Download January 14, 2005 DRAFT David J. Brailer, MD, Ph.D. National

January 14, 2005
DRAFT
David J. Brailer, MD, Ph.D.
National Coordinator, Health Information Technology
Department of Health and Human Services
517-D, Hubert H. Humphrey Building
200 Independence Avenue, SW
Washington, DC 20201
RE: Request for Information: Development and Adoption of a National Health
Information Network
Dear Dr. Brailer:
On behalf of the American College of Emergency Physicians (ACEP), I am pleased to respond to
your Request for Information on the Development and Adoption of a National Health Information
Network. ACEP is a national medical specialty society with more than 23,000 members. ACEP
is dedicated to improving the quality of emergency care through continuing education, research,
and public education. We appreciate the opportunity to provide the Department with our
comments on developing the infrastructure, standards, and proposed use of information
technology in healthcare, particularly as it affects the delivery of emergency medicine services.
ACEP members are actively involved in research and development projects that
contribute significantly to the evolving National Health Information Network (NHIN). In
1994, ACEP developed and first presented the “Emergency Department of the Future”
project which includes many of the concepts now planned for implementation as part of
the national health information infrastructure. More recently, in cooperation with the
Society for Academic Emergency Medicine, ACEP members coordinated an Emergency
Medicine Information Technology Consensus Conference in May 2004. The results of
that meeting were published in the November 2004 issue of Academic Emergency
Medicine (Vol 11, No 11) as a special issue devoted to medical informatics. This
consensus document represents a landmark publication in the field of medical
information management technology, and we would be pleased to share it with you and
your staff.
The emergency department is one of the most complex and challenging practice
environments in all of medicine, making emergency medicine one of the specialties most
in need of an improved national health information infrastructure. According to the
CDC’s estimates for 2003, the nation’s emergency departments care for more than 114
million patients per year of all ages; for undifferentiated acute medical and traumatic
conditions; in rural, urban, and suburban areas; 24 hours a day, 7 days a week, 365 days a
year. Due to the very nature of emergency care, it is often delivered without the benefit of
a patient’s vital past medical information. Nevertheless, emergency care providers
perform admirably as the safety net for a healthcare system that is chronically
overcrowded and poorly supported. Clearly, all patients will benefit from improved
healthcare information technology, but none will benefit as much as those cared for in
emergency situations.
The American College of Emergency Physicians is actively participating in and endorses
the Collaborative OCNHIT RFI response developed by the Connecting for Health
workgroup. In addition, we offer our own comments to address issues specific to
emergency medicine and to clarify the impact that the implementation of a national
network will have on the practice of emergency medicine.
Background
1. National Health Information Network (NHIN) definition
The value of NHIN, as defined in the Collaborative Response, includes several
capabilities that American College of Emergency Physicians believes are so important to
emergency medicine that they must be highlighted. The NHIN must:
 Provide the connectivity necessary for high quality healthcare by allowing
individuals and their authorized health professionals to access necessary health
information about a person exactly when, where, and how it is needed, in real
time.
 Support the creation of distilled datasets that are useful for quality measurement
and reporting, product effectiveness monitoring, research and other purposes.
 Enhance quality, safety, and professionalism by providing physicians with the
ability to look at aggregate outcomes of care and benchmarks of performance.
2. The overall NHIN model
The American College of Emergency Physicians believes improvements in emergency
care information systems are vital to the interests of the more than 114 million Americans
who seek care in EDs each year. Emergency care providers interact with all other
medical specialties, and the ED frequently serves as the hub of patient care by bridging
inpatient and outpatient services. Use-case analyses in medical informatics and
information exchange frequently are based upon emergency medical encounters.
Because of our unique position as the health care system’s safety net and our
organization’s unique position in the house of medicine, we believe ACEP should and
must play a leadership role in the pursuit of a NHIN.
ACEP agrees conceptually with the vision of developing a series of regional health
information networks that are integrated to form a coordinated national system. An
important component that should not be neglected is the development of specialty-based
communication and secondary datasets to support research, benchmarking, and health
policy. Specialty societies such as ACEP are uniquely positioned to play an important
role in facilitating these capabilities. Also, ACEP is a non-profit organization whose role
is to promote high quality emergency care, as opposed to the sometimes-conflicting
priorities of insurance companies or other commercial stakeholders.
Consistent with this vision, ACEP is already pursuing projects leading to a national
emergency medicine web-based communication and preparedness network, and a
national emergency medicine encounter registry. These projects will create additional
significant
benefits for the other specialists that interact with emergency medicine every day. We
urge and seek funding for these projects in the near future as key components of NHIN.
3. National vs. local/regional aspects of NHIN
The American College of Emergency Physicians concurs that both local and national
strategies are necessary with two areas of particular importance to emergency medicine:
While interoperable regional exchange organizations remain a sensible model on which
building blocks can be created for a national system, policy supporting national
capabilities is vital. An interoperable national routing service is imperative for
innumerable patients who travel among multiple geographic regions. It is of paramount
importance that all regional systems share their information to support the national
communication and preparedness and benchmarking initiatives previously described.
Emergency medicine, more than any other specialty, is affected by the speed of system
response and requires information in real time and with 24 x 7 dependability. If multiple
local regions build their own solutions, specific criteria must be developed that define
acceptable system performance for each Regional Health Information Organization
(RHIO) in order to meet the critical demands of busy emergency departments nationwide.
Organizational and Business Framework
4. NHIN organizational framework
a. Development b. Operational policies c. Acceleration d. Operations
The American College of Emergency Physicians strongly supports capitalization
assistance to establish additional RHIOs, evaluation studies, and models for sustaining
operations. From our experience with disaster preparedness funding, ACEP believes that
federal funding directed only to state governments achieves less than optimal results. A
more effective funding mechanism to support development and operation of RHIOs
should be provided directly to RHIOs that are already working to achieve articulated
results.
5. Financial model for building NHIN
At this early stage of NHIN development, funding is most likely to come from a
combination of federal sources, private foundations, and enlightened companies that
foresee the future benefits. An important requirement for this early funding must include
systematic evaluation, preferably with formal return on investment studies.
6. Financial model for sustaining NHIN
Various communities are considering transaction fees, subscription, or utility models for
supporting ongoing operations. The American College of Emergency Physicians believes
that the “transaction fee model” is ill advised for a variety of reasons. Transaction fees
create a strong disincentive for providers to access the NHIN system. This is particularly
true in emergency medicine, which provides a disproportionate share of charity care to
uninsured and otherwise disadvantaged patients. Therefore, EDs would have few means
to recover extra costs associated with use of the NHIN system. Further, it is those that
pay for health care (government and employers) who will benefit financially from a more
cost-
effective health information-sharing environment. We believe that the most reasonable
funding mechanism is one that aligns both the return and the investment and thus favors
either a public utility model or a payer-supported system.
7. Privacy and security considerations
The American College of Emergency Physicians supports the general statements in the
Collaborative Response, and believes network operation should be consistent with
current HIPAA rules and with provisions that facilitate access for continuing care and
emergency situations. Given the nature of emergency medicine, cumbersome or onerous
authorization requirements must be avoided. Moreover, it is vitally important that a
"break the glass" policy be included, whereby authorized emergency clinicians are able
to gain access to critical information with a doctrine of presumed consent when patients
have emergency conditions and are unable to provide consent.
8. Support for public policy
The overriding reason for creation of a NHIN must be improvement in the quality and
efficiency of healthcare for all Americans. Quality can be defined in many ways,
including improvements in morbidity and mortality, cost effectiveness, patient
satisfaction, and access to care. Secondary use of NHIN data should support
improvements in public health through surveillance, benchmarking, and policy support
initiatives. The Collaborative Response recommends the establishment of a Standards
and Policy Entity (SPE) that defines the standards and policies that underpin the
Common Framework. The American College of Emergency Physicians believes that
medical specialty societies should be provided representation within such an entity.
Management and Operational Considerations
9. Encouraging competition
As noted above in Section 4, the American College of Emergency Physicians believes
funds should be made available to a variety of local, regional, and state-based initiatives,
including public and private partners, in order to stimulate innovation at many levels.
10. Infrastructure that encourages: a. Private investment b. Nonproprietary
control c. Interoperability d. Innovation
The American College of Emergency Physicians is concerned that reliance on private
investment as the primary funding source will result in undesirable and unintended
consequences. Propriety stakeholders that invest in the infrastructure may bias
development in favor of their business needs. This could result in an unfair advantage in
the marketplace and disrupt the usual competitive forces that drive innovation. It could
also result in an infrastructure optimized for the needs of private investors rather than one
optimized for the needs of our healthcare system as a whole.
The banking industry is a frequently cited example of a system funded by private
investment that uses data standards to achieve interoperability. However, this privately
funded system succeeds because banks are free to turn away non-paying customers,
impose fines on those who do not comply with their rules, and manage their financial risk
under legal contracts. By altruistic mission and by federal law, emergency departments
cannot
turn away patients. Further, hospital emergency departments go well beyond the
requirements of federal law and provide the full spectrum of care to patients regardless of
their ability to pay. Because of its ability to provide a virtual continuum of care across
facilities, one of the beneficiaries of a NHIN will be patients without a regular source for
medical care who utilize a variety of healthcare settings. Therefore, a public utility
model would best serve the needs of the NHIN by providing a system that is fiscally
responsible, yet not unduly influenced by corporate profit motive. By establishing
standards by which all systems must interact, the health information technology industry
will be free to innovate and compete on features and functionality rather than holding
customers hostage with proprietary data formats and structure.
11. Broad based use
In 1998, the American College of Emergency Physicians ACEP adopted a policy
recommending that every emergency department provide access to the Internet as a
clinical resource. The recent Society for Academic Emergency Medicine Information
Technology Consensus Conference re-stated this policy in its final recommendations.
Virtually every hospital emergency department in America now has Internet access
making it the logical means for data exchange. Limiting the NHIN to a non-standard or
proprietary system has the potential to limit its access and usability.
Ensuring broad-based use will also depend on minimizing the effort and expense each
healthcare entity must commit to participate. Rather than requiring healthcare entities to
make every data element available to the NHIN, data elements should be prioritized
based on the needs of the various specialties. The highest value data elements for the
various specialties should be carefully chosen and required for the initial NHIN
implementations.
When prioritizing the data, objective data is of primary importance. ACEP believes that
the highest value objective data elements for emergency medicine include discharge
summaries, patient medications, allergies, problem lists, reasons for previous encounters,
EKGs, and the results of major tests such as CT scans and angiograms. (This is basically
a subset of the Continuity of Care Record (CCR) HL-7 specification). Limiting the data
elements required for participation to those with the highest value will lower the cost for
smaller healthcare entities, particularly those in low-income areas.
12. Community and Regional Information Organization Effects
The NHIN will impact CHINs and RHIOs by ensuring that they develop local
infrastructures that will meet the national need. The nascent RHIOs and CHINs have
helped to break the traditional data barriers that sequester patient data within each
healthcare entity. It is critical that these organizations recognize that their existence is
not an end, but a means to an end. The goal is to ensure that healthcare providers have
access to critical patient information no matter where that patient might present for care,
even if that happens to be outside of the patient’s community or region. A NHIN will
help CHINs and RHIOs to think beyond their local agreements and standards and build
an infrastructure that can seamlessly interact with other CHINs and RHIOs to better meet
patient needs.
One issue that is likely to arise is data mapping among various standards and protocols
already in use to ensure that systems can communicate with one another. Even with
common standards, there are issues with integration at the application and institutional
level. For instance, hospitals may use different units or different methodologies for the
same lab test. For example, a D-dimer test done at Hospital A may use the latex
agglutination method while the same test at Hospital B uses the ELISA method. The two
tests have the same name but different reference ranges and different uses in clinical
care. Such issues may lead to errors if not addressed.
Another issue likely to arise is the ability of RHIOs and CHINs to manage the various
data-sharing concerns. The Society for Academic Emergency Medicine Information
Technology Consensus Conference concluded that, when caring for the emergency
patient, “Electronic clinical records should be released immediately upon the
certification of a clinician that there is an immediate clinical need for the release of those
records.” The issues of security, identification and authentication should facilitate that
process rather than hinder it.
13. Impact on Health Information Technology Industry
The American College of Emergency Physicians believes that the impact of a NHIN on
the Health Information Technology (HIT) industry will be powerful and positive.
Companies will form to help institutions meet the needs of the NHIN, and the existing
members of the industry will be forced to reconfigure their systems to be inter-operative
and standards-based. These changes have been recommended by the informatics
community for decades. The NHIN will create the market forces necessary to make
change a reality.
This environment also presents an opportunity for powerful players in the industry to
manipulate the system to their own ends. Whenever appropriate, the standards and
protocols adopted should be those already proposed by governmental and not-for-profit
organizations such as the National Library of Medicine, HL-7, the National Committee
on Vital and Health Statistics, and medical societies. The Society of Academic
Emergency Medicine’s recent consensus document makes very specific recommendations
on many of the standards and protocols that should be used for emergency medicine
purposes and we would be pleased to share it as a resource document for the NHIN.
Standards and Policy Requirements for Inter-Operability
14. Standards oversight entities
Several standards have been developed and are in active use today. The organizations
that exist, such as HL-7, have been very effective in creating useful and widely used
standards and protocols. The National Library of Medicine (NLM) has done an
outstanding job of collating various terminology standards and even licensing standards
to make them available to the general public. They have also done much of the necessary
work to map the terminologies from one to another so that data in one format can be
“translated” to another format.
While our standards and terminologies are far from comprehensive, the primary problem
is not the lack of standards but the failure of existing systems to comply with these
standards. The NHIN will be the impetus to address that shortcoming. The American
College of
Emergency Physicians recommends following the methods used by the HL-7 organization
to achieve success in getting multi-stakeholder input to generate a useful standard that is
not unduly influenced by a single faction or group. The NLM has successfully integrated
and disseminated more than 100 standards, and ACEP believes the NLM should be
charged
with the diffusion of the NHIN standards and protocols, as well as the identification of
needs and gaps in that standards repository.
15. Open standards
A standards-creation process protected from undue proprietary influence can be achieved
by following the examples of existing successful not-for-profit standards-making
organizations, such as HL-7 and the College of American Pathologists (developer of
SNOMED). HIPAA itself defines a number of standards that healthcare institutions
should use to be compliant with the rule, and these standards should be adopted by the
NHIN. Given emergency medicine’s broad clinical base and special connection to the
goals of the NHIN, the involvement of the American College of Emergency Physicians in
the development and diffusion of the standards is critical to the success of the NHIN and
its real-world implementation.
16. Existing Standards Development Organizations (SDO)
Carefully defining the scope of standards will help to ensure that multiple SDOs do not
create competing standards for the same content or purpose. The not-for-profit
standards-making organizations will certainly be willing to work to meet the needs of the
NHIN, but the standards-making process is a slow and deliberative one, particularly when
multiple stakeholders are involved. Maximizing the use and development of the NLM
Meta-thesaurus will rapidly facilitate the interoperability of existing systems with
overlapping content. Too many standards can be a bad thing, and as noted earlier, the
need to adopt, incorporate, and extend the standards that exist is greater than the need for
entirely new standards.
17. Standards requirements
The health care information market is primarily driven by legislative mandates, medicolegal concerns, and payment policy. If federal payers reimburse health care providers
who use the NHIN at a higher rate, a strong market incentive will be created to offer
products that can take advantage of the NHIN. Mandating healthcare institutions to
participate in the NHIN will also drive the rapid diffusion and widespread adoption of
these standards. Much of this is already occurring due to the HIPAA requirements.
The American College of Emergency Physicians believes that widespread adoption of
these standards will be achieved if the resulting NHIN system is data rich, easy to use,
and fast. Clinicians will support access to such a system once it is available, but only if it
can be seamlessly used in their busy clinical practice.
18. The Federal Role
The federal government transformed the medical informatics landscape when the NLM
created the Meta-thesaurus to serve as a repository of standards mapped to one another.
By licensing standards such as SNOMED-CT, the federal government took the healthcare
industry another leap forward. Expanding these efforts by licensing other existing
standards so that they can be freely used, and then mapping them in the Meta-thesaurus
would greatly facilitate the development of the NHIN and benefit the entire healthcare
information industry.
Financial/Regulatory Incentives and Legal Considerations
19. Incentives needed
Given the complexities and costs associated with initial data sharing with a NHIN, it
seems intuitive that incentives will be needed to drive participation. While nearly every
healthcare entity will require some degree of re-tooling of their IT infrastructure to share
data, it is unlikely that significant immediate financial rewards for participation will be
realized.
At first glance it might seem that significantly more effort will be required to share data
upstream with a NHIN than it will be to use downstream data. However, the American
College of Emergency Physicians believes that ultimately, the most effective presentation
of NHIN data to clinicians will be at the point of care, and will likely be maximized by
seamless integration and presentation of NHIN data as a key feature of clinical systems
of the future.
If delivered and executed properly, incentives for using the NHIN to obtain patient data
at the point of care should not be required. However, incentives will be required at the
beginning to drive the process change, hardware and software implementation, and
behavior change inherent to initial participation in the NHIN by clinicians and health
care enterprises.
20. Incentive types
Individual clinicians and smaller health care organizations may need financial support to
offset initial investment to comply with system requirements. Initially, all participants
should receive a small direct add-on payment for services rendered for public program
patients through CMS in the context of upstream data sharing with the NHIN.
Alternatively, for entities not participating after a specific deadline, the federal
government could mandate that specific, highly structured, NHIN critical data elements
be required within the body of all bills submitted to CMS.
However, if true convenience, cost savings, or efficiencies can be realized through access
to NHIN data, any and all premiums can be phased out over time once use of NHIN data
downstream shows value to end users. Ultimately, once the healthcare IT industry adopts
recommendations for data sharing with the NHIN, downstream access may simply
become predicated on upstream data sharing for all health care entities.
21. Legal impediments
The American College of Emergency Physicians believes that two major legal
impediments must be addressed if the NHIN is to be successful. The first involves liability
for breaches of security, and the other involves liability for failure to notice or correctly
interpret issues hidden in the vast volume of newly available results for tests that may
have been ordered by another clinician.
According to a 2001 Evans Data poll, roughly 27 percent of developers surveyed in the
banking and financial services industries said they had experienced a security breach in
the prior year. According to the New York Times, nearly ten million people were victims
of identity theft and fraud in a recent 12-month period. Ongoing fraud and identity theft
has
been reported as costing businesses and financial institutions about $48 billion and
consumers $5 billion annually.
When the NHIN exists, breaches of security will be inevitable. Hospitals recognize this
and will not participate without strong protection from litigation, HIPAA-mandated
penalties, and penalties from other local and federal laws.
A common cause of malpractice suits relates to the failure of a clinician to notice or
properly interpret a test result, even if that test was not ordered by the clinician or related
to the patient visit. Physicians and hospitals are well aware of many cases in which
lawsuits are brought against physicians who have seen an x-ray on a patient and allegedly
have failed to recognize some subtle finding unrelated to the reason for treatment.
There is a credible fear that with an NHIN in place, clinicians will be held responsible for
every test at every institution the patient has ever visited. To be successful, the liability
for test result management should be limited to the clinician who actually ordered the
test.
The costs of litigation are high and are increasing. Successfully defending a frivolous
case can bankrupt a small practice. The NHIN should provide some mechanism, such as
binding arbitration, by which issues may be resolved without costly litigation.
22. Organizational mechanisms
Enabling legislation and regulation for RHIOs and the NHIN must address the concerns
listed above and provide appropriate liability protections for all participants in the
system.
Other Issues
23. Technical architecture
Emergency departments provide critical care to patients 24 hours a day in a fast-paced
and challenging environment. In an emergency department, clinical information must be
constantly available in a manner that is fast and intuitively simple. Each component of an
NHIN must be designed for 100% up time, using parallel redundancy and hot-plug
hardware and software techniques to ensure that access is never interrupted for longer
than is required for a server reboot. An appropriate technical infrastructure must be easily
maintained and inexpensive, but these issues are secondary. Speed and reliability are
crucial; if the system is not fast and always available, it will not meet the needs of
clinicians and patients.
Comprehensive multi-center systems currently exist that have reliably achieved subsecond access times for multi-terabyte datasets containing every known type of clinical
data – including all image types as well as all ASCII data within an entire healthcare
system. Such systems have demonstrated 99.9997 percent up time and a very low staff
overhead by exploiting the intrinsic modularity and strong encapsulation of stringently
object-oriented designs and metadata-driven data-centric architectures. Designs that
depend upon a rigid
hierarchical or highly defined relational data structure have not been shown to meet
minimum clinical performance measures in any live emergency care environment. Thus,
we are concerned that systems based on this approach might fail to provide the
performance and reliability critical to quality emergency care.
One architecture that is popular for political reasons has been a fully federated model in
which each producer of data is solely responsible for maintaining and providing access to
that data. The viability of this architecture is suspect for several reasons. The majority of
data producers are small clinical entities that cannot provide 24 x 7 support for a data
system. Many small entities have no physical space that is appropriately conditioned for
“always on” computing equipment. Connectivity and bandwidth may not be adequate to
serve any significant number of users. Building and staffing thousands of small 24-hour
data centers is likely not an economically attractive approach.
At the opposite end of the spectrum, a fully centralized regional data store model as
described above is technically reasonable, but politically unappealing to many
stakeholders. The American College of Emergency Physicians believes a hybrid model
may be technically robust, politically palatable, and much more likely to meet the needs
of the emergency care environment. In this model, each creator of data has three options,
each of which provides constant access to the data with zero scheduled downtime and 24
x 7 support to resolve unanticipated problems. Larger institutions may elect to provide
external access to data that is maintained within a compatible on-site data repository
managed around the clock by their own staff. Mid-size providers may elect to maintain a
local repository of data with a replicated copy in a dedicated database hosted at some
central exchange. Queries may be auto-directed to either copy of the data, so that if the
local copy is unavailable at any time, the centrally replicated version remains accessible.
Those who choose this option would be considered to own the hosted (replicated)
database as well as their on-site database. Smaller care providers may simply prefer to
export their data directly into a central exchange, with no need for the cost and difficulty
of managing a locally stored data store. Those who choose this option would be
considered the owners of their data as it exists within the regionally hosted data store.
As noted earlier, ACEP is concerned that the constant up-time, high speed, and reliability
needed for emergency care cannot be assured with a totally decentralized infrastructure
(data always residing with the creator). To an unacceptable degree, such a system would
be at the mercy of the speed and uptime of each participant and of each hardware and
software component at every data storage location. Centrally-cached systems routinely
provide sub-second access to all components of a patient’s record across entire regions;
fully distributed data stores, in which a central collator merely stores pointers to data
wherever it resides, have not been shown to approach this needed level of performance
and reliability.
The requirement to collate data from many different locations multiplies the potential
points of failure in a decentralized system, reducing reliability at the same time that it
reduces speed. A more comparable architecture is that utilized by “Google”, which
centrally caches web pages to speed searching and provides a reliable way to obtain the
page data even when the originating system is temporarily or permanently down. Google
could not begin to approach any acceptable level of performance if it contained no cached
copies of any data, and was forced to read each and every web page from the original site
whenever a query was performed.
24. Measuring success
Important metrics of success should include:

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
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The speed of the system as measured by the average access time for common
queries.
The reliability and uptime of the system as a whole, of its various nodes, and the
percentage of queries for which some or all of the data is inaccessible.
The frequency of use in clinical practice by the full spectrum of clinicians whose
patients would benefit from the ready availability of NHIN data.
The frequency of use by emergency physicians, whose patients are at the highest
short-term clinical risk and who have the highest need for immediate access to
historical information from other sites.
Measurement of real clinical outcomes such as mortality reduction, morbidity
reduction, medical error reduction, and other objective quality metrics.
At least some of the metrics should be measured using integrated, real-time survey
mechanisms that are part of the NHIN. It is very important to note that any outcomes
metrics should represent real clinical outcomes rather than pseudo-outcome metrics (e.g.
reductions in test utilization) that are not directly based on clinical outcomes. Cost
savings should not be used as a primary measure of success, because although cost
savings is an important goal of the NHIN, it is not necessarily a good outcome measure.
Cost savings analyses are complex. There may be times in which the NHIN provides the
data that guides the clinician to order an expensive but decisively diagnostic test. While
the short-term cost for that visit might have been increased by the NHIN, the long-term
effect on the system of that focused diagnostic plan might be a net cost savings.
To provide a “real-life” context for the importance of EHRs, an ACEP member shared
the following true anecdote that demonstrates a tremendous benefit of an improved NHII
on safety, quality, and costs.
A 78 year- old woman, presented to the emergency department with
symptoms of a urinary tract infection. Both the nurse and physician asked
her about allergies, and she claimed she was allergic only to penicillin.
She was prescribed a sulfa-based antibiotic and discharged. The next day
the patient developed a severe reaction which progressed to StevensJohnson Syndrome (a potentially life-threatening, drug-induced disorder
in which a patient’s skin blisters and peels off). Over an excruciating
thirty-day period, the patient was hospitalized in the intensive care unit
where she required multiple skin grafts. Her course was also complicated
by multiple infections and blindness. Her medical costs exceed $500,000,
and her pain and suffering were extraordinary. Subsequently it was
discovered that the patient’s primary care physician's record clearly
documented a past allergy to sulfa drugs. Tragically, the emergency care
providers who initially treated her did not have access to these records.
Had a National Health Information Network been in existence, the scenario would have
been much different:
The local Health Information Exchange would have connected to the
patient’s primary physician’s electronic health record and added allergies
to both penicillin and sulfa to her emergency department electronic
medical record. She would have been treated with ciprofloxacin as an
alternative antibiotic and recovered uneventfully. Over $500,000 in
medical expenses, plus legal expenses, and pain and suffering would have
been averted.
We appreciate the opportunity to offer these comments and we look forward to working
cooperatively with your office in order to address these crucial issues. If you have any
questions about our comments and recommendations, please contact Barbara Marone,
ACEP’s Federal Affairs Director at (202) 728-0610, ext. 3017.
Sincerely,
Robert E. Suter, DO, MHA, FACEP
President