The definition of meaningful use is still evolving, but it's clear some level of information exchange between hospitals and physician practices will be required to qualify for HITECH incentive payments. And while a hospital may be well positioned on meaningful use with its own EMR, its affiliated independent physician practices may not be. Can hospitals afford to leave EMR implementation up to the practices and risk losing stimulus money due to a lack of information exchange?

Though a number of hospitals have been offering EMR funding and support to physicians since the relaxation of the Stark laws, HITECH has sent independent practices rushing for help, and CIOs are paying attention. “There's a feeding frenzy with the HITECH stimulus,” says Todd Rothenhaus, M.D., senior vice president and CIO of Boston-based Caritas Christi Health Care, a seven-hospital system. “Two-thirds of our physicians are not employed, but those physicians are valuable to us, and we want to service that group, too.”

Rothenhaus says CIOs can't afford to ignore this group of doctors - not only for quality of care issues, but for the hospital's business model. “For health organizations, the ability to help with electronic health records is becoming a competitive edge,” he says. “The ones that look away from this miss an opportunity to align with a physician who might go to another hospital system because they are supporting an EHR.”

It's an interesting environment, says John Whitman, principal at ECG Management Consultants (Arlington, Va.). He says that although hospitals are feeling the pressure to connect this group, not all of them are able to do so - at least for now. “We do see organizations that aren't doing anything with those docs and are just focusing on an employed group strategy,” he says. “They realize that something needs to be done with the community, but it may or may not be a priority depending on their competitive environment.”

Whitman, whose firm works with many smaller hospitals, believes the best approach to community doctors is to devise a physician IT strategy that aligns with their overall IT strategy - and not to be distracted from a coherent plan by HITECH.

Many CIOs are already on that track. Richard Shirey, CIO of the 1,500-bed Baptist Health System (Birmingham, Ala.), says he has “a vision of an integrated health record, and the only way we can accomplish that is if our (community) physicians are aligned as well as our employed physicians. It's the only way we'll be able to gather quality measures and help improve patient care, and I don't think the dollar number is all that important.”

At Christiana Care Health System in Wilmington, Del., a key component of the overall IT strategy is around primary care. “We were doing this before HITECH,” says Terri Steinberg, M.D., CMIO of the two-hospital system. “It's very important for Christiana Care to maintain a viable primary care community - we feel a sense of responsibility.” Steinberg says the organization has been reaching out to primary care docs to learn how the hospital can help them stay in business and thrive. “One of the things we heard is that they want help picking a system.”

Choosing an EMR, however, can be overwhelming, according to Shirey. “Physicians are conservative businessmen who like sure things,” he says. “They know that technology can help them, but it hasn't been an easy road. Many of them are scared.”

Lindsey Jarrell, senior vice president and CIO of BayCare Health System in Tampa, Fla., has also seen his independent practice physicians' interest in EHRs rise. “I think HITECH caught a lot of people flatfooted,” he says. “Most of the community physicians we meet with still do not know how meaningful use is being defined. They don't understand the timeframe, and we're spending a lot of time on those conversations.”

Jarrell says the doctors are asking BayCare for help in selecting a system. He says they typically approach the vice president of medical affairs, or at times the CMO or the CMIO, who then routes them to Jarrell. “We immediately get it down to four to eight options for them, depending on which way they want to go,” he says.

BayCare, a nine-hospital system, is typical of many large systems in that it had an existing plan to connect its community doctors. Jarrell says larger IDNs may already have these strategies in place as they tend to have more resources. However, though larger hospital systems may already be out of the gate with their community docs, smaller community hospitals are just joining the race.

Though many financially-strapped hospitals don't have money to subsidize physician practices through Stark, they can still participate. “A hospital may not have the funds, but coming up with a strategy and sharing it with the community docs gives the physicians a direction to work towards,” he says. “It's putting that strategy out there and getting physician participation.”

And while the large IDNs may have already had a strategy, timelines are speeding up. Rothenhaus says he is presently up to two practices per week. In the past year-and-a-half, he's quadrupled the size of his implementation team. Those numbers have stepped up, he says, because of Caritas' decision to consider non-employed physicians equal to employed physicians in terms of information sharing.

For many, that support begins with answering questions from independent physicians. At Christiana Care, Steinberg has been holding workshops with community physicians, and says the one thing they request is guidance. “It's not actually the money that scares them; it's picking the wrong system and being marooned,” she says. “They want somebody like me to give the seal of approval.”

Steinberg's hospital is using a consulting service to help doctors through the phases of implementation. The hospital is helping them implement according to best practices, creating order sets. “The clinical content won't vary if it's NextGen or Epic,” she says. “We want to make sure if they want our help, we'll give them what they need.” Delivering that support is also having an effect on internal staffing, and many hospitals are creating new positions expressly designed to interact with physician practices.

BayCare hired a director of physician support services this year, reporting to the CMIO, who is responsible for the subsided EMR program, as well as physician outreach and education. That director is constantly in the community meeting with physicians around EMRs.

Like Jarrell, Shirey too created a new position to deal with the doctors - the chief integration officer. “We think it's a key position,” he says. That new executive is skilled in both the outpatient setting and in building physician relationships and, he adds, helps focus strategy on the inpatient and outpatient integration. “Hospital administrators typically don't have a lot of knowledge about the ambulatory setting or the pressures on a doctor in the payer market, let alone the workflow issues of a physician practice,” says Shirey.

Jarrell says getting the big picture is critical. “If a hospital chooses the EMR vendor, it may not be what the physicians really need. We need to understand that the physician's life and the physician's office are completely different from the hospital.”

Rothenhaus says it's important to have an integrated suite with both sides - the practice management and billing, as well as the EHR. “You're left trying to find support for both of those pieces,” he says. “You need an analyst that understands physician billing and revenue cycle. And since that's not necessarily a core business of a standard hospital, you're going to have to develop that expertise.”

Differences in those core business models are a reason hospitals have largely not been successful getting their practices on board. But those differences also illuminate what many think is most effective. “Don't treat this like a typical inpatient acute IT initiative,” says Whitman. “If you do that, the initiative will fail.”

He says that instead of the “design, test, implement, train” model, implementing an EMR in physician offices requires physician input, education and workflow redesigns. “It's a process that is going to be difficult, and you have much less control over the outcome,” says Whitman. “And though you can say it's the physician groups that are going to be responsible, ultimately they're going to come back to you as the CIO. Don't underestimate that.”

So, in the end, what's really at stake? “The country can't afford to let the docs fail,” says Shirey. “Without doctors, there is no healthcare.” He says he believes that if hospitals can't support these doctors, they will begin to flee markets. “We can't afford to let doctors fail, and the federal government can't either. The stimulus program was not intended to create haves and have-nots; it was intended to stimulate everyone to a higher level.”