. However, he said, “right now, we’re in a lull.”

LaHIE decided not to compete in HHS’ recent round of HIE contracts, Soonthornsima said, because more federal funding would not do much to push the organization toward sustainability.

However, state officials have asked for about $1 million a year in federal support for LaHIE, and they have also earmarked state funds for support of HIEs.

One promising avenue toward self-sufficiency could be the formation of the Louisiana Health Care Quality Forum, another public/private partnership with many of the same leaders as LaHIE. The forum plans to monitor the health of the state’s population and encourage providers to improve quality, make better use of funding and keep Louisianans healthier. LaHIE and other HIEs in Louisiana could deliver the necessary data to the quality overseers.

Leaders at the top Louisiana’s Department of Health and Hospitals has been involved in all those efforts. From Gov. Kathleen Blanco to state legislative leaders and Townsend’s predecessor at the Department of Health and Hospitals, Dr. Frederick Cerise, state leaders have supported health IT since before Katrina. Townsend, who became the department’s leader late last summer, gets high marks from observers.

Janet Marchibroda, chief executive officer of the eHealth Initiative in Washington, has worked with the state since 2005. “What really impressed me early on is that they got it,” she said, meaning that Louisiana leaders understood the potential of health IT and recognized that they needed a strategy for implementing it.

This year, the state legislature appropriated more than $53 million for health IT, most of it in connection with Medicaid. About $10 million will go to HIEs and EHR projects, and $30 million will pay for EHRs for Louisiana State University’s hospitals and clinics, Townsend said.

“We’re looking at ways of trying to encourage physicians to adopt electronic medical records and try to offset some of the cost but not purchase them for physicians because we do think the physicians have some responsibility to pick up at least a piece of that cost,” Townsend said.

She added that the state already pays doctors a monthly case-management fee for each Medicaid patient and is considering increasing that fee for doctors who use EHRs.

‘Rowing upstream’ Advocates of building a new health care system that relies on IT to help provide consistent, high-quality care are overlooking the fact that the payment system doesn’t reward information sharing, Marchibroda said. “They are rowing upstream” in Louisiana if they try to implement health IT without real changes in the way health care is delivered and paid for, she added.

In addition, the health care system that was fragmented before Katrina is perhaps even more so today.

“Nobody is trying to put the whole big picture together,” said Dr. Kevin Stephens, director of the New Orleans Health Department, and many efforts are proceeding in isolation from one another. For example, when asked about LaHIE’s status, Stephens said he didn’t know much about it.

“I have been working for some time to get everybody together, and it has been very difficult because of the competitive nature of the business,” Stephens said. “Part of the problem is that you have all these different vendors out there who are trying to corner the market, if you will, and so that is preventing a composite solution.”

Stephens said the Veterans Affairs Department, Louisiana State University, the New Orleans community clinics and a major hospital system in the city all use different EHR applications that do not easily communicate with one another, posing problems for any information-sharing system in the city.

“The biggest question is who’s going to pay for it,” Stephens added. All those inspiring statements about the potential of health IT to mitigate the next Katrina led some in Louisiana to expect sufficient federal funding to support their efforts. If they thought that, they were wrong, Townsend said.

“There was not a promise of additional funding from the federal government,” she said. “I know that in some of the first conversations that people had with Secretary Leavitt, they thought that what he meant was that there was going to be additional funding placed in the hurricane-affected area. However, in subsequent conversations, he very clearly said that there were not going to be additional federal funds.”

Even without those funds, Townsend is upbeat about the prospects for health IT as the city’s rebuilding proceeds. Given the commitment at the state and local levels, she said, “everything looks like it may be coming together very nicely.”

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