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Session 1: The Potential Impact of Clinical Informatics on Health Care Costs, Quality, and Safety (continued)

Mike Kassis: Well, I have been listening to the wonderful presentations by Dr. Bagley and Dr. Ortiz, and I have sort of restructured a little bit what I want to say. My points that I am going to make may not actually pertain to the slide that the audience is now seeing. But focusing on your question, Cindy, the State plays many roles. The State certainly plays the role of payer through the public healthcare programs such as Medicare, Medicaid, and whatnot. They are also a purchaser of health care for their employees through State programs. The State is also a regulator. The State is an advocate, also, for patients. But, for example, in the area of purchaser or payer, the thing that the State or any other purchaser or payer is going to be interested in for that matter is the issue of cost/benefit. Of course, Dr. Bagley mentioned the concern the physicians have regarding a return investment. Sometimes the expenditure for these kinds of technologies is large and immediate and people oftentimes don't see what the payoff is going to be for some time. Trying to convince policymakers, whether they be policymakers within a private institution who have to allocate resources or even State policymakers facing difficult budget times, they have to be convinced that this expenditure really will have the payoff. As both noted, some of the research in this area is limited. There are certainly performance measures that have been analyzed. Outcome measures I think are going to have to be demonstrated before policymakers are willing to commit. Let me give you an example. You had mentioned that the State of California recently passed a law requiring facilities, hospitals for example, to help reduce errors through some sort of an automated pharmacy ordering or medication ordering system. That is a piece of legislation that has passed. Facilities are required to provide a plan to the State Health Department by January of next year and then implement these new procedures.

But interestingly enough, there is an exception in there and people are granted, the facilities, excuse me, are granted some leeway in complying with that law. Really what it has to do with is a law that we passed a few years back that require hospitals to improve the seismic performance of the buildings. That is, help them to withstand earthquakes. So here the hospital industry is faced with a huge problem that they have to retrofit their buildings and spend lots of money to do that. There is a certain time frame and yet at the same time they are asked to implement these new kinds of informatics technologies to improve the quality of care. Well, the law provides the facilities with some leeway in complying with those seismic safety requirements. They can push it out a little bit further because the legislature felt that reducing medical errors was more important at this point in time than spending money on bricks and mortar to improve the seismic performance of the facilities.

So, you see here, the legislature was trying to grapple with the issue of a cost benefit and budget priorities. Without more evidence in these areas when new technologies come up, when it becomes required to have online medical record systems or the kinds of clinical diagnostic tools that are computer-based or network-based and then the State has said, "OK, you have to pay for that. You have to increase your rates of reimbursement under your Medicaid program to cover that."Questions are going to come up, "Why? Why is this more important now than retrofitting that hospital building that you said was so important a few years ago?"Being able to demonstrate that cost benefit to the policymakers I think is absolutely critical because the State, as I mentioned, is a payer and a purchaser for its own employees. They are the regulators, the State helps to ensure quality of care by ensuring that the facilities meet both State and Federal requirements as Dr. Ortiz mentioned. We are looking at issues of outcomes here as well. Trying to measure performance of facilities based upon outcome studies, but issues also come up in terms of appropriate use and safety. Again, what kinds of evaluations have been done of these systems to ensure that they are appropriate and they are safe? Certainly the online physician order entry systems that allow physicians to check to see whether or not a prescription is not going to interact inappropriately with another prescription. That is great. We know the systems do that. How do we know one system is better than another one in terms of identifying those kinds of drug interactions? Who is setting the standards for those kinds of online ordering systems so that the State licensing agencies can evaluate these applications when the facilities put them into place? Issues of regulating the new technology come up. Of course, there are always issues of liability and that is if a patient in a facility experiences some negative outcome as a result of the application of this technology, what recourse do they have? What recourse do they have with the plan to ensure that this technology is being used appropriately and also being used to provide them the care that they are supposedly guaranteed under the provisions of the plan?

I think we are going to talk in a minute or so about the issues of confidentiality and privacy and security. The last point I want to make is the State also, in addition to being a purchaser, payer, and regulator, is also an advocate for its people, its population. They want to make sure that people have access to care. If suddenly a community standard is established in the area of provision of care using information technology informatics, they want to make sure that every segment of the population, whether they be rich or poor, have access to this kind of quality medial service.

Then one point that Dr. Bagley noted, the benefits of Internet access. Being able to communicate with your physician and having access to best practices and learning about your medical condition, we face and continue to face the issue of the digital divide. It is all well and good for the middle class individual that has Internet access at home, high-speed DSL [digital subscriber line] line trying to get on to the Johns Hopkins site to look up their medical condition, but the individual who is living with three other families in a home and they barely have a telephone line, is going to find that kind of access difficult. Now, we always say they have access to libraries and whatnot, but I think we need to recognize that those expectations I think are a long way off.

Cindy DiBiasi: You are raising some really good points here, Mike, and I want to come back to you. We are going to have to open this up for questions because we really are being inundated right now, which is a good sign because the presentations are so interesting.

I would just like to remind you that you can communicate your questions to us in the following ways. If you are on the phone, press "14." You may fax your question to us and the fax number is (301) 594-0380 or you may E-mail us your question at info@ahrq.gov. You may also directly type your question in the messaging field and hit "enter." Please note that your sent message will not appear in the chat box. Please also remember that if you prefer not to use your name when you communicate with us, that is fine. We would like to know what State you are from and the name of your department or organization, so please indicate that regardless of the way in which you transmit your question.

Before going to the questions, I want to say a few words about AHRQ and the User Liaison Program [ULP]. The mission of AHRQ is to develop and disseminate research-based information that will help clinicians and other healthcare stakeholders make decisions to improve healthcare quality and promote efficiency in the way that healthcare is delivered. The User Liaison Program serves as a bridge between researchers and State and local policymakers. We not only take research information to policymakers so they are better informed; we take the policymaker's questions back to researchers so they are aware of the priorities. Hundreds of State and local officials participate in ULP workshops every year. There is a relatively new addition to the ULP portfolio of products. We hope that today's Web-assisted teleconference and the other two events in this Web-assisted teleconference series will provide a forum for discussion between our audience of policymakers and researchers like those joining me for our discussion today. We certainly would appreciate any feedback you have on these Web-assisted teleconferences, so please E-mail your comments to the AHRQ User Liaison Programs at info@ahrq.gov. Now why don't we go to your questions?

Cathy Siddell from Pennsylvania has a question for Eduardo. Do you have statistics on the reduction of medical error rates at this point?

Dr. Eduardo Ortiz: We actually do have numbers on those. Maybe what I should do is let you go to another question so I can pull up some of those exact numbers.

Cindy DiBiasi: That sounds good. Let's go to Bruce. This is from Alden. (End of tape)

Dr. Bruce Bagley: ... to the patient. That means the information. The piece of paper that it is written on right now belongs to the physician, but the information belongs to the patient. So anybody should have access to their record now. It is just that electronic format allows that to be much more available without actually copying or going to the office to pick it up or having it mailed. We look for a time when it is appropriate for a patient with a proper security to go into their own medical record and read it online through a Web link up. I think we have a ways to go before that will happen, but there is really no reason they shouldn't know what is in that record.

Cindy DiBiasi: They can correct it if there are any mistakes?

Dr. Bruce Bagley: Of course, a medical record is a legal document so nobody can go in and just kind of correct it. You can do addendums or additions and say, "I don't agree with this statement."You can't kind of wipe out what it said there and write your own. But you certainly can make some comments to fill out the history or say well, it really was going on for three weeks instead of one week or it was really my left foot instead of my right foot or something like that.

Cindy DiBiasi: Which is nice because it is more than they can do now, really.

Dr. Bruce Bagley: Absolutely.

Cindy DiBiasi: Mike, we have a question for you from Marty. The question is, what about the State role with required reporting for public health disease surveillance? This would seem to be another category to your list and it would include cancer registries and immunization registries and infectious disease reporting.

Michael Kassis: Absolutely. In fact, in California we are exploring and actually starting some pilot projects in that area to use network-based systems to gather this information and report it to the State as part of an automated process. There are extreme benefits to that in terms of the administration of these programs. The information gets into the system and into the State registries at a much faster and more efficient and accurate basis than does the current paper-based process. I think there are extreme advantages for that. These also do, however, raise concerns of issues of privacy and confidentiality. I think that as we in the industry move forward to implement these practices, it is going to be a culture change within the organizations to ensure that the information and data are transmitted appropriately and we use all the available technologies to secure it.

Cindy DiBiasi: Let's talk about that because Jim and Steve from North Carolina want to know how HIPAA [The Health Insurance Portability and Accountability Act] and confidentiality fit into informatics.

Michael Kassis: I think they play an extremely important role. I think while they are troubling to some people in terms of the degree or extent to which these protections will have to be put into place, I think they are long overdue, number one. Number two, I think they raise issues of privacy and confidentiality protection that have I think been overlooked over the years as medical practice has moved into the 21st century of using electronic records already to this point. So I think HIPAA is important. It helps to set the standards and I know there are going to be further discussions and refinements as to how it actually gets implemented. I think it really gives us some benchmarks to use nationally and gives some places for the States to start to add additional protections as well.

Cindy DiBiasi: Bruce, would you like to add something?

Dr. Bruce Bagley: Yes. I agree. I think it is going to force us to do the right thing. There certainly will be a lot of weeping and gnashing of teeth along the way. It really just demands that we be very careful about confidentiality as we move to an electronic format which is, as you know, so much more accessible. Our paper records aren't terribly secure right now. We have a room full of charts and almost anybody can walk in there and open up a chart and see what is in there. There is no way to actually trace that, to see who opened it up unless you are going to fingerprint all of the charts and we are not about to do that. But at least with electronic medical records, you will actually be able to have an audit trail. You will know who looked at it from which workstation and what code they used to get into it. The interesting thing is that patients want to know who looked at their chart. They would want to know if the consultant they went to looked at their chart and what was done before. They would be surprised to find out if they didn't look at it. It is just as important as having somebody look at it who shouldn't have looked at it.

Cindy DiBiasi: I may be asking the impossible here, but just to make sure that we are all up to speed on HIPAA, if you could give us a very brief overview of a very complicated set of standards

Dr. Bruce Bagley: No, I could not (laughs). Nor will I attempt to.

Cindy DiBiasi: Just as it relates to informatics and standardization of confidentiality.

Dr. Bruce Bagley: That is really the issue. I think as we move forward with electronic medical records, it will cause us to design our systems so they will have the proper confidentiality. What is actually going to happen in the physician's office, we need to do; the regulations now say what is reasonable and appropriate. Believe it or not, it does say that in there. They are not going to make us do things that are not reasonable and appropriate in our office. But they will make us pay attention to the things that are reasonable and appropriate as we move forward in the electronic age.

Cindy DiBiasi: Mike, did you want to add something? I feel like I cut you off.

Michael Kassis: : The point I wanted to add was in addition to the protections that the systems offer in terms of cracking accesses, as the doctor was saying, they also provide a high degree of security in terms of protection against loss. I can't imagine the worst nightmare of having a physician come to their office and discover that there has been a fire or a flood and these records are now destroyed. Whereas with an electronic medical records system backed up to an appropriate network resource, you could restore most everything with simply the push of a button. I know that is being a little simplistic, but the idea is that if a fire burns paper, there is no backup.

Cindy DiBiasi: Eduardo, how are we doing on those numbers? I feel like we have lost you.

Dr. Eduardo Ortiz: Oh, that's OK. Actually, I do have some data. Unfortunately, I didn't bring all of my data because I actually just have a paper that has everything in detail. I can at least give you some numbers to give you an idea of some of the reductions we have found. I have a couple of examples here of some of the studies. In one study here, we found a 25 percent improvement in the ordering of corollary medications. Now what that means is basically, let's say a patient comes in and they end up having some kind of a condition and when they have that condition you are prompted that you should be ordering something else in a medication for a diabetic patient or a lab test. Let's say you started someone on potassium and then you want to make sure you monitor their potassium and order a lab test for that. They found a 25 percent improvement in corollary orders. That's one example.

Another example here found a 55 percent decrease in non-intercepted serious medication errors. Basically a serious medication error is supposed to be distinguished from a non-serious. Let's say you have a patient who gets a dose of medication, instead of 10 mg gets 20 mg but it really is a benign thing; it really doesn't make much of a difference. Then that would be considered maybe a just a medication error, but not a serious medication error. So this found a 55 percent decrease in serious medication errors. By the term "non-intercepted", what that meant is that this error was not picked up. Oftentimes there may be a medication error that somebody picks up or intercepts before it is actually carried out. So before you actually give that medication to a patient, a nurse or a pharmacist could have picked up that the doctor wrote 10 mg instead of 0.1 mg. So this is important because these are things that were not intercepted by somebody else and could potentially be very devastating.

Also, another study showed a 17 percent decrease in preventable, what we call adverse, drug events. The distinction between that and the medication errors is that goes one step further. You can have a medication error that does not result in an adverse event. But then you have something that you gave to a patient and results in an adverse event. They could go into renal failure, they could develop a rash, and they could develop any sorts of things. Some could be mild; some could be very serious. They can go into shock. They can have an anaphylactic reaction. A 17 percent decrease in preventable adverse drug events.

Another study showed an 81 percent decrease in medication errors, an 86 percent decrease in non-intercepted serious medication errors. So in that 80 percent range, we also have some studies that are what they call meta-analyses. What they do is they basically pool the results of all these studies and evaluate the outcomes of multiple studies that have been done. In one of these meta-analyses, they don't have specific numbers, but basically show that 43 of the 65 studies showed improvement in physician performance using computerized systems. Another one actually showed that six of the 14 studies showed improvement in patient outcomes.

Once again, these are not hardcore outcomes like mortality, but they are outcomes that were evaluated. Another study here showed a 17 percent reduction in bacterial susceptibility and things like that actually increase in bacterial susceptibility by using the proper antibiotic that was prompted by computerized decision support systems. Basically those are just a few examples. If you look at the literature, it is anywhere from about 20 percent to as high as 80 percent in terms of the reduction in either medication errors or adverse events. If you are looking at medication errors, the numbers tend to be higher. If you are looking at more serious adverse events, it ends up being more in the 20 percent range. So a substantial improvement.

Cindy DiBiasi: What about the consumer? Do you really see advances in informatics changing the way that patients deal with the healthcare system and their providers?

Dr. Eduardo Ortiz: I think so. There are a lot of potential applications that the consumer can take advantage of. Dr. Bagley already kind of alluded to some of these and discussed them. Just to reiterate a couple of these things, there is excellent potential for providing consumer health information. Once again, as I said earlier, you have got to be very careful because it is a double-edged sword. You have got to make sure that the information is accurate. It should be based upon the best available evidence and it should be up to date. There is a lot of junk out there and that is important because you want to make sure, as Dr. Bagley said, when that patient comes in and is right about prostatitis, that they have read good information on prostatitis and they haven't read a bunch of other stuff and then come in requesting things that are inappropriate. I think there is a tremendous opportunity for them to improve their communication with their providers as was previously discussed with E-mail. Although, if you are going to do that, you need to restructure some of the systems because right now, as Dr. Bagley said, these systems of patient/provider interaction were developed a long time ago and it is basically to achieve a different goal. Nowadays, if you are going to build in electronic mail communication, you have to restructure the workflow to build that in. Otherwise, that is just an added burden to the clinician. Most clinicians aren't going to want to be involved in that if this is just extra work. Now a patient can E-mail them any time of day. They don't get reimbursed for it and they have to do this on top of everything else they are doing. You have to take that into account.

There are also some opportunities for what we call Interactive Decision Support Tools. That is basically where patients can develop these, there are these tools that can be developed on making decisions like, should I get this screening for prostate cancer? Should I have a PSA done? Should I be screened for breast cancer? Should I undergo this test? There are these things called shared decisionmaking where they have these tools where the patient can be provided with information, good evidence-based information. Then they can kind of make what we call an informed shared decision with their doctor.

There are also some opportunities for patients even accessing their own medical records. That is still kind of controversial, but is something that is being looked at where patients can actually access their medical records and in some situations we are even looking at issues where they might even be in control of their medical records. So they control their medical records and they are kind of portable. They are basically the ones that take them to the physicians instead of vice-versa where the physician controls the records. This is all kind of experimental at this point.

Finally, I think there are good opportunities for things like patients in our disease management programs. An example of that would be, let's say you have asthma and you are at home. With a patient-centered disease management program, you could provide some education tools to that patient about asthma. Other things they could do is, for example, they could actually test themselves. They could blow into their peak flow meter that measures how good they are breathing that day and then they could either manually enter in their data or there are even some systems that are working where you could actually electronically download that data, transmit it over a phone line to the doctor's office and the patient can either get recommendations based on the results, kind of automated and electronic recommendations, or it could even prompt somebody in the office if there's kind of a concern. For example, their level drops below a certain threshold and it could basically beep the nurse or the doctor's office or someone and then they basically get a call back from the physician's office saying, "We see that your peak flow levels are down today. What is going on?"and maybe have the patient come in. So there are a lot of opportunities that way of using some of this information technology on the consumer side.

Now, some of these are already being utilized; some of these still are kind of futuristic.

Cindy DiBiasi: You mentioned earlier Smart Cards. We had a question, if you could explain exactly what is a Smart Card? What is on a Smart Card?

Dr. Eduardo Ortiz: A Smart Card basically is just a small card. It is about the size of a credit card. What it is, it basically contains an electronic chip and it is imbedded into the Smart Card and it is a way of actually carrying healthcare information on a little card that is portable. So basically, instead of having all this information on a paper-based record or on an electronic medical record on a computer, you could see where you could miniaturize this data, put it on a Smart Card. Patient carries it with them. Patient goes on vacation to New York. Something happens. Gets hospitalized. Has that Smart Card, almost like an ATM card and plugs it into the system in their New York hospital and it can basically download the data on their medical record. It could also have things like their allergies and things like that. You could even potentially make them interactive where if somebody gives you a medication, that Smart Card, once you enter it into the Smart Card that you are getting this medication, it could basically warn somebody, "Oops. He is allergic to this thing. Don't give it to him."

Cindy DiBiasi: So a Smart Card is sort of like a medical record on steroids?

Dr. Eduardo Ortiz: It's actually kind of a miniaturized, portable medical record that you carry around kind of like an ATM card. Actually, it is interesting. The Department of Defense is really the leading agency in the country really working on this. They have been working on it, very interested of course with a perspective like battlefield, that is an excellent way for soldiers to carry their information, which becomes a problem. It is still something that is being worked on. They have done some work on them but we don't have any really good clinical data on them.

Cindy DiBiasi: Bruce, you talked about informatics applications at the provider level. What developments are you seeing at other levels, for instance, the health plan level?

Dr. Bruce Bagley: I think the health plans are going to be a major beneficiary of this. We have actually in our office, tried to get some of our health plans to give us a per-member, per-month contribution to help pay for our electronic medical records. I just put up a slide here that talks about some of the benefits that would come to the health plan. Having all the information on a relational database, which is a computer construct, which allows us to do some chart reviews that we never could do before. For instance, we had a woman who was going to come in to our office and spend two weeks examining our charts about diabetes for one of the health plan's studies. In about 15 minutes, we were able to produce a list that had 1,500 patient numbers with the doctor that they saw, the medications that they were on, the last time they had a hemoglobin A 1C, and what the value of that hemoglobin A 1C was, just listed right out there. Her work went from two weeks that she had set aside in her schedule to about four hours to fill out that data. We are not even designed as a research practice. We are just a regular family practice. The side effects of having this kind of technology are great.

We also, there is a lot of talk about disease registries to try to be able to do population management. Being able to keep track of all your patients with high blood pressure, all your patients with high cholesterol. By having electronic medical records, it does that automatically. You just can call up any code-able disease and get a list of those folks and make sure they get flu shots or make sure they get the latest medicine that just came out or make sure they get off the medicine that was out. Those kinds of things are just impossible with the paper record. We can also do outcomes-related research. I think in the future, we will probably be paid based on outcomes. We will get bonuses based on our best clinical outcomes. Right now, we have no way to keep track of that very well. With the electronic medical record, we will be able to do that.

Cindy DiBiasi: That has got to be something that is causing controversy.

Dr. Bruce Bagley: For sure.

Cindy DiBiasi: Let me ask you, if you had a crystal ball and you were able to look into the future, what do think the physician's office or a hospital would look like? How would it be different because of developments in informatics?

Dr. Bruce Bagley: I am not as familiar with the hospitals as I am with the physician's office. I think that the interaction between the patient and the relationship between the patient and the clinician is really what the care is. Right now we are very focused on the visit as the care and we pay for the visit. We don't pay for the interaction. We pay for the visit. The transfer of information and the interpretation of all this information that we have available to the patient, in a way that helps them understand the complex medical information in view of their values and their wants and dislikes. To actually mold that information to be most effective for that patient, to use their belief systems in their care rather than our belief systems, their care would be more effective.

Cindy DiBiasi: Well, now, let me ask you, this comes from Valerie and it talks about consumer focus efforts. She wants to know, how will this affect the financial aspects of the physicians when you have patients doing tests that are normally done in the office for a fee?

Dr. Eduardo Ortiz: That is an interesting question also. Bruce maybe might want to dive in here later. One of the things that we found, like for example, the Institute of Medicine [IOM] report that just came out on crossing the quality chasm where they looked at basically quality issues in the U.S. and found that we have significant problems here in terms of the quality that we have and what we really want to achieve and what we should achieve. It is interesting. One of their sections was on reimbursement and financial incentives. I think it is something that will really have to be looked at very seriously by payers, by government payers, by basically private payers, as well. In terms of if we really want to improve quality, you are going to have to pay for it and you are going to have to look at how you do some of these things. We are going to have to start thinking outside of the box of the way we have been thinking about the healthcare encounter, which is based on this person-to-person, face-to-face visit. That is still a part of medicine and that is not going to go away. For example, as you start developing some of these tools, a lot of things can be done without a patient visit. Perhaps you can E-mail me and you have a problem or my office and it is something that we can take care of through electronic mail. We may be able to prevent your making a visit to the hospital or to my clinic. Which is actually beneficial for you, because you have to work or you have kids or you have other issues going on. But on the other hand, no one is going to want to do that if that decreases the number of visits and that is going to decrease reimbursement rates for providers because basically they are shooting themselves in the foot because providers are dependent on these visits to make their income.

Michael Kassis: This is Michael in California. There is always the argument that in cases where you have a capitated rate where you get paid a flat amount a month each month to see a particular patient no matter how many times you see them, medical informatics can help the physician keep the costs down and deliver the services under those kinds of rates.

Dr. Eduardo Ortiz: Right. Exactly. So that is perfect. In a capitated system, then it works nicely. But if you are in any type of a fee for service system, then there are negative incentives at this point for that.

Cindy DiBiasi: Bruce, let me ask you, what incentives do you think would be best to encourage the implementation of electronic medical records and other informatics changes?

Dr. Bruce Bagley: Somehow we have to get away from this visit-based thinking and the visit-based reimbursement. It is an impediment to moving in the right direction. The IOM report clearly discusses that. We have to have some way of taking care of patients without running on what I call a fee-for-service treadmill. You have all been to the doctor's office where you know and the doctor knows that you don't have to be face to face to solve the problem that you bring to the doctor that day. To me, that is an embarrassment. We shouldn't make them come in for something that they don't have to be there for.

Cindy DiBiasi: Is there any concern over legal liability, though? If the patient isn't sitting there and that doctor is trying to prescribe or treat over the phone or electronically or...

Dr. Bruce Bagley: That is an excuse, yeah. I don't think that is a big problem. I think if you have a relationship with the patient and a long-term relationship with the patient, you know what their risk tolerance is and your risk tolerance is. I have got patients that need to be seen every week. That is nuts, but they think they need to be seen every week and other patients who don't come in often enough. We have to adapt to that.

Cindy DiBiasi: Mike, did you want to add to that?

Michael Kassis: I think he covered it very well. (laughs)

Cindy DiBiasi: You were just in violent agreement.

Michael Kassis: Oh, absolutely.

Cindy DiBiasi: We have a call from Marty in Minnesota. He wants to know what percentage of clinic staff has access to basic technology such as E-mail and access to the Web? Does it vary by urban vs. rural clinics? So we not only are talking about a digital divide when it comes to the patients, but how about the providers?

Dr. Eduardo Ortiz: We actually have a little bit of information. We did an EMR survey, an electronic medical record survey of active academy members, and we found very little difference in locations, in geographic location, urban vs. rural.

Cindy DiBiasi: It sounds like it is wonderful for rural areas because this brings people together in a different way.

A question from Barbara. Could one of the presenters talk about the use for people with disabilities or elder people and their issues regarding correct self-medication? Different population, possibly a more susceptible population.

Dr. Bruce Bagley: Not as computer literate and not as ready to jump on their computer and find out what they need to know. I think that is going to be a slow go. One of the things that was encouraging to us in our computer survey was that we found, of course, in people under 35 that 80 percent or more were using the Internet already in taking care of patients. But the great part of the study was it showed that 40 percent of physicians over 65 were using the computer on a regular basis in their interaction with patients. It's not just an age thing. There are a lot of doctors who are over 65 who are willing to do what needs to be done to jump into the Information Age. There may be just as many patients out there.

Dr. Eduardo Ortiz: The other thing I would add to that is the fact that the agency here, basically we like to focus a lot of our efforts on what we call priority populations. Priority populations include minorities, patients with disabilities, the elderly. There is a whole group that we basically define as priority populations. In several of our RFAs, these Request for Applications, which is where we put out solicitations to fund research. For example, now we have one called Clinical Informatics to Promote Patient Safety, which is on the use of innovative informatics applications to improve patient safety and quality of care. We specifically ask for studies that are going to focus on priority populations. We are looking to fund proposals such as that. It really does kind of give you an edge when you are actually applying for a lot of our funding. We are very concerned with that as well and we know that that is an issue. We are trying to address that issue through our funding mechanisms and trying to make sure that priority populations are covered in the proposals that we are funding.

Michael Kassis: This is Michael from California. Another point is, and I don't know how many of you are familiar with implementing large-scale technology projects, but one of the basic places you start is taking a look at your business processes. You don't just simply buy a computer application or piece of technology and plug it in and make it work. You have to understand how your process works and then you adapt the technology and you adapt the tools to make it work. I think that simply that strategy, that approach towards implementing information technology has benefits in terms of patient care. As you are looking at what you are doing for patients, how you are providing that care and how you are delivering that care. In order to implement some of these systems, you are automatically looking for ways to improve what you are doing for patients right from the beginning. So when we brought up that point that one of the audience members brought up, what about people with disabilities, what about the seniors? Well, if you are going to implement a system of information technology, you look at your customers. You look at the patients. You understand how your business process works and then you adapt the technology accordingly.

We have situations out here in terms of long-term care where we are dealing with a community of individuals who are trying to get out of institutions and back into the community and technology is playing a critical role in that. I think that the answer to that question is it is going to do nothing but benefit those population groups.

Cindy DiBiasi: What you are talking about is a much more strategic approach. Bruce?

Dr. Bruce Bagley: Mike, I agree 100 percent. As we implemented our computerized medical records, we actually looked at all of our office systems. It is really just to support our platform for process redesign is what it amounts to. It allows us to do some process redesign that we never could do before. I think if you just computerize the same mess you have got now, it is really a missed opportunity.

Michael Kassis: Absolutely.

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