Docs Tell Congress EHR Adoption Presents Serious Challenge

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Doctors representing small physician practices gave Congressional representatives on the House Small Business Committee's Healthcare and Technology subcommittee an earful as they spoke of the significant barriers to the adoption of health information technology (IT) and the potential consequences that this could have on the healthcare sector. These barriers include regulations, financial penalties, an unpredictable marketplace, and concerns over interoperability between different IT systems, and the most prominent barrier of all--costs.

It's no surprise that the task of implementing electronic health records (EHRs) at small physician practices comes with enormous challenges. For a start, these practices have limited budgets and many don't have full-time employees with technology skills. Moreover, staff must be trained and the workflow at these practices is often significantly disrupted when new EHR systems are implemented.

"The worst thing that could happen would be to lose my practice because of the costs--both known and unknown--of implementing an EMR system." said Dr. Denise Elliott, a podiatrist with a solo practice in Marrero, La.

Elliott told the hearing that she hasn't purchased an EHR as yet, but has conducted an investigation into the one used by West Jefferson Medical Center, the hospital her practice is affiliated with.

"As I investigated the system, I was astounded at the costs. An upfront fee of $5,000 per doctor, an installation fee of $2,000 per office, and then a monthly maintenance fee totaling $7,200 annually per doctor," Elliott explained.

Not only would this crimp any future plans to expand her practice with the addition of new physicians, but there are other costs associated with EHR implementation. For instance, Elliott looked at a lease to purchase option, but those costs are only related to the actual electronic health record software.

"The cost for additional hardware--computers and servers that I would have to purchase--was not included and could run an additional $15,000 to $20,000. Also, I would need to purchase a digitized x-ray system at an additional significant cost to be truly EMR compliant--all of this at a time when Medicare is decreasing reimbursements for radiology services and physicians," Elliott said.

While the federal EHR incentive program will reimburse her $18,000 for implementing, and attesting to the requirements of meaningful use this year, Elliott noted that the money will only cover part of the cost and the bulk of the financial burden "will fall on me as a small business owner."

Another compelling story was shared by Sasha Kramer, a dermatologist with a small practice in Olympia, Wash. Within a two-year period, Kramer said she will spend more than $53,000 to buy two EHR systems because the first system she bought is already obsolete.

Two years ago, Kramer said she bought an EHR system for $41,349. While part of the cost was paid for from a grant of $19,964 given by the Washington Health Information Collaborative for Health Information Technology, the balance of more than $20,000 was paid from the her cash reserves. Kramer told the committee that she was exclusively responsible for the research, selection, and ultimate implementation process of the EHR vendor and system, but after pouring time, effort and money into installing the EHR, she was told by the vendor one-and-a-half years later that she had to change the system.

"I was notified by my software vendor that it had been acquired by another company and that the new vendor's products would not support my current network platform," Kramer said. "Currently, I am looking at a new system that will cost in excess of $27,000 with $6,000 in annual charges; all of which must come out of my business cash reserves. It's not just the financial investment; I will again have to take time away from my patients to implement and train my entire practice on this new system."

Kramer estimates that she spent more than two weeks selecting the vendor and an additional two weeks dedicated to staff training. Her normal routine of seeing 4 to 6 patients per hour was also disrupted.

"During system implementation, my patient volume was dramatically reduced in order to integrate the EHR system into my practice. Initially, I saw one patient per hour so that the office staff and I could learn how to use the new system," Kramer said.

The thought of spending less time with patients during EHR implementation is something Elliott wrestles with. "Typical EMR implementation takes anywhere from 6 to 8 months, and I anticipate that I will not be able to treat the same patient load during that period. This could potentially impact my patients' health as well as my practice's bottom line," Elliott said.

While both physicians said the adoption of health IT is a critical component to providing improvements in healthcare delivery and patient safety, Kramer and Elliott touched on several other issues that physicians with small practices are worried about as they plan for EHR implementation.

Here are a few excerpts from their testimony:

Elliott: "EMR vendors are currently not certified beyond Stage 1. In fact, vendors have only temporary certification of their software programs. The fear that I and many of my podiatric colleagues have is that as vendors are obligated to meet the demands of Stage 2 and Stage 3 requirements, they may not meet those requirements or retain certification. Also, we fear that vendors will incur increased costs to meet the requirements and these costs will eventually be passed along to the end users--the doctors."

"It is clear that the components of qualifying for meaningful use are focused on services provided by primary care providers. While as a podiatrist and eligible provider I can qualify for Stage 1 meaningful use, it is more burdensome moving forward to Stage 2 and Stage 3. This is true for all specialty healthcare providers, not just for podiatrists. It would be helpful, as the program moves forward, for CMS to work with specialty providers to adapt the meaningful use requirements to the quality elements that are directly related to the important care that specialists provide for patients with chronic disease conditions."

Kramer: "There remains a large question as to whether we can build an interoperable, national infrastructure, long a barrier to health IT adoption. Right now, we appear to be running the trains, but the tracks are not yet built. To deliver on the promise of effective care coordination and improvement in quality of care, a fully functional health information exchange is a prerequisite to enable all physicians to maximize use of health information technologies."

"Dermatologists and other providers investing in EHRs are struggling with the structure of the CMS meaningful use timeline. The current schedule calls for the administrative rule governing Phase 2 to be released in mid-2012. For early adopters who purchase a system and have contracts with technology service providers to meet 2011 and 2012 requirements (Phase 1), there will be a very short window between the release of Phase 2 requirements and the deadline for physicians' vendors to fully update their systems in order to qualify for the incentive payment in 2013."

In her testimony, Kramer took the opportunity to urge the committee to provide sufficient financial and other resources to enable physicians to select and implement health IT systems, consider delaying the penalties associated with Health IT adoption until a functional integrated system is in place, and, if penalties are not significantly delayed, provide a "safe harbor" for those early adopters of Health IT to protect them from financial penalties related to the "meaningful user" requirement.

The Healthcare IT Leadership Forum is a day-long venue where senior IT leaders in healthcare come together to discuss how they're using technology to improve clinical care. It happens in New York City on July 12. Find out more.