Most of the 1,500 largest U.S. hospitals have already deployed electronic health record systems. Not so for the nation's 700,000 practicing doctors. Less than 20% of them use EHRs, and many aren't using fully functional systems. So what's at stake if all these doctors don't get on board with deploying these systems? A lot.
Digitized records provide a timely, cost-effective way to share patient information. If physicians aren't using them in their private practices, they lose those benefits, as do the hospitals they work with. Paper records continue to be shuffled, putting patients at risk for medical mistakes, ill-informed treatment decisions, and unnecessary tests because hospitals and doctors don't have easy access to information about recent tests, health histories, and other important data.
There are looming financial implications as well. The Health Information Technology for Economic and Clinical Health Act, part of last year's stimulus legislation, provides more than $20 billion in incentives to doctor practices, hospitals, and other healthcare organizations that show they're making "meaningful use" of EHRs. A first round of rules defining what constitutes meaningful use was released last month and includes some requirements that providers be able to electronically exchange patient data; later stages of rulemaking are likely to include more stringent requirements.
At risk are incentive payments of as much as $64,000 for a physician practice. For hospitals with fewer than 50 beds, incentives could run as high as $2.5 million, and for ones with 500 or more beds, as much as $5.2 million, according to the American Hospital Association. Penalties for non-compliance start in 2015, when physicians and hospitals that treat Medicare patients would see a reduction in fee reimbursements.
Another blowback from not having doctors on EHRs could come from the healthcare reform legislation signed in February. It includes provisions for changing the way doctors who treat Medicare and Medicaid patients get reimbursed. Instead of being paid per service, they'd be paid, at least in part, based on quality of care. To the extent that their ability to efficiently exchange data affects care, there's added incentive to get on board with EHRs. What has doctors particularly worried is that private insurers are likely to follow the federal government's lead with payment reform.
With so much at stake, most large hospitals aren't leaving it up to chance that doctors will adopt EHRs. Partners HealthCare, which operates several Boston hospitals as well as clinics, home-health, and other facilities, has taken the atypical approach of mandating that its physicians start using EHRs. Other large hospitals are offering free and discounted EHR software tailored to the needs of physician practices, subsidizing hosted systems, and providing advice and assistance.
What follows are four examples of large healthcare organizations pushing their affiliated physicians to adopt EHRs.
More than two years ago, Partners told its 4,200 employed and 2,000 affiliated doctors that they must roll out EHRs by 2009 or lose some significant benefits of being part of the provider's network.
"We didn't say you're out, but we did say you're on your own" when it comes to negotiating reimbursement rates from healthcare payers, such as Blue Cross Blue Shield of Massachusetts, says CIO John Glaser, who recently spent a year advising the nation's health IT coordinator, Dr. David Blumenthal. Because of its size, Partners is able to get insurers and other payers to agree to higher rates than individual doctor practices can get.
Affiliated doctors could choose between GE's Centricity EHR or Partners' homegrown system, says Glaser, who is leaving Partners this month to become the CEO of Siemens Healthcare's Health Services business unit. The Centricity option is less integrated with Partners' other systems, alleviating some doctors' concerns about how Partners might use their data.
Partners provided technical assistance for a fee to help doctors roll out EHRs in their practices, including training, screen design, device placement, and workflow. All but 30 of its affiliated doctors complied, and most of the physicians who didn't were close to retirement.
Glaser doesn't apologize for all but forcing doctors onto EHRs. He thinks Partners is helping them survive. Eventually, physician practices that don't adopt them will receive fewer referrals from other doctors and hospitals that don't want to deal with practices with which they can't easily share data. Once a market has 40% to 50% of doctors using EHRs, "a tilt happens," Glaser says, and there's competitive pressure to use them.
A provider's continued reliance on paper impacts the workflow of doctors who've made the change, he says. For instance, a primary-care doctor choosing between two cardiologists to refer patients to will pick the one who has gone electronic. "Referrals will shift away from the one without the EHR," Glaser says. "Business shifts in volume."
E-Prescriptions: EHR On-Ramp
Huntington Memorial Hospital, a 636-bed facility in Pasadena, Calif., started a program earlier this year to give a branded version of Allscripts' e-prescription software, called Huntington RX, free to the 1,000 independent doctors the hospital works with. More than 100 affiliated doctors and their staff are using it.
Huntington Memorial hired Rebecca Armato for the new post of executive director of physician and interoperability services after an e-prescription program she had started at Hoag Hospital, a 490-bed facility in Newport Beach, Calif., prompted doctors there to move to EHR systems after a year or so. Huntington is hoping for similar results.
Independent doctors are the lifeblood of Huntington's business, Armato says. And it's hard for them to stay independent in a city like Pasadena, where the cost of living is 20% above the U.S. average but doctors are reimbursed at a 30% lower rate than the national average, she says. "We want to recognize and support these independent doctors," Armato says. "They're an endangered species."
Huntington also has reached the point where the only way it can get significant efficiency improvements from its own Meditech EHR system is by being able to exchange patient data with its affiliated physicians, she says. To push more doctors in that direction, Huntington is sponsoring readiness assessment seminars that help doctors identify which EHR systems are best suited for their practices, as well as seminars on the federal incentive program. Armato also plans to hire advisers to help physicians choose EHR platforms and get them compliant with meaningful use criteria if they've already rolled out systems.
Physicians affiliated with the hospital have found the programs helpful. "Our patients go in and out of the hospital," says Dr. Yafa Minazad, a neurologist and solo practitioner. "Without the flow of information, the continuum of care isn't smooth and the patient is hurt."
Minazad attended the EHR readiness seminar and spent two hours discussing with Armato how e-health records would improve her practice and patient care. Doctors "need a great deal of assistance because the knowledge and work involved with transitioning from a paper world to digital records seems overwhelming to them," she says.
Dr. Howard Kaufman, medical director of Huntington Memorial's cancer care center, has started the process of selecting an EHR for his private practice. After attending one of the hospital's seminars, he's leaning toward a hosted model so that he doesn't have to worry about in-house support. "I want to be as flexible as I can," he says.
More than a year ago, Beth Israel Deaconess Medical Center, a Boston facility with more 600 beds, and Beth Israel Deaconess Physician Organization, which supports 300 affiliated doctors, launched an initiative to get those physicians using EHRs via a private cloud managed by the medical center.
The services include eClinicalWorks' EHR and practice management software, hosted by Beth Israel Deaconess and managed by Concordant, which runs medical center's data center. Concordant also provides help-desk support and network services. Beth Israel underwrites 85% of the cost of the EHR and practice management software. The physicians' group offers primary-care doctors $10,000 grants for hardware purchases, and doctors get technical assistance and training on the software from Massachusetts eHealth Collaborative, a nonprofit organization. Doctors pay about $500 a month for application support and the hosting services.
It took a year and half to persuade most doctors to sign on, says Bill Gillis, director of clinical applications with Beth Israel Deaconess. Some initially were concerned about giving up control of their data--afraid of "getting too cozy" with the hospital group, he says. Beth Israel Deaconess analyzes only aggregated data to assess quality-of-care metrics, and doctors retain ownership of their data and have been assured that they can get it back in a machine-readable format, Gillis says.
To date, 240 physicians have signed on for the services and about 90 are using them, he says. With two practices going live a week, there's a waiting list for the hosted EHR program, Gillis says.
Inova Health System, a nonprofit network of hospitals, nursing homes, and other healthcare facilities in Northern Virginia, offers its 3,500 affiliated doctors several different options for getting on EHRs. Through an alliance with GE, Inova offers doctors subsidies for a bundle of services, including help deploying GE's Centricity software either on-site or through a hosted private cloud. It also provides project management assistance.
While CIO Geoffrey Brown declined to disclose the exact amount of the subsidies, he says they're significant. Doctor practices pay a monthly subscription fee, and the hosted model includes site backup.
Doctors choosing to deploy an EHR other than GE's get help linking to Inova's EHR, as well as assistance with optimizing their workflows and accessing Inova data and treatment plans, Brown says. Doctors also get access to quality-of-care databases that let them compare their practices with national benchmarks.
Several hundred of Inova's affiliated doctors are now using EHRs, Brown says, with four or five practices going live a month. The next phase will be for doctors to start sharing patient data with Inova that's had personally identifiable information removed, for clinical trials, disease management programs, and research, Brown says.
Inova, like Partners, Huntington, and Beth Israel Deaconess, is intent on helping the independent practices it works with make the complicated and expensive transition to EHRs but leave them intact as independent entities. Now's the time to move on EHRs, while stimulus funds are available, large healthcare providers are helping out, and penalties for not using them are still years away.