Cover Story - May 2009
Tex Med. 2009;105(5):16-22.
By Crystal Conde
Plainview family physician Sidney Charles Ontai, MD, switched from paper records to an electronic medical record (EMR) system in 2003. He learned a few lessons when he did so.
Initially, the cost of maintenance and upgrades took a toll on his practice, along with the challenge of securing reliable technical support in a rural area. But once the system was up and running, Dr. Ontai says his entire staff embraced the new technology. His practice and his patients benefitted from his adoption of health information technology (HIT).
However, there was an unanticipated side effect.
"I had problems with patients complaining about my staring at the screen when I charted with a laptop in the room the first year after implementation," said Dr. Ontai, chair of Texas Medical Association's Council on Practice Management Services and a member of TMA's HIT Committee. "I have heard many similar complaints from patients about colleagues with EMRs, so now I chart in the hallway immediately after the encounter and have done so since 2003."
HIT Committee Chair Joseph Schneider, MD, has some advice to avoid disrupting a practice when going electronic. He recommends physicians try different types of computers before buying a system. He encourages his colleagues to work with vendors on developing flexible technologies that are less obtrusive and that can be customized to a physician's patient population. Pediatricians, for example, will complete different fields of information than will geriatricians.
Congress hopes to sway more physicians like Dr. Ontai toward adopting and using EMRs and has set aside $19 billion in funding in President Obama's economic stimulus package to help physicians purchase and implement HIT systems.
The portion of the stimulus package known as the Health Information Technology for Economic and Clinical Health (HITECH) Act makes some big promises to physicians who use EMRs. Physicians will not receive payments upfront but will be eligible for funds from 2011 through 2016 if they demonstrate "meaningful use" of a certified EMR technology.
Non-hospital-based physicians who accept Medicare patients could earn up to $44,000 in incentives in those five years. For those who meet the requirements by 2011 or 2012, the first Medicare incentive payment is $18,000. The incentives then drop to $15,000 by 2013 and $12,000 by 2014. (See " Breakdown of Physician Incentive Payments .")
Eligible physicians who work in health professional shortage areas will receive a 10-percent increase in incentive payments, which end after 2016. The legislation also includes historic new consumer privacy and security protections.
What's "Meaningful Use"?
Cleaning out the file folders, scaling back the mountains of charts, and having instantaneous access to patients' medical records and prescription histories all appeal to physicians. When executed properly, EMRs can improve care by alerting physicians to necessary screenings or medication allergies, for example. If put into action too quickly and without the proper foresight, however, EMR systems can reduce efficiency in a physician's office. (See " HIT Can Improve Patient Care .")
For that reason, TMA urges physicians to be cautious in purchasing an EMR system and to tap into the association's considerable resources for guidance. (See " TMA HIT Resources Aid Physicians .")
In addition, HITECH leaves many important questions unanswered. For starters, at press time the U.S. Department of Health and Human Services (HHS) had not defined "meaningful use." The agency also must establish standards for certified EMR technology and appoint someone to lead the Office of the National Coordinator. Whoever gets that job will be responsible for endorsing standards and certification criteria and coordinating HIT policies and programs, among other duties.
HHS was scheduled to establish HIT Policy and Standards committees in April. The Policy Committee will recommend ways to implement a national HIT infrastructure to the national coordinator. The Standards Committee will establish guidelines for the electronic exchange and use of health information.
An explanation of HIT provisions in the economic stimulus bill is available on the American Medical Association Web site at www.texmed.org/amahit.
HIT use in Texas is not yet widespread. TMA's 2008 Electronic Medical Records Report found that 33 percent of physicians use an EMR system. Forty percent of physicians reported they are planning an EMR implementation, while 25 percent had no plans to do so.
Whether the incentive payments outlined in the economic stimulus package will spur widespread physician adoption of EMR technology is debatable among physicians. But Dr. Schneider says the funding will help.
"The incentive payments in this legislation can have a significant impact in terms of getting physicians over a big EMR hurdle -- the cost of purchasing software. If they choose wisely and don't spend all of their money on software, the incentives could help with training and implementation costs, as well," said Dr. Schneider, a pediatrician at The University of Texas Southwestern Medical Center and chief medical information officer of the Baylor Health Care System.
Impact on Small Practices
Enticing physicians with incentive payments from 2011 to 2016 offers them a "carrot" for "meaningful use" of HIT. The "stick" appears in the form of penalties that begin in 2015. Eligible physicians who haven't become "meaningful users" of EMRs by that point will be subject to reduced Medicare payments, beginning with a 1-percent cut in 2015. The penalties increase to 2 percent by 2016 and 3 percent by 2017.
Physicians who apply for Medicaid incentive payments could earn up to $67,000 for "meaningful use" of a certified EMR system from 2011 to 2016. The stimulus legislation says the government will not penalize physicians in the Medicaid program for not adopting a certified technology.
HITECH prohibits physicians from "double-dipping." Doctors who use an EMR with e-prescribing capabilities will qualify for HIT incentives only. They forfeit their eligibility for the Centers for Medicare & Medicaid Services (CMS) e-prescribing bonuses established by the 2008 Medicare Improvements for Patients and Providers Act. Also, physicians may qualify for payments for using HIT under Medicare or Medicaid but not both.
Many Texas physicians stand to benefit from the incentives if they go electronic. According to the 2008 TMA Physician Survey, 64 percent of Texas physicians accepted all new Medicare patients, and 42 percent of physicians accepted all new Medicaid patients. Nineteen percent limited acceptance of new Medicare patients, and 17 percent accepted no new patients. Among Medicaid participants, 24 percent had limits on accepting new patients, and 35 percent accepted no new patients.
David Fleeger, MD, an Austin colon and rectal surgeon and immediate past chair of TMA's Council on Practice Management Services, doubts the incentives outlined in HITECH are enough to persuade physicians who don't participate in Medicaid or Medicare to begin doing so. But he says the payments are enticing for those who currently participate.
He also cites cost as a significant barrier that hinders some physician practices from adopting EMR technology.
"The incentive payments aren't enough to cover your expenses, but at the same time, if five years from now there will be penalties, none of us can tolerate having our Medicare reimbursements decreased. Seeing the stick not too far down the road, you might as well nibble on the carrot," he said.
TMA's EMR survey shows substantial variation in reported implementation costs. The median cost per physician was $25,000 in 2007, up from $20,000 in 2005. But 18 percent of respondents reported prices below $5,000 per physician, and 17 percent reported prices above $50,000.
Ruben Amarasingham, MD, MBA, says small physician practices will struggle with EMR adoption the most, but only partly due to cost. After physicians purchase an EMR system, he says, they and their staff will have to learn to use the system and maintain a commitment to making it part of the practice.
An assistant professor of medicine at The University of Texas Southwestern Medical Center and codirector of Parkland Health & Hospital System's Center for Knowledge Translation and Clinical Innovation, Dr. Amarasingham stresses that technology systems can improve coordination of care and information sharing, but only if the systems are well designed and properly implemented.
For example, when adopting an EMR system, instead of transferring inefficient methods for completing tasks to the new system, analyze your practice's workflow and make necessary modifications to improve completion of duties and to streamline patient visits. Once the new system is operational, physicians and their office staff members need to remain committed to using the EMR to facilitate patient care. Practitioners should undergo additional training as needed and work with all members of the health care team to ensure the transition to an EMR system is as smooth as possible.
TMA suggests physicians be careful and thoughtful when determining whether to go paperless, because rushing to implement an EMR system could do more harm than good.
Dr. Schneider points to findings from TMA's EMR report that he says indicate haphazard EMR implementation could financially hurt physicians. When asked what they like least about their EMRs, 27 percent of physicians reported increased costs in the absence of offsetting savings.
"Even if an EMR is low-cost, once you factor in the government incentive payment, it won't do any good for smaller practices that don't do this well. TMA and our professional organizations really have to figure out a way to use this funding to help smaller practices so they're not damaged in the long run by implementing an EMR," Dr. Schneider said.
Dr. Fleeger is in the process of setting up an EMR system.
"With implementation, physicians face a disruption in office workflow; initially most people experience a decrease in cash flow in the office because they can't see as many patients," he said.
He anticipates a steep learning curve early on, but says he realizes once it's operational an EMR system will ease the process of record keeping and accessing patient information.
Security of Data
HITECH includes expanded Health Information Portability and Accountability Act (HIPAA) provisions to help ensure the privacy and security of health records and personal information. Deborah Peel, MD, an Austin psychiatrist and founder of Patient Privacy Rights , says the privacy protections Congress passed are a historic step forward in giving patients control over who can access their protected health information.
She says previous lax protections led to the sale of confidential patient information by pharmacies, hospitals, data-mining companies, and EMR vendors.
Among the noteworthy new protections, the law:
- Prohibits selling patients' medical records without their consent;
- Limits marketing of protected health information;
- Requires any entity using an EMR to keep an audit trail of three years worth of disclosures of all people and organizations with whom it shares protected health information;
- Requires the HIT Policy and Standards committees to consider setting standards for technology systems to segment sensitive information, and for data encryption;
- Ensures new business entities that weren't contemplated when HIPAA was originally written, such as EMR vendors, are subject to the same privacy and security rules as physicians by requiring business associate contracts;
- Increases monetary penalties for violations, grants attorneys general authority to file suit on behalf of a state's citizens, and requires monitoring of contracts and reporting on compliance; and
- Requires patients be notified regarding security breaches of their health information.
To aid physicians in complying with the new HIPAA regulations, TMA is offering "Protected Health Information: Managing Your Medical Records." The practice management seminar will cover protection of personal health information and will run July 14 through Sept. 23. For more information, contact the TMA Knowledge Center at (800) 880-7955.
TMA's HIT Committee developed health information exchange principles that advocate giving patients complete control over all uses of individually identified medical data. The policy specifies that, except for emergencies, patient medical data must not be disclosed or disseminated to others without the patient's consent.
To further strengthen the security and confidentiality of patients' private health information, Dr. Peel says, physicians should read their vendor contracts carefully.
"In many of the EMR systems, the vendor reserves the right to own or use and sell the data," she says. "Unless physicians read that legal language of the vendor contract, they won't know and could be giving their patients false assurances."
TMA's HIT Department is working on a contract review process with some EMR vendors. Visit the HIT Web site for updates.
Dr. Peel encourages physicians to purchase EMRs with consent tools that allow patients to update their information electronically and instantly notify all doctors and information holders when they attempt to move medical records or other data.
"EMR products and the health care industry will have to improve patient control over use and disclosures of protected health information for patients to be willing to trust electronic health systems," she said. "Patients avoid treatment when they know their protected health information will not be kept private."
Physician Involvement Needed
Some physicians worry the HITECH offices and committees may lapse into another government bureaucracy, adding one more hassle doctors must endure to do their jobs.
Dr. Fleeger is skeptical.
"I've got a feeling a lot of that $19 billion will get caught up in bureaucracy," Dr. Fleeger said.
He says that for the system to work, the money must flow directly to individual physicians.
Dr. Schneider agrees and strongly urges physicians to be deeply involved in this process.
"They have to understand the guts of the systems and be involved in the governance and leadership of this. If not, what happens is you get what someone else thinks you want," Dr. Schneider said. "The only way we can do this is to have lots of physicians at the table speaking clearly. If we can do this through TMA and our professional associations, we'll be more powerful and the message will be better received."
Dr. Amarasingham adds that medicine hasn't begun to scratch the surface of how HIT can improve patient care.
"Right now we have a fragmented system, and too often decisions are made without appropriate data. I think the opportunities for sound public health decisions and for predictive modeling are profound," he said.
He also has a message for physicians who continue to cling to paper records: The health care system will keep getting more complex, making the switch to an electronic system necessary to survive. He encourages physicians to take advantage of the federal funding and use this opportunity to redesign and enhance their practices.
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde .
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HIT Can Improve Patient Care
Results of a research study published early this year in Archives of Internal Medicine show a link between hospitals' use of HIT to track patients' medical records and manage care and its relationship to lower inpatient mortality rates, fewer complications, and lower costs.
Ruben Amarasingham, MD, MBA, is the lead author of the six-year inpatient study. His team examined four conditions - coronary artery bypass grafting, congestive heart failure, myocardial infarction, and pneumonia - and found decreased adjusted odds ratios for fatal hospitalizations from greater uses of HIT.
The study included a cross-section of 41 urban Texas hospitals and used a clinical information technology assessment tool to measure a hospital's automation level based on physicians' use of information systems.
Among the findings:
- The use of advanced order entry led to a 9-percent decrease and a 55-percent decrease in the adjusted odds of death from myocardial infarction and from coronary artery bypass graft procedures, respectively;
- Notes and records automation resulted in a 15-percent decrease in the adjusted odds of death from each of the four study conditions;
- Application of decision support technologies produced a 16-percent decrease in the adjusted odds of complications for each of the four study conditions; and
- Automated test results, order entry, and decision support resulted in hospitalization cost reductions of $110, $132, and $538, respectively.
Dr. Amarasingham says his team adhered to high standards when evaluating a hospital's use of HIT. Rather than simply asking if an institution had an electronic medical record (EMR) system, the researchers assessed whether physicians knew how to use the technology and whether they chose to use it instead of other processes.
While research results aren't directly applicable to the individual doctor's office setting, he says improvements in health outcomes could be even greater for outpatients with a larger degree of well-executed physician HIT usage. And an EMR system can improve continuity of care from an inpatient to an outpatient setting.
"It's almost certain that type of result would be translatable in the outpatient environment in which physicians have many demands on their time and undertake administrative obligations," he said.
But Dr. Amarasingham warns that poorly implemented and designed HIT systems could actually cause physicians to become inefficient, having a negative impact on quality of care. He cites as an example the installation of identical information systems in two pediatric intensive care units in different parts of the country. Although the vendor and system were the same, one institution saw an increase in mortality rates while the other one experienced a decrease after implementation.
"It shows that the software is only one small layer of the entire process. All the decisions you make during implementation will have an impact on the final product. We found that the more the system catered to physicians and their workflows, the better the outcomes were," he said.
Dr. Amarasingham and his team are conducting research into the impact of HIT systems on the outpatient care environment. He hopes to have results within two years.
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TMA HIT Resources Aid Physicians
For tools to help physicians assess whether their practices are ready to adopt an electronic medical record (EMR) system and information about health information technology (HIT), log on to the HIT page on the TMA Web site.
Resources include TMA's EMR Implementation Guide , which offers up to 3 hours of continuing medical education credits, and TMA's EMR Readiness Assessment Questionnaire and white paper. Additional materials include HIT-related articles and case studies that offer firsthand physician accounts of implementing an EMR system.
The HIT Department also offers an EMR comparison to aid physicians in shopping for an EMR system. It includes an apples-to-apples comparison of frequently purchased products in Texas, available from eight vendors.
For more information, contact the HIT Department help line at (800) 880-5720, or e-mail HIT .
In addition, TMA Practice Consulting provides doctors with a practice assessment and workflow analysis to start them on the path to adopting and implementing an EMR system. Information is available by calling (800) 523-8776 or e-mailing TMA Practice Consulting .
Plus, the Learn @ Lunch audio session, sponsored by the Texas Medical Liability Trust (TMLT) and hosted by TMA on July 30 from noon to 1 pm, will focus on how funding for HIT in the economic stimulus package may affect physician practices. Speakers include Joseph Schneider, MD, MBA, chair of TMA's HIT Committee, and Rich Johnson, TMA's vice president of medical economics.
For information on registration and the dial-in process, contact the TMA Knowledge Center at (800) 880-7955.
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