ATLANTA—Will electronic health records (EHRs) ever live up to their potential?
The question hung over a session, “Transforming Rheumatologic Care with the Electronic Health Record,” here at the 2010 ACR/ARHP Annual Scientific Meeting, as experts lauded the ability of EHRs to improve office efficiency and health outcomes even as they acknowledged physicians’ frustrations in choosing and using new systems. [Editor’s Note: This session was recorded and is available via ACR SessionSelect at www.rheumatology.org.]
“[Health information technology] is an interesting environment in the ACR,” acknowledged Charles King II, MD, chair of the ACR’s health information technology (HIT) subcommittee. “People ask the questions and no one likes the answers.”
The presenters contended that the EHR (also known as electronic medical record or EMR) could indeed be transformative. Robert Warren, MD, PhD, MPH, chief of the rheumatology service and medical director of information services at Texas Children’s Hospital in Houston, reminded the audience that when the stethoscope was introduced, many physicians doubted its value. “So often we think of the electronic medical record as a pain in the rear end, and as purely a documentation tool,” Dr. Warren said. “That is not the way you should be thinking of an electronic health record. It is as much a medical instrument as a stethoscope, I’d argue even more.”
The 2009 federal stimulus package contained considerable carrots and sticks to incentivize health providers to adopt an EHR, noted Stacey Empson, JD, MHA, founder of Epiphany Healthcare Advisors, a consultancy. But the legislation’s intent was to improve health outcomes, access to information, the quality of care, transparency, and efficiency, and Empson believes EHRs can deliver on that intent. “If you adopt an EMR, you will practice, over time, more efficiently,” she said.
As evidence, Empson referred to a recent survey of nearly 1,400 members of the Medical Group Management Association from primary care and specialty practices. Independent practices that used an EHR reported nearly $50,000 more operating margin, while hospital-owned multispecialty practices reported $42,000 higher margins. Costs were highest in the first year, but after five years, independent practices reported 10% higher operating margins than the first year.
EHRs have the potential to greatly improve the efficiency of practice workflows, said Salahuddin Kazi, MD, chief of health informatics for Taos Medical Center. The greatest rewards will accrue to practices that use EHRs as catalysts for change, rather than merely attempting to mimic paper-based processes. “You will get out of the EHR what you are willing to put in,” Dr. Kazi said.
So often we think of the electronic medical record as a pain in the rear end, and as purely a documentation tool. That is not the way you should be thinking of an electronic health record. It is as much a medical instrument as a stethoscope, I’d argue even more.
—Robert Warren, MD, PhD, MPH
The Devil in the Details
The stimulus package’s HITECH provisions contained $19.2 billion in funding intended to jump-start computerized health records. “It’s really been game changing for vendors and providers,” Empson said. The provisions contain a big incentive for independent medical professionals: Beginning in October of 2011, the government will increase Medicare and Medicaid payments by up to $44,000 per eligible provider over four years if those providers are deemed “meaningful EHR users.” It also contains a big penalty: Providers who are not deemed to be meaningful users by 2015 face Medicare payment reductions that increase every year that the provider does not demonstrate meaningful use, up to a 5% reduction.
As for what it takes to obtain the incentive and avoid the penalty, the devil is in the details, as made clear by the presenters’ discussions of what constitutes an “eligible provider” and “meaningful use.” For example, Dr. Warren noted, the definition of an eligible provider differs for Medicare and Medicaid, and physician assistants and clinical psychologists would not qualify as eligible providers.
The definition of “meaningful use” will expand each year as physicians are expected to become more sophisticated in their use of EHR, noted Empson. In the first stage, the criteria mostly revolve around data capture and sharing. In upcoming years, meaningful users will be expected to use EHRs to facilitate advanced clinical processes, such as disease management, and eventually improved outcomes, including performance improvements and enhanced clinical decision support.
Complying with the first stage alone requires demonstrating compliance with 20 criteria, including providing patients with clinical summaries of office visits, implementing clinical decision support and maintaining an active medication list. The presenters emphasized that “meaningful use” requires going beyond simply installing a system to establishing workflows that ensure its regular use. “In your practice, it’s not just about putting in a system but adopting and using it effectively,” Empson said.
The incentives (and disincentives) may have little impact on physicians who treat few Medicare or Medicaid patients, Warren noted. But practices that do intend to become “meaningful users” should be prepared as early as 2011 for an audit, Dr. Warren warned.
He believes that the reasons for installing EHRs go far beyond the monetary incentives. Some private insurers have already declared that EHR utilization will play a role in contracting decisions. In the future, EHR utilization could also play a role in board certification. And with the government planning to disclose lists of meaningful users, some practices could use an EHR as a competitive differentiator in their marketing. “Think about the market impact of not being a player,” he said.
Falling Short
Despite the promises of EHRs, the rate of adoption by practices has been quite low, Empson observed. One problem is the fragmented landscape of EHR vendors. More than 400 companies are competing in the market, Empson said, but that number is likely to decline quickly due to consolidation.
Many of these vendors are hitting physicians with the hard sell, noted Dr. Warren. “Physicians are asking, why do I have 10 vendors beating on my door saying I have to put in their product in the next twenty days, or they won’t have time for me?”
Yet many of these vendors are apparently not up to the task, if comments from the audience at the session are any indication. One physician who selected a national provider said that after six months of effort, the records supplied are still “unworkable,” the templates “impossible,” and the records received from other practices were “unreadable.” Today’s electronic records amount to “drivel,” the physician said, that did not get to the “meat of the issue—what is your assessment, what is your plan.”
The shortcomings of today’s EHRs are legion, Dr. Warren acknowledged. For example, quality measures appropriate for rheumatology have not been integrated into the systems.
But practices that want to stay ahead of the curve—and ensure the maximum financial reward from the federal government—will want to get started soon on implementing EHRs. The federal government offers low- or no-cost help to physicians through a network of health information technology regional extension centers. However, these programs are geared toward primary care physicians and rheumatology practices may not qualify for assistance, or may have to pay for the help they receive. Meanwhile, the ACR’s HIT subcommittee is designing electronic templates specific to rheumatology that can be adopted by any commercial EHR provider, Dr. Kazi said. The ACR’s HIT site, www.rheumatology.org/HIT, also provides a wealth of information for physicians seeking guidance. For example, the site provides more details on the EHR incentives and links to ratings of certified EHR vendors.
Richard Sine is a medical journalist based in Atlanta.