Tuesday, August 18, 2009

Is it Time to Purchase an EHR?

Advocate Blog Guest Blogger: Michael Barr, Vice President, Practice Advocacy and Improvement

With the passage of the health IT incentive program (also referred to as the HITECH Act) as part of the American Recovery and Reinvestment Act of 2009 (also known as ARRA), structured payments were put in place to stimulate the adoption of Electronic Health Records (EHRs) with the caveat that these EHRs would need to be "certified" and used to demonstrate "meaningful use." If a practice documents meaningful use of a certified EHR at the start of 2011, over the subsequent 5 years (2011 - 2015) that physician would receive payments equaling $44,000. You can start in 2012 and still receive the maximum amount. However, start later and you get less (i.e., starting in 2014 would result in incentives totaling only $24,000 at the end of 2016). Note, these dollar values are specific for the Medicare incentives. If you qualify under the Medicaid program, the incentives are a bit higher (click here for more details).

But what does "meaningful use" mean and how will it be demonstrated? The legislation defines it as follows:

"A meaningful user of EHR is defined as one who: (1) demonstrates to the satisfaction of the Secretary that the professional is using certified EHR technology in a meaningful manner, which includes the use of electronic prescribing; (2) demonstrates that the technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of health care; and (3) uses the EHR to submit certain performance measures to the Secretary (but only if the Secretary has the capacity to receive the information electronically)." The Secretary has some flexibility to define additional criteria or to change the criteria over time.

So far, so good - but what does this really mean you might ask? The Health IT Policy Committee released a "Meaningful Use Matrix" on July 16, 2009. There are plenty of well-intentioned measures of clinical parameters included in the set of metrics for 2011 but a quick review raises some important questions. Here are a few to consider:

- Can EHR vendors develop the data collection and reporting capabilities of EHRs to incorporate such measures into EHRs by 2011 (or even 2012) - especially since many of the clinical measures identified were originally designed to be based on claims data and/or chart review and not developed with enough specificity for computer programmers?
- Many of the proposed measures still rely on paper-based activities which could add administrative burdens and costs to practices. Should proof of meaningful use include dependence on paper processes?
- One of the measures is the "percentage of orders entered directly by physicians through CPOE" (CPOE = computerized physician order entry). However a footnote explains that, "CPOE requires computer-based entry by providers of orders (medication, laboratory, procedure, diagnostic imaging, immunization, referrals) but electronic interfaces to receiving entities are not required by 2011." This seems odd and, frankly, backwards. Physicians will be required to generate orders through their EHR for which there is no guarantee - and in fact no requirement - for receipt of these orders by the "accepting" entity. Shouldn't the capability of receiving electronic orders be built and tested prior to the requirement for those orders to be initiated?
- One measure is a requirement to report on the percentage of patient encounters for which insurance eligibility was confirmed. Meaningful use of an EHR? I thought this is a practice management system function.
- Another metric simply states, "Full compliance with HIPAA Privacy & Security Rules." How will that be measured through the use of an EHR? Does this imply that EHRs will now have to include security and privacy applications that monitor and report on all access/clicks/views/prints/emails of protected health information?

To be fair, there are good clinical measures on the meaningful use matrix relating to diabetes care, cholesterol management, blood pressure control, cancer screening, vaccinations and others. But as noted above, there are going to be challenges with specifying the denominators and numerators in order to accurately provide meaningful information from "meaningful use."

Imagine you are a practicing physician and leader in a group of fewer than 10 physicians (where the vast majority of ambulatory care visits take place). You have been contemplating the purchase of an EHR off and on for a couple of years but now have decided to get serious given all of the attention being paid to health IT. After reading about the ARRA incentive program, are you more or less likely to purchase an electronic health record? Has the business case been made? Are you feeling pressure to do so? If you are not ready, what would help you make the leap? In short - is it time to purchase an EHR?


Jay Larson MD said...

Our community has several providers using different EHR’s, none of which communicate with each other. When a common language code is developed (other than paper), then purchasing an EHR from a vendor would be reasonable. Currently, once data is entered, it is trapped in proprietary code fields. The cost is still an issue when hardware and software maintenance are included in the EHR cost. There is more work to be done before proprietary EHR’s are meaningful and useful. BTW, I do not use a paper based medical record but a homegrown EHR. There is just too much data to manage to use a paper medical record.

DrJHO7 said...

I am so done with paper.

Three months after I implemented my EMR, we let our part time filer go because there was no work for her to do. We buy 1/10th the copy paper that we used to. Of course we buy no charts or chart supplies. 1 paper rx pad lasts me months, as most of our rx's are send by escript, fax or printed down. I can dial into my office and do chart work/review results/messages/correspondence from home or anywhere in the country where I can log into a secure network with a laptop. We spend no time looking for charts or test results in the office. We have electronic interfaces with the major labs and local hospital. We are involved in a mcr screening/prevention project using the emr to generate meaningful use data via the reporting capabilities of the EMR.

Downsides of all this:
expensive: yup, initially. Cost savings are increasingly recognizable down the road.
slows you down: yup. until you enter most of the data in the right places on most of the patients, and until you customize the exam templates and short lists of information items that you use frequently, it will slow you down.
interconnectivity with other docs/practices - capabilty is built in but can't use til security issues are mastered by the IT community - will take years.
CPOE: no reason to until the appropriate entities can receive the orders and act on them, unless you want to track orders and reconcile results: huge time/manpower drain, almost nobody is doing this yet, although we probably should be.
power outages: are a problem, but they were with paper charts, too. light is generally necessary to see paper, the patient, use an otoscope, etc.

Take advantage of ARRA? YES. How many more opportunities like this will come along? 44K is 44K.
The good-competitive CCHIT Certified EMR companies that want to stay in business will make sure
their product is capable of satisfying the meaningful use requirements as they become available.

Tricky part: finding the one that's right for your practice. The remedy is putting in the time on the research of the different products, after identifying what the needs of your practice are, and having the courage and plan to move forward with it.

Yes, it is still time.

Marshall Maglothin said...

Outstanding, timely and informative information!

The HITECH Grants will produce the most profound advancement in health information, and I believe in ultimately the delivery of personal health care, in mankind's history. This platform will move us from a fragmented electronic structure for financial transactions to the breath-taking new vista of disease prevention and management.

I encourage all of your HIT readers to be aggressive and involved participants in networking to energize this transformation with the regional organizations which will burst forth in the next 18 months.