Virginia takes a lead role in the stimulus plan's push for health IT

Contained in the economic stimulus package is $19 billion for the expansion of health care information technology. Most of the money will come in the form of grants to state and local governments and health care providers to develop electronic health records. The Commonwealth of Virginia is taking the lead on implementing electronic health records.

Virginia's secretary of technology, Aneesh Chopra describes health IT as "a labor of love" and has spent his career in state government, advancing the cause of using IT to improve patient outcomes and reduce costs. He is a former managing director with the health care think tank The Advisory Board Co.

Chopra also was a member of Obama's transition team, helping craft the priorities for the federal chief technology officer, whom the president has yet to appoint. Chopra has been mentioned as a candidate for the post, but he declined to discuss whether he has been asked to take the position.

Nextgov interviewed Chopra to learn more about Virginia's approach to health IT and to discuss his views on the role stimulus funds will play in encouraging nationwide adoption of electronic health records.

Nextgov: Virginia has been a leader in pushing for the implementation of electronic health records. What is the state's approach?

Chopra: We have a three-legged stool approach and are conducting initiatives for each. The first is simplifying electronic health records adoption. The second is establishing a policy framework at the state level to determine what the state's role is in health IT. The third is a commitment to seeding clinical innovation.

Nextgov: One of the biggest barriers to the adoption of electronic health records is in physician offices, where the cost of an electronic records system is sometimes prohibitively expensive for small practices -- $40,000 to $60,000 on average. How do you propose getting around this barrier?

Chopra: Adoption is the major barrier. The New England Journal of Medicine estimates between only 4 percent and 17 percent of the physician community has electronic medical records that are capable of sharing information with other systems. Virginia is in the same boat. The key is simplifying. We have a short-term and a long-term approach.

We were awarded an electronic health record demonstration by the Centers for Medicare and Medicaid Services. They picked 12 communities where they would increase Medicare reimbursements for physicians who adopted electronic health records, implemented quality control measures and showed improvement. We were awarded in 2008 and our implementation is in 2010.

The second piece is more vision than execution. I believe the industry is ready to move to the Web. We are ready as an industry to see a more dramatic move toward Web-based software as a service in electronic health records. This would be a cloud-based solution, based on existing software similar to Salesforce.com.

Nextgov: Why hasn't the industry already moved in that direction?

Chopra: The incentives in the health IT industry are largely to sell what they've got rather than to make a better mousetrap. I'm saying this because the market has been so difficult to sell into. It's relatively small in software terms. The total customer base is maybe 200,000 to 300,000 doctors. The upfront capital needed to build Web-based platforms is so much, the math may not work.

I'm encouraging the market to do this on its own, without any state money. I'm trying to inspire the industry to do this in preparation for the health IT money in the stimulus.

Nextgov: The recently signed stimulus package includes $19 billion for the purpose of expanding health care IT, mostly in the form of grants aimed at small practices and local health care providers. Will the money encourage more physicians to implement electronic health records systems?

Chopra: My general view is the [stimulus package] will encourage physicians to move to the tipping point of saying, "Maybe I will take the plunge." But there is still risk the physician has to take.

My guess is that President Obama views this money as a down payment, the initial component of an overall health reform goal that will include reform of our health payment system in general to pay for outcomes and quality. The secret will be watching closely Obama's health reform goals to see if quality is tied to payments. I have strong confidence in the discussion taking place.

Nextgov: So what is Virginia's role in health IT?

Chopra: I believe we are the first state to adopt health IT standards to better manage our own procurement of health IT. Virginia now requires that any health IT investment made by the state shall adhere to national standards for data sharing or interoperability. What we're going to be doing is standing up a standards approval body that shall set the standards. We'll be establishing a committee similar to the federal health IT standards committee. The federal government is supplying the standards, while we are the demand side. This subset of those national standards will be required features of any health IT purchase the state makes.

Nextgov: Is Virginia planning to make any large health IT purchases?

Chopra: There are roughly 200 providers in our network of state health clinics around the commonwealth. Today, for the most part, they're on a paper-based environment. In the near future, we will likely invest in an electronic health records system for public health physicians. As part of that, we may require that the system be able to report out of the box on immunization stats, HIV status, the things we deem important to public health. We want the system to automatically report to the mothership information we deem important.

For a vendor that proposes that capability, the standards committee has sufficient nonstate players to inspire the market to realize that we all have to report on the same things, so we should require that in the systems we buy as well. It should start to move the market share toward products capable of delivering that functionality.

Nextgov: How can IT lower the state's health care costs and improve quality?

Chopra: One of the key goals we see out of the health IT movement is the progression toward population health outcomes: lowering heart disease, improving the quality of life for people with cancer, reducing infant mortality. You look at these categories and you could see that there is data in a physician's office that could help us share best practices to improve on each of these indicators. In that light, we wish to see health IT adoption so the investments would help us improve on these priorities.

But we're not entirely sure what the role of the government is. We're moving into the clinical innovation piece. We set the goal: lower obesity, for example. How do we as a society do that? Maybe a practice is seeking resources to send text messages to patients who are diabetic to remind them to take their medication. There is no state issue there, but there is a health IT application waiting to be built. We want to make sure our innovation fund can seed projects that can do this.

Nextgov: How do the projects that you want to fund help achieve those goals?

Chopra: One example: In the Shenandoah Valley the rate of preterm births, those are births before 37 weeks of pregnancy, is 11.6 percent. The Centers for Disease Control and Prevention suggests it should be under 7 percent. What that means is a preterm baby has to sit in intensive care for weeks. It's bad for the patient and costly for the system, since most of these women are covered under Medicaid. We would love to see women getting better prenatal care so their pregnancies can run the full term.

Unfortunately, in Shenandoah, we don't have a lot of high-risk obstetrician-gynecologist practices. Instead, we funded a $130,000 pilot project in the valley where we would implement telemedicine that can share data from the rural community into the health system at the University of Virginia [at Charlottesville]. The university can monitor patients from the health system and send a specialist once a month to see the truly high-risk patients.

We will monitor it over the course of a year to see the impact on the birth rate and tie it back to Medicaid to see what the savings are. It's an example of seeding innovation. I can't guarantee success, but I can guarantee we can fund that type of initiative.

Nextgov: What other roles can Virginia play in health IT?

Chopra: Encourage simplification. The whole issue of billing, insurance paperwork, forms, all that hassle. We have launched a public-private partnership that kicks off on March 11. The first action is to create a single Web portal to check the availability of a patient's insurance.

One of the biggest problems is when the doctor sends a bill to the insurance company, the company says the person is not on their insurance. There are any number of administrative reasons why the doctor shouldn't get paid for their service. It's so complicated for doctors to validate that stuff on the front end, so too many physicians don't do it.

The system is supposed to send out an electronic query to the insurance company, to say "yes" or "no" to whether the patient is on the system. There was an electronic way of doing that, but the problem was costly intermediaries who charge to do that. We're offering a free, Web-based portal that will charge no fees and cut out the middleman. We will say to the hospitals and health plans, share the costs, log in and check whether a patient is insured. We hope to have it up and running by August.