Electronic Health Records

In December of 2007, the California HealthCare Foundation published a new study that indicated that despite the efforts by state and federal governments to accelerate the use of electronic health records (EHRs), nearly three-quarters of medical groups as well as hospitals, clinics and long-term care facilities in California are still relying on paper records.

Despite this limited statewide adoption of EHRs, it is of particular interest that California leads the nation with 37 percent of physicians using EHRs, compared with 28 percent nationally. Not surprisingly, the larger the medical practice, the higher the utilization; 79 percent at Kaiser Permanente, 57 percent in practices of 10 or more physicians, 25 percent in small/medium practices, and 13 percent of solo practitioners. More disappointing is the fact that 88 percent of physicians with EHRs fail to take advantage of their full capabilities such as alerts about potential adverse drug events, electronic warnings about abnormal lab results, or reminder notices that can be sent to patients about preventive care.

Most physicians agree that electronic health records can save lives and money by reducing medical errors and by cutting down on redundant tests and procedures. However a number of challenges have slowed their implementation:

• Affordability. Currently, most standalone EHRs cost a minimum of $10,000 per physician to purchase, install, train staff and adjust workflow. Maintenance and upgrades can easily run up to $2,000 per year per physician.
• Return on investment. The American Medical Association estimates that doctors see only 11 cents of every dollar saved through the use of information technology. In response, Blue Cross Blue Shield of Massachusetts recently announced that is has decided not to require physicians to install an EMR to participate in its bonus program.
• Reduction in productivity is a surprise for most physicians. Typically, for primary care physicians (PCPs), there is a reduction in billings by 20 percent. Beyond the first year, productivity rarely surpasses what it was with paper records for PCPs. Select primary and specialty physicians may experience an improvement in productivity depending on how they integrate the systems into their workflow.
• Lack of adequate government or insurance reimbursement for the extra effort and cost it takes use EHRs for quality and Healthcare Effectiveness Data and Information Set (HEDIS) reporting.
• Interoperability remains a major barrier. Physicians who buy a standalone EHR that is not fully integrated with their practice management system for billing and collections will be frustrated with the ongoing costs of making the two systems work seamlessly. Any time there are upgrades to one system, there are unanticipated costs and glitches with the second system. Also, hospitals, labs and other stakeholders cannot at present deliver health information to the right field in the right patient’s chart. This feature is necessary to eliminate the errors and the time associated with having to re-key patient data into each patient’s chart. Based upon my survey of the San Diego County healthcare landscape, I suspect that we will not reach this point until at least 2012.
• Unexpected downtime also presents challenges to solo and small practices who cannot afford to have full-time, dedicated technicians available to solve the problems inherent with electrical outages, computer glitches, and server problems. Even one hour of downtime can completely disrupt the office.

Many stakeholders are pressing physicians to adopt EHRs, and therefore physicians need to be cognizant of their motivations:

• Health plans possess the most extensive database on patients from their claims departments. They also have the most to gain financially in that EHRs will allow them to reduce the cost of data collection to meet HEDIS and quality measures. In the future, I would not be surprised if health plans and hospitals offer significant incentives (possibly even free software) to primary care providers (PCPs) in an effort to capture the physician desktops.
• The government envisions huge savings through a reduction of medical errors, fewer redundant tests and procedures, and standardization of care. However, Congress’ failure to pass health information technology legislation in the past two years and the relatively low funding for the Office of the National Coordinator for Health Information Technology raises questions about the ability for the Centers for Medicare and Medicaid Services (CMS) to provide adequate and sustainable reimbursement for the use of EHRs.
• Hospitals, nursing homes, labs, pharmacies and X-ray facilities expect to cut down on the costs of faxing, phoning, and mailing results and at the same time capture the physician’s business by luring them to utilize software that is uniquely interoperable with their systems.
• For-profit vendors, e.g., Microsoft, Google, and Web MD, and a large number of software companies see huge business opportunities in collecting and managing electronic patient data.
• Patients are being nudged into using personal health records (PHRs) by health plans, employers, and private companies in light of the recognition that patients are the only legal owners of their medical information. There is legitimate concern that PHRs may be used by insurance companies to deselect patients or by commercial vendors to target relevant product ads based upon their data.
• Physicians control 85 percent of the decisions relating to the cost of healthcare, and we have the largest amount of clinical patient information. However, the data is fragmented across providers and stored in incompatible formats, including paper charts. Although physicians are generally trusted custodians of patient information, studies show that in one out of every seven visits to the physician’s office, the information needed to make timely decisions is not available at the point of care.

Despite these barriers, there is significant progress being made in eliminating barriers to adoption, particularly in the area of interoperability, security, and privacy. The Certification Commission for Healthcare Information Technology (CCHIT) has recently established 250 standards for EHRs. In addition, the U.S. Department of Health and Human Services (HHS) has recognized the first set of interoperability standards developed by the Healthcare Information Technology Standards Panel (HITSP).

Despite the challenges, there are physicians who are eager to make the leap, and for those I would offer the following advice:

• Look for a fully integrated practice management and EHR. Do not buy separate systems in the hope that they will always work well together.
• Physicians should look for an EHR that easily performs all the functions necessary for their unique specialty (talk to colleagues and your specialty society). For example, voice recognition in the EHR is often a big plus for surgeons and enables savings on transcription costs.
• Pay attention to the vendor’s track record for service and support.
• Look for software that automatically flags common tasks that are unique for your specialty (e.g., cancer screenings for internists and family practitioners).
• If possible, find an EHR that can receive data from your preferred lab and hospital and deliver patient specific data into the correct field in each of your patients’ electronic charts.
• Take a look at the 2007 Best in KLAS Awards based on customer satisfaction with healthcare information technology vendors and consultants.
• Finally, you may want to attend the 2008 TEPR (Towards the Electronic Patient Record) Conference in Fort Lauderdale on May 19, 2008, where there will be more than 100 exhibits that will allow you to compare systems by price and functionality.

For those of you who can wait, you will be rewarded with a cheaper, more robust EHR that is fully integrated with a practice management system (PMS) for scheduling, billing, and collections. This EHR/PMS will be fully interoperable with all stakeholders in healthcare and provide you with the clinical decision support to generate a differential diagnosis, order and receive test results, prescribe formulary-specific medications, and educate patients, all while in the exam room.

Despite the proven benefits to patient quality and service, physicians must recognize that the return on investment only becomes adequate when the EHR/PMS automatically determines eligibility when the patient arrives, captures all the proper codes for billing during the visit, allows the check-out desk to determine what the patient owes in real time, and, most importantly, adjudicates 90 percent of claims and deposits payments into your practice bank account in less then two minutes.

Several insurers, including Humana, United Healthcare, and several Blues plans have already started to pilot the software necessary for real-time adjudication of claims. I am pleased to report that this functionality will be standard on all EHR/PMSs and required of all public and private payers. However, it is up to organized medicine to make sure that those who will enjoy the greatest savings and benefits (third-party payers) contribute their fair share of the dollars to make this happen.