The White House's HIT man: An interview with David Blumenthal, MD

The nation's health information technology coordinator is trying to help get physicians up and running with electronic health records systems.

By — Posted Aug. 3, 2009

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David Blumenthal, MD, came to his latest job just after it became a whole lot busier.

When President Obama on March 20 appointed Dr. Blumenthal, 60, to be the national health information technology coordinator, it was barely a month after the enactment of a federal stimulus package that included about $19 billion in net Medicare and Medicaid incentives for electronic health records adoption. A major part of the coordinator's job is to help determine how to use the EHR stimulus money and other inducements for physicians to become part of a national, interoperable health IT infrastructure.

The appointment also coincided with the release of a study authored by Dr. Blumenthal and other researchers that found only 1.5% of nonfederal U.S. hospitals use a comprehensive EHR system -- a lower adoption figure than some past estimates. A study by the same group published in June 2008 found that only 4% of physicians are using comprehensive EHRs.

American Medical News recently spoke with Dr. Blumenthal about his first several months on the job.

AMNews: President Bush in 2004 established a 10-year goal of getting most of the country on interoperable health records systems. Is that a goal the Obama administration shares?

Dr. Blumenthal: The goal of the Obama administration is to improve health and health care in every possible way, to make it higher in quality, more efficient, deliver better value, empower consumers and patients. We look at health information technology as one enabler to accomplishing that goal.

I think in the previous administration, it had the tendency to become an end in itself. That's not how people in my office viewed it, but it stood out there in the absence of a larger health reform agenda. The objective of getting physicians and hospitals to use computers came to assume a value independent of what I think its real purpose is, which is to make doctors better doctors, hospitals better hospitals, consumers more informed purchasers, and the health care system better.

AMNews: So does that mean you're not bound by that 10-year goal? Right now we would be at about the midpoint of that timetable.

Dr. Blumenthal: We are not tied to the Bush administration goal or timetable. Now, the president has said that he would like all Americans to have the benefit of an electronic record by 2014, and the Congress has also pointed to that as an important time frame, and we are going to do everything we can to make that possible.

We also have other time frames that have been created for us by the American Recovery and Reinvestment Act, the stimulus bill, including an obligation to help physicians become meaningful users of electronic health records as soon as possible -- preferably in time for them to benefit from the incentives that are available under the act, and certainly to avoid the penalties that come along after 2015.

AMNews: Have you been able to determine in your first few months whether your office and the physician community are on track with those deadlines?

Dr. Blumenthal: I think it would be presumptuous of me to say that everything is just perfectly lined up and ready to go. This is a tall order and a big challenge. It's a challenge for our office, it's a challenge for American physicians. It's a challenge, though, that I think they are up to, and one that is perfectly consonant with their ideal of professionalism and the traditional notions of American physicians, which is that they desire and are obligated to do everything they can to make care better for their patients.

I have two children in medical school, and I also was, until 10 weeks ago, teaching young physicians on the medical wards. I think for young physicians in the United States, they have no trouble with electronic records. They are expecting delivery systems that enable them to communicate with their colleagues and to treat patients with every bell and whistle available from every technology company in the world -- and many that haven't been invented.

It's us physicians of a slightly older vintage that have to kind of shake ourselves off and decide that we're going to make this transition to what is the best possible medicine.

AMNews: We've spoken to medical students who are shocked to see the difference in the level of health IT between what they encounter in their training and what they encounter in practice. How do you make that transition less jarring?

Dr. Blumenthal: That's the agenda of this office and the agenda that the Congress and the president laid out for us. And that is to create the capability for willing users to raise the level of practice using electronic health records.

I think older physicians -- and I'm one of them, so I speak from personal knowledge -- have to learn how to use an electronic health record. There were many rocky moments for me. Older physicians who control practices and are recruiting young physicians into them are going to have trouble competing for the best young physicians unless they create the infrastructure in their offices that enables young physicians to practice medicine as they feel it ought to be practiced.

Then those young physicians can teach us older guys and girls how to use those records. There will be bi-directional value. The older physicians can share the wisdom that they have accumulated over decades of practice, and the younger physicians can share their familiarity with new technology.

AMNews: The two biggest concerns we hear from physicians are about the cost of the system itself, and whether it will be certified, either by the government or somebody else. The White House says the stimulus funding starts to address the cost issue, but what about certification?

Dr. Blumenthal: We are working on redesigning the certification system. We are working on making it simpler and less expensive while we also focus it on the things that really matter for making patient care better.

AMNews: You asked the committee working group looking at the stimulus act's meaningful use standards to go back and take another crack at them. Why?

Dr. Blumenthal: We had three options: accept, reject or table. And we wanted to take into account the input that we had gotten from the committee during that discussion and bring revised recommendations back for the committee to consider.

We also wanted to be able to look at the input that we got from the more than 700 comments that we received in the aftermath of that first committee meeting.

AMNews: There is some grumbling that the recommendations would entail physicians being asked to do too much too quickly, such as using computerized physician order entry. Is that a concern for your office as well?

Dr. Blumenthal: I'm not going to comment specifically on this issue, but I will tell you that we are very aware that we need to find a balance between our long-term goals of using electronic health records to improve practice and the practical realities of everyday medicine. So that consideration is part of our thinking as we look at these meaningful-use recommendations.

And by the way, these are proposed recommendations from an advisory committee to me. I will not be writing this regulation. The Centers for Medicare & Medicaid Services will, and ultimately, the Dept. of Health and Human Services takes responsibility for it. We are not bound by the recommendations, and we will be taking comment after we issue the notice of proposed rulemaking. So there will be plenty of opportunity down the line to get plenty of input from the public and the profession.

AMNews: You're the third practicing physician to take on this role. You mentioned when you took the job that you were a primary care doctor who worked with an electronic record for about 10 years. How did that go for you?

Dr. Blumenthal: What I remember is a process of learning bit by bit how to use the features of the record that I needed the most, and then gradually adding on new uses as I got better and more used to the old uses.

And I also got help from some of my younger colleagues, who would have mercy on me and show me how to use a particular application that I hadn't known about or some way to do a shortcut that made things fall together better. But it was a process that, were I still practicing, I would be continuing. Because these technologies, just like our home computers and word processing software that we use, have capabilities many of us are lucky if we discover, much less use.

The way to do this right is to put in place an infrastructure that helps at least some physicians, -- the ones who need it, like myself, to become effective users of an electronic health record.

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Who is David Blumenthal, MD?

Born: Aug. 31, 1948

Birthplace: New York, N.Y.

Hometown: Washington, D.C.

Education: BA, Harvard College (1970); MD, Harvard Medical School (1975); master's degree in public policy, John F. Kennedy School of Government, Harvard University (1975)

Medical experience: Intern and resident in medicine, Massachusetts General Hospital, Boston (1975-80); clinical fellow in medicine, Harvard Medical School (1975-80); assistant in medicine, Massachusetts General Hospital (1983-87); associate physician, Brigham and Women's Hospital, Boston (1987-91); associate physician, Massachusetts General Hospital (1991-97); physician, Massachusetts General Hospital (1997-present)

Teaching experience: Fellow, lecturer of health policy, Kennedy School of Government (1980-87); instructor, professor of medicine, social medicine and health policy, and health care policy, Harvard Medical School (1980-present); lecturer on health services, health policy and management, Harvard School of Public Health (1983-present)

Other professional experience: Professional staff member, U.S. Senate Committee on Human Resources' health and scientific research subcommittee (1977-79); research program coordinator, executive director, Center for Health Policy and Management, Kennedy School of Government (1980-87); senior vice president, Brigham and Women's Hospital (1987-91); chief, Health Policy Research and Development Unit, Division of General Medicine, Massachusetts General Hospital (1991-present); director, Institute for Health Policy, Massachusetts General Hospital and Partners HealthCare System (1998-present); national correspondent, New England Journal of Medicine (2002-present); national coordinator for health information technology (March 2009-present)

Of note: Chief health adviser for the Dukakis for President campaign from 1987-88; senior health adviser to the Obama campaign in 2008

Source: Dept. of Health and Human Services

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The health IT alphabet soup

When most physicians refer to paperless records systems, they refer to them as electronic medical records, EMRs, regardless of how sophisticated the systems are. But the national coordinator for health information technology's office is trying to help build a national infrastructure in which most records systems are interoperable, one of the key features that defines electronic health records, EHRs. Last year the coordinator's office asked the National Alliance for Health Information Technology, a partnership of senior health care executives, to sort out the acronyms that were prone to confusion. The group came up with several official definitions:

EMR, electronic medical record: An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization.

EHR, electronic health record: An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization.

PHR, personal health record: An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared and controlled by the individual.

HIE, health information exchange: The electronic movement of health-related information among organizations according to nationally recognized standards.

HIO, health information organization: An organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards.

RHIO, regional health information organization: A health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community.

Source: National Alliance for Health Information Technology, May 2008

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