Summary: Public and private financial incentives are aligned as never before to encourage physicians to adopt electronic health records. To aid in the transition, the government has also put billions into training health information technology workers and establishing regional extension centers to provide technical and other advice. Even so, progress is slow and obstacles remain. Chief among those obstacles may be the investment of time required to transition to an electronic system.
By Brian Schilling
In 2009 as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act, the federal government set aside $27 billion for an incentive program that encourages hospitals and providers to adopt electronic health records systems (EHR). Billions more were allocated to help train health information technology (HIT) workers and assist hospitals and providers in setting up EHRs that would enable the health data historically sequestered in paper files to be shared among providers and used to improve health care quality.
Hundreds of studies of EHRs and decision support systems across the country have demonstrated the benefits of such tools. EHRs can slash drug-drug interaction rates, decrease mortality rates among the chronically ill, cut nurse staffing needs, and lower costs. A 2011 meta-analysis of HIT-implementation studies found that 92 percent of published reports to date had predominantly positive results. Yet the adoption of HIT in the U.S. has been slow. Only about 10 percent of physicians use what might accurately be described as a fully functioning electronic medical record system, while slightly more than 50 percent have at least partial EHR systems in place. By contrast, 90 percent of doctors in the Netherlands, the United Kingdom and New Zealand use EHRs.
Implementing an EHR is not cheap. Cost is frequently cited as the main obstacle to broader adoption of such systems, but it's not necessarily the cost of an EHR system itself that gives many physicians pause. Instead, the more significant cost involved may be lost revenue incurred during the months of preparation, planning, training, and workflow redesign that typically comes with switching to an EHR.
The Rewards of EHR Adoption
For physicians willing to adopt EHRs, the financial incentives offered by the federal government are substantial. The average physician with at least 30 percent of his or her patients covered by Medicare is eligible for up to $44,000 in total incentives. A physician with at least 30 percent of his or her patients covered by Medicaid is eligible for even more, up to $63,750. To earn any of that money though, physicians must do more than simply purchase an EHR system; they are required to show that they have achieved "meaningful use" of that system in terms of improving quality. At a minimum, that will mean having systems capable of e-prescribing, reporting quality data, and exchanging data among providers.
As of May 19th, 320 health care providers (including 283 physicians and 37 hospitals) have received a total of $75 million in Medicare incentive payments for demonstrating meaningful use of electronic health records. The relatively slow start was perhaps to be expected—to qualify for this first round of incentives, practices were required to not only meet certain EHR requirements, but also sign up for the payments within the first two weeks they were available. Many practices simply weren't that far in the process.
More telling for the future of HIT may be the number of physicians and hospitals that have registered for the incentive program: 42,600. That much larger number suggests that many more practices are currently in the process of implementing an EHR and expect to qualify for incentives soon. CMS estimates that roughly 485,000 physicians in total could ultimately be eligible to participate.
The disconnect between the number of physicians who are eligible to participate and the number who actually are participating is likely a matter of both timing—the program is still relatively new—and time. That is, transitioning to an EHR requires a significant time investment, and many physicians remain unable or unwilling to make that investment, regardless of any other pros and cons involved.
"Forgetting for a moment that the initial financial investment is not insignificant," said Amanda Parsons, M.D., M.B.A., assistant commissioner of the primary care information project with the New York City Department of Health and Mental Hygiene, which oversees New York City's regional extension center (see below). "The truth is that it takes months to transition from paper to an EHR. And for most doctors, at least initially, it's easier to document things in their own written short hand. I tell them that transitioning to an EHR is like agreeing to become a triathlete—it's ultimately great for you, but you have to commit to serious and ongoing training. It's not something that is going to be over in 2 to 3 weeks. It's an ongoing process of keeping up with the technology as new versions and new functionality are released."
Indeed, even staunch EHR advocates concede that the transition from paper isn't easy. Among the more difficult aspects of demonstrating meaningful use is simply using the EHR to capture and report on patient demographics, vital signs, and smoking status. This requirement has forced some practices to re-ask for this information if it wasn't recorded or properly dated. And the standards will only get harder—the U.S. Department of Health and Human Services (HHS) is presently drawing up "stage 2" and "stage 3" meaningful use criteria that are expected to include requirements related to population health management and quality improvement. HHS has yet to say publicly when practices will be expected to meet those tougher standards.
Support in the Field: The Regional Extension Centers
To help physicians overcome these obstacles, the HITECH Act has established a network of 62 Regional Extension Centers (RECs). The RECs—which are longer on expertise and energy than they are on staff—are specifically charged with supporting primary care providers in quickly becoming adept and meaningful users of EHRs. To that end, they offer seminars, advice, and even direct technical support to practices. Each REC office is assigned a specific target for the number of physicians it is expected to engage in the EHR effort.
"Our goal was to get 1,000 physicians to sign a letter of commitment saying that they would adopt an EHR by year's end," said Todd Thornburg, Ph.D., director of South Carolina's Center for Technology Implementation Assistance, the regional extension center for the state. "We just announced that we met our goal, which means that since June 2010 we've engaged about 20 percent of all the primary care physicians in the state. That's pretty good market penetration."
Getting to that point wasn't easy. Thornburg's initial pitch to South Carolina physicians fell on deaf ears. "We tried leading with the message that adopting an EHR would help them earn all these really substantial incentive payments," he said. "But it came off like we were telling them what to do, which doesn't go over well with doctors."
Thornburg scrapped the original message and instead focused on how HIT could help doctors improve the care they deliver and how it could allow doctors to practice medicine the way they want to practice medicine. "There was an immediate difference in receptivity," he said. "It changed the tenor of our conversations with doctors and put a little eagerness back into the exchange."
The 1,000 physicians who have committed to adopting an EHR in North Carolina represent a wide range of practice sizes and types. "We have both small and large practices, practices in rural areas, and practices in more major metropolitan markets—there is no special trait that distinguishes them," he said. That said, the larger and more electronically adept practices may meet all the "meaningful use" criteria as quickly as this year, while the rural practices may take four years to reach that milestone because in many instances they're starting from square one, Thornburg said.
In New York City, Parsons reports that the local REC just recruited its 2,500th physician, which is still well short of its goal of 4,543 by 2014. "We estimate that we've spent anywhere from $12,000 to $16,000 per physician in technical support just to help them get up and running," Parsons said. "That gives you an idea of the amount of support each practice has needed thus far to adopt and use the EHR in a way that improves quality of care."
Parsons said that part of the issue is that EHR vendors—of which there are several hundred—simply haven't had the client volume and experience necessary to do a better job of making EHRs easy to use and glitch free. "There is still a lot of work to be done to deliver a product that is both "out-of-the-box ready" and at the same time, easily configured to a unique provider's workflows," she said. "If you've seen one practice, you've seen one practice."
To aid physician practices in selecting among EHR vendors, ONC has established an EHR software certification program and now posts online the names of all certified software products on a searchable database. To earn meaningful use incentives, practices are required to use one of the certified vendors. That doesn't limit their options very much—525 EHR products are listed for ambulatory practices and 263 are listed for inpatient practices. Interested parties can, however, narrow down their search for a vendor by specifying what features they want in an EHR.
Fostering Physician Interest
To encourage physicians to make the investment of time and staff resources necessary for implementation, EHR advocates often point to the operational benefits of such systems. Daniel Saylak, D.O., chair of the board of trustees of the American Osteopathic Association for Medical Informatics, a specialty affiliate of the American Osteopathic Association (AOA), notes EHRs help practices run more smoothly and, perhaps consequently, make more money. They also improve quality and safety. EHRs have is built-in checks to ensure that no drug/drug interactions take place and can eliminate problems related to poor handwriting. "There were a number of problems associated with prescribing which, for us, no longer exist," Saylak said of his own practice. "No doctor who has converted to e-prescribing would ever feel comfortable going back—it's just not as safe or efficient a process."
Other quality gains that typically follow EHR adoption are attributed to the system capabilities that help physicians keep abreast of medical advances, match patients with appropriate therapies, coordinate prescriptions, and communicate with diverse, geographically separated treatment teams.
Engaging Patients
The benefits of transitioning to an EHR system aren't just for doctors. Many EHR systems being marketed today feature a "patient portal" which gives individuals immediate access to their own lab results, x-ray reports, lists of medications, and other information. These portals also typically allow patients to communicate securely via e-mail with their physicians and other medical personnel. It has been suggested as far back as the 1970s that giving patients access to their own medical records would help engage them in their own care. The same has been said of expanding the use of e-mail between physicians and patients. Neither contention has been rigorously investigated, but anecdotal evidence suggests that patients do indeed appreciate easy access to their records.
Security Concerns
With reports about large-scale data loss, security breaches, and targeted hacking of databases of various sorts making national news on a regular basis, concern about EHR security is extremely high. To help allay related concerns, the Office of the National Coordinator is presently engaged in an 18-month-long effort to draft standards and guidelines to improve the state of cybersecurity across the HIT spectrum. Key initiatives will focus on helping practices install HIT systems securely, educating the health IT community about security issues, and even creating support functions to help when security emergencies strike.
Training HIT Workers
Just as securing provider interest in HIT is critical to the program's success, so too is having enough skilled workers to make the transition possible. At present there is a big gap to fill—in May 2010 the Office of the National Coordinator for Health Information Technology (ONC) estimated that hospitals and physician practices would need an additional 50,000 HIT workers over five years to satisfy the meaningful use criteria. That figure would be of no surprise to group practice chief information officers, 54 percent of whom said in a recent survey that they have had difficulty recruiting or retaining enough appropriately skilled IT workers to help build, use, and maintain the systems.
Recently established educational programs may eventually fill in the gap. In April, the first 1,274 students graduated from and 8,741 had enrolled in 82 community college-based HIT programs, which were funded by $36 million in grants from ONC. Graduates of these six-month, non-degree programs will be qualified to help implement, upgrade, test, maintain, and otherwise support the implementation of HIT programs. ONC expects these programs to graduate more than 10,000 new HIT professionals by the end of 2012 and as many every year thereafter. If they don't, the skilled worker gap may present a serious obstacle to achieving meaningful use on a broad scale.
Perhaps not surprisingly, a recent survey found that HIT offered the best job prospects for new college graduates of any career. With that, interest is growing. William Hersh, M.D., professor and chair of Oregon Health and Science University's department of medical informatics and clinical epidemiology said that his university's program had "three or four times as many applicants as it could handle."
Private Insurers/Private Incentives
Private insurers and large employers are also facilitating the adoption of HIT. Virtually every major health insurer has some sort of incentive program for physicians and medical groups to adopt EHRs and/or meet the meaningful use requirements. The incentive programs differ considerably from insurer to insurer. At CIGNA, for instance, physicians who are certified by the National Committee for Quality Assurance's (NCQA) Physician Practice Connections (PPC) program (a program that requires the use of EHRs to e-prescribe, track test results, and offer e-mail communication with patients) are highlighted in CIGNA's physician directory, which helps drive patients their way.
At Highmark, primary care physicians are encouraged to adopt EHRs and e-prescribe through a $29-million Health Information Technology Grant program. To date, Highmark has given nearly 650 practices more than $5.3 million to assist with HIT initiatives. And Kaiser Permanente has established a system that links members' electronic medical records with their appointments, registration, and billing information. The system gives physicians instant access to patients' medical histories and provides online decision support tools to help doctors determine which treatments will be most effective. The system can also send prescriptions electronically and order lab tests online.
Employers are also putting cash on the table in an effort to prompt physicians to adopt HIT. More than a dozen large employers, including General Electric Co., IBM, United Parcel Service, Proctor & Gamble, and Verizon Wireless, now coordinate their pay-for-performance efforts through the Bridges to Excellence program, which recognizes "practices that use systematic processes and information technology to enhance the quality of patient care." Incentives under that program can reach well into the five figures for group practices, but incentives vary from employer to employer.
Will the Sidelines Remain Comfortable?
While EHRs hold great promise for improving quality of care and practice efficiency, the adoption of such systems is a challenge for physicians, who must invest in expensive hardware and software and devote substantial time to training themselves and staff to use these systems at the same time they practice medicine. The efficiency benefits of EHRs—though ultimately significant—are not always immediately apparent as new workflows and new processes must be learned. Moreover, simply selecting a system can be difficult as well. This leaves some physicians content to wait on the sidelines for now.
But physician leaders believe this ambivalence is only temporary. As word of the financial and quality-related benefits of EHRs spreads, more physicians are likely to engage in the process. At the last AOA annual meeting, for example, a survey of participants showed that 53 percent of attending physicians had already gone ahead with EHR adoption. "I was hoping we'd see 20 percent," Saylak said. "That over half our members were engaged in adopting EHRs is great news."
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