New England Journal of Medicine: Accelerating the Use of Electronic Health Records in Physician Practices

Posted on Jan 21, 2010 in Records Management News

Steven Shea, M.D., and George Hripc­sak, M.D.

North Shore Hos­pi­tal Sys­tem on Long Island in New York recently announced that it will pay an incen­tive of up to $40,000 to each physi­cian in its net­work who adopts its elec­tronic health record (EHR) — pay­ing 50% of the cost to physi­cians who install an EHR that com­mu­ni­cates with the hos­pi­tal and 85% of the cost if the physi­cian also shares de-identified data on the qual­ity of care.¹ This pay­ment would appar­ently come on top of the $44,000 incen­tive that the Amer­i­can Recov­ery and Rein­vest­ment Act of 2009 (ARRA) has autho­rized Medicare to pay each eli­gi­ble health care pro­fes­sional who uses cer­ti­fied EHRs in a mean­ing­ful man­ner. “Mean­ing­ful use” is still being defined, but the over­ar­ch­ing goal is to improve the population’s health through a trans­formed health care deliv­ery sys­tem with the use of EHRs to improve local processes, fos­ter qual­ity mea­sure­ment, and increase com­mu­ni­ca­tion. North Shore’s announce­ment is a sign of the con­tin­u­ing accel­er­a­tion of EHR adop­tion by physi­cians’ offices² and hos­pi­tals.³ Sup­port for infor­ma­tion sys­tems is exempted from the Stark amend­ment to the Omnibus Bud­get Rec­on­cil­i­a­tion Act of 1989, which pro­hibits hos­pi­tals from offer­ing physi­cians incen­tives for pro­vid­ing refer­rals or admis­sions. The exemp­tion for infor­ma­tion tech­nol­ogy acknowl­edges that the like­li­hood of addi­tional refer­rals may be part of the moti­va­tion for hos­pi­tals to form closer links with com­mu­nity physi­cians through EHRs. Another ben­e­fit to hos­pi­tals from sup­port­ing the use of EHRs by physi­cians who are linked to them by geog­ra­phy, aca­d­e­mic appoint­ment, or prac­tice pat­tern is the enhanced abil­ity to man­age the qual­ity and out­comes of care. For exam­ple, if finan­cial penal­ties and incen­tives are to be imposed on the basis of rates of read­mis­sion, then the more closely aligned a hos­pi­tal is with the physi­cians who pro­vide its patients’ post­dis­charge care, the greater the ben­e­fits it will reap.

The cost–benefit cal­cu­lus behind physi­cians’ adop­tion of EHRs is also chang­ing. Finan­cial incen­tives are one ele­ment. The prices of EHRs have come down as the vol­ume of soft­ware licenses being sold has increased. A sec­ond fac­tor is that the time invest­ment asso­ci­ated with data entry, which has long rep­re­sented a major obsta­cle to adop­tion, has been reduced as sys­tems have improved in per­for­mance and become more flex­i­ble with regard to indi­vid­ual pref­er­ences for data entry, includ­ing free text, tem­plated data entry, dic­ta­tion, speech recog­ni­tion, and free­hand graphic input. Sys­tem usabil­ity has also improved, thanks to com­pe­ti­tion and cus­tomers’ resis­tance to cum­ber­some prod­ucts. Third, the addi­tion to EHR sys­tems of capa­bil­i­ties beyond doc­u­men­ta­tion, includ­ing cod­ing func­tions, the abil­ity to cre­ate and export bills, the auto­mated cre­ation of con­sul­ta­tion and patient let­ters, elec­tronic pre­scrib­ing, and task track­ing, now trans­lates into greater time sav­ings for users. And a fourth fac­tor is the increas­ing empha­sis on qual­ity of care, since pay­ment for qual­ity requires doc­u­men­ta­tion of qual­ity.

Other trends favor­ing EHR adop­tion include the emerg­ing con­sen­sus that align­ment of hos­pi­tals and physi­cians is nec­es­sary to pro­vide higher-quality care and ser­vice for patients as they move among providers and tra­verse lev­els of care, as well as the recog­ni­tion that infor­ma­tion trans­fer is an impor­tant com­po­nent of care given by mul­ti­ple providers. Younger physi­cians — and some older ones — are more com­fort­able and func­tion more effi­ciently and effec­tively in an electronic-information envi­ron­ment than in a world of paper records.

Some obsta­cles per­sist, of course. EHR prod­ucts remain expen­sive to install and main­tain — cost issues that should not be under­es­ti­mated. The deci­sion by North Shore to pro­vide a finan­cial incen­tive as well as the soft­ware license sug­gests that many physi­cians still do not believe that current-generation EHRs will offer a return on invest­ment directly to physi­cians.

Wide dis­sem­i­na­tion of EHRs requires pub­lic trust. The shar­ing of patients’ infor­ma­tion — which has been com­mon prac­tice for decades for the pur­poses of billing, treat­ment, and pub­lic health — has come into the pub­lic eye because of the risks asso­ci­ated with vastly expanded shar­ing and the new­found abil­ity to eas­ily and quickly trans­fer many patient records simul­ta­ne­ously. The Health Insur­ance Porta­bil­ity and Account­abil­ity Act of 1996 (HIPAA) cre­ated a frame­work for defin­ing pri­vacy, breaches of pri­vacy, and penal­ties. The ARRA fur­ther defined pri­vacy breaches and increased the penal­ties for them. One of the chal­lenges to set­ting pol­icy in this area is that elec­tronic pri­vacy and its rel­a­tive impor­tance are still being defined. The capa­bil­ity of pro­vid­ing a secure elec­tronic envi­ron­ment for patient data — like the capa­bil­ity of pro­vid­ing reli­able data stor­age — is beyond the reach of most indi­vid­ual physi­cian prac­tices. Truly secure and reli­able EHRs are cur­rently fea­si­ble only for larger orga­ni­za­tions with cen­trally sup­ported tech­no­log­i­cal capa­bil­i­ties. This may be one rea­son why the rate of adop­tion has been much higher among large prac­tices (see graph).

Rates of Adop­tion of Elec­tronic Health Records Accord­ing to Prac­tice Size.

The per­cent­age shown above each bar is the pro­por­tion of physi­cians who work in a prac­tice of the given size. The green por­tion of each bar rep­re­sents the per­cent­age of physi­cians in a prac­tice of a given size who have adopted at least basic elec­tronic health records (EHRs), and the yel­low por­tion rep­re­sents the per­cent­age of physi­cians who have not adopted EHRs.² For each prac­tice size, the per­cent­age of physi­cians who have not adopted EHRs rel­a­tive to the total num­ber of physi­cians in prac­tice is shown at the bot­tom. Physi­cians in the small­est prac­tices account for more than 50% of those who have not yet adopted EHRs, whereas physi­cians in the largest prac­tices account for only about 3%.

EHRs that are inter­op­er­a­ble can con­nect not only to each other but also to com­mon ser­vices. Shar­ing infor­ma­tion allows local care providers to coor­di­nate the pro­vi­sion of care — for exam­ple, by avoid­ing con­traindi­cated med­ica­tions and duplica­tive test­ing. It sup­ports pub­lic health goals by facil­i­tat­ing population-level mon­i­tor­ing, and it sup­ports shar­ing of infor­ma­tion about the care process itself, includ­ing qual­ity mea­sures. The Depart­ment of Vet­er­ans Affairs’ VistA sys­tem is the best known large-scale exam­ple of these capa­bil­i­ties.

Exchang­ing infor­ma­tion requires that EHRs share com­mon stan­dards. Work is ongo­ing at orga­ni­za­tions for stan­dards devel­op­ment and facil­i­ta­tion such as Health Level Seven (HL7), which have been pro­vid­ing prac­ti­cal stan­dards for decades. The ulti­mate in inter­op­er­abil­ity would be a sin­gle EHR for all health care providers, but the dis­ad­van­tage of this model would be a loss of com­pe­ti­tion among ven­dors — a fac­tor that has pre­sum­ably con­tributed to increased usabil­ity and lower cost. More­over, inter­op­er­abil­ity among dis­parate EHRs may actu­ally increase com­pe­ti­tion and inno­va­tion if it makes it eas­ier for health care providers to change ven­dors by pop­u­lat­ing a new sys­tem with an old system’s data. Inno­va­tion is not pred­i­cated on com­pe­ti­tion alone, how­ever. Increas­ing fund­ing for EHR research and devel­op­ment — as opposed to imple­men­ta­tion and eval­u­a­tion — may pro­duce evo­lu­tion­ary and rev­o­lu­tion­ary improve­ments in EHRs.

The next major step in EHR deploy­ment is a con­crete def­i­n­i­tion of the require­ments — in terms of mean­ing­ful use, infor­ma­tion shar­ing, and report­ing of qual­ity mea­sures — for physi­cians to receive ARRA incen­tives. The fed­eral Health Infor­ma­tion Tech­nol­ogy Pol­icy Com­mit­tee has sub­mit­ted rec­om­men­da­tions⁴ to the National Coor­di­na­tor of Health Infor­ma­tion Tech­nol­ogy; the Cen­ters for Medicare and Med­ic­aid Ser­vices pub­lished draft rules on Decem­ber 30, 2009, and this pub­li­ca­tion will be fol­lowed by a period for pub­lic com­ment before a final set of rules is issued. Clar­ity on fed­eral incen­tives for physi­cians to adopt EHRs will allow these incen­tives to be aligned with those offered by state gov­ern­ments, provider orga­ni­za­tions, and com­mer­cial pay­ers. Poorly aligned incen­tives may have unin­tended con­se­quences, such as increases in health dis­par­i­ties or incen­tives for specialty-specific silo sys­tems.

Elec­tronic inter­ac­tion between hos­pi­tals and physi­cians is just the begin­ning. Patients are also inter­act­ing elec­tron­i­cally with the health care sys­tem, exchang­ing infor­ma­tion with providers through secure patient por­tals and patient-based health records. More active trans­ac­tions, such as remote case man­age­ment by nurses for patients with chronic dis­eases,⁵ may occur through telemed­i­cine. Some pos­si­bil­i­ties that will be advanced by physi­cians’ adop­tion of EHRs include the use of cell-phone tech­nol­ogy for mes­sag­ing, the capa­bil­ity of mov­ing data from home mon­i­tor­ing devices to cell phones and upstream to EHRs, yet-to-be devel­oped soft­ware capa­bil­i­ties that will allow EHRs to man­age these uploaded data streams within clin­i­cal work­flows, and the effec­tive pro­vi­sion of out-of-office care.

Finan­cial and other dis­clo­sures pro­vided by the authors are avail­able with the full text of this arti­cle at NEJM.org.

Source Infor­ma­tion

From Colum­bia Uni­ver­sity Med­ical Cen­ter, New York.

Ref­er­ences

1. Lohr S. E-records get a big endorse­ment. New York Times. Sep­tem­ber 28, 2009.
2. DesRoches CM, Camp­bell EG, Sao SR, et al. Elec­tronic health records in ambu­la­tory care — a national sur­vey of physi­cians. N Engl J Med 2008;359:50–60. [Free Full Text]
3. Jha AK, DesRoches CM, Camp­bell EG, et al. Use of elec­tronic health records in U.S. hos­pi­tals. N Engl J Med 2009;360:1628–1638. [Free Full Text]
4. Health IT Pol­icy Coun­cil rec­om­men­da­tions to National Coor­di­na­tor for Defin­ing Mean­ing­ful Use: final — August 2009. Wash­ing­ton, DC: Depart­ment of Health & Human Ser­vices, 2009. (Accessed Decem­ber 29, 2009, at http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10741_888532_0_0_18/FINAL%20MU%20RECOMMENDATIONS%20TABLE.pdf.)
5. Shea S, Wein­stock RS, Teresi J, et al. A ran­dom­ized trial com­par­ing telemed­i­cine case man­age­ment with usual care in older, eth­ni­cally diverse, med­ically under­served patients with dia­betes mel­li­tus: 5 year results of the IDEA­Tel Study. J Am Med Inform Assoc 2009;16:446–456. [Cross­Ref][Med­line]

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