Paving the Way for the Second Wave of EHR Adoption

Universal physician adoption of EHRs will require hospitals to play a pivotal role.

This type of problem occurs almost daily in the American healthcare system. Patient Lynn Green (not her real name) has her annual mammogram. The results come back abnormal. Her internist orders tests that reveal a malignant tumor, so he refers her to a surgeon, an oncologist, a radiologist and a plastic surgeon.

Universal physician adoption of EHRs will require hospitals to play a pivotal role.

This type of problem occurs almost daily in the American healthcare system. Patient Lynn Green (not her real name) has her annual mammogram. The results come back abnormal. Her internist orders tests that reveal a malignant tumor, so he refers her to a surgeon, an oncologist, a radiologist and a plastic surgeon.

After surgery and completion of prescribed therapy, Lynn is referred again for behavioral health counseling and physical therapy. Throughout the process, she must complete forms for each physician specialist, the hospital, testing centers, radiation clinic and physical therapy practice, all asking for the same demographic, medical history, medications, allergies and insurance information.

Lynn is 70 years old and has been negatively impacted by this experience. She can’t remember all the details, so a family member accompanies her to each visit to help her provide the same information to each provider. In this case, that’s six physicians, one hospital, four clinics or testing centers, Medicare and supplemental insurer. None is linked electronically with each other or with Lynn.

Obviously, physician adoption of information technology remains an issue. To date, much of the discussion has focused on how physicians can acquire and manage electronic health records (EHRs) to meet a bold goal established by President George W. Bush in 2004 for broad adoption of EHRs within a decade. But, how much progress have we made in the past two years?

Not nearly enough, according to a study released on Oct. 11, 2006, funded by the Robert Wood Johnson Foundation and the U.S. National Coordinator for Health Information Technology at the Department of Health and Human Services (HHS). Study researchers found that while approximately 24 percent of doctors use electronic records for basic patient information, only 9 percent have more advanced features that allow them electronically to write prescriptions, type patient notes and record laboratory test results. Researchers further found that solo practitioners and doctors in small group practices were less likely to use electronic records than those working in large group practices.

The report indicates that healthcare providers are moving to electronic health records at a rate of 3 percent per year. At this pace, only half of all providers will have EHRs by the 2014 deadline—and even that is misleading, since EHR adoption is skewed toward larger practices.

How can we, as an industry, advance broad scale IT adoption and utilization by every physician, in every size practice, for every patient, every day? Much of the answer lies in identifying and tapping the resources of the healthcare stakeholder with the largest investment and experience in deploying healthcare IT—the hospital. In a rapidly changing environment, hospitals can play a key role in connecting different members of the healthcare community to support physicians in their efforts to deploy EHRs.

The First Wave of EHR Adoption
The first wave of EHR adoption was biased toward larger practices with more than 25 physicians. Estimates indicate that up to 40 percent of large, standalone practices have acquired an EHR. The reasons why are twofold.

First, IT vendors needed a viable business model to market, sell, contract, install, support and train members of the large practices. Second, larger practices generally have more capital and a more sophisticated infrastructure. They were logical places to start the automation process and are now the group with the highest penetration of IT systems. These practices were identified early, and IT vendors began crafting technology solutions for practices with the resources to purchase, manage and maintain IT systems. The result of this first wave of EHR adoption is the creation of functional silos of clinical information that do not extend beyond the practice.

One problem illustrated by the Lynn Green example is that her primary care physician was not part of a large group practice. Neither were her specialists. Her healthcare team fit the profile of the majority of physicians today who are organized into small, paper-driven practices.

POMIS data tracks more than 550,000 physicians in the U.S. today in 190,000 practices. Only 1,400 of these are large practices. The median practice has two physicians who don’t have the technical infrastructure or personnel to support clinical IT. These physicians are under a tremendous amount of pressure, both financially and clinically, resulting from major shifts like the rise in consumerism and consumer-directed health plans, pay-for-performance issues and decreasing reimbursements. Clinical data standards do not yet exist, although CCHIT (Certification Commission for Healthcare Information Technology) is moving the industry in the right direction. Therefore, interoperability is not yet a reality for the typical physician practice.

This core group is the majority of the 76 percent of doctors who, according to the HHS study, have not migrated to electronic systems, or the 91 percent who are not using advanced applications like e-prescribing and interoperable information sharing. They are the second wave who need an IT infrastructure to make EHRs a reality for every American by 2014. The business model of the first wave will not meet the needs of the second wave.

The Second Wave, Dispelling the Myths
Before examining how that new model might work, we need to dispel three key myths.

Myth #1: Physicians can’t be sure they are getting the right systems for migrating to EHRs or that they will be compatible with systems used by hospitals, clinics, payers and other healthcare entities.

Physicians today have help in choosing the right systems to meet their needs. The first group of CCHIT-certified EHR vendors in July 2006 reflected, for the first time, a set of minimal standards or basic criteria for functionality, interoperability and security for EHRs. This facilitates a functional baseline for community-based information sharing that can extend beyond the hospital to include not only staff physicians but also independent and affiliated physicians. As a result, physicians have a benchmark to help them make the right choices in selecting vendor partners. Of more than 250 EHR vendors, only 33 were certified in the first two rounds of certification.

This dramatically reduces the pool of vendors that physicians have to research. Most importantly, it reduces the risk of a bad IT decision. The message is clear: If a vendor isn’t certified, think twice before buying or using its systems.

Myth #2: Healthcare technology is too expensive for all but the largest practices, with little government assistance to make it more affordable.

Help has arrived. In October 2006, the federal government finalized new healthcare IT and e-prescribing safe harbors for the Stark and anti-kickback regulations. As attorney Paul F. Danello noted in his article, “Preparing for Interoperability: EHRs and the Law” (Health Management Technology, September 2006), “Congress and HHS have seized the opportunity to encourage the development of EHR networks by creating broad Stark exceptions and anti-kickback statute safe harbors for the provision of health information technology below cost by a medical facility to physicians as long as it increases patient safety and is interoperable.” These exceptions open the hospital as a funding source for small group practices and make it possible to create a true information network based on the hospital’s existing IT infrastructure.

Myth #3: Physicians don’t trust or want IT solutions from hospitals.

To determine whether this myth was true, the Harris Interactive organization conducted a survey commissioned by McKesson of more than 400 physicians in June 2006. The major finding from that study, announced in September 2006, was that physicians were ready to work with hospitals in making EHRs a reality. Just as the relaxation of Stark federal regulations allows hospitals to provide information technology to community physicians, so the survey showed that more than seven in 10 physicians were receptive to working with local hospitals to leverage a hospital’s IT infrastructure and buying power.

In fact, 74 percent of the physicians plan to implement EHRs, and 91 percent of them plan to do so within three years. Most significant, physicians ranked clinical benefits of EHRs higher than financial factors, with “coordination of care across settings” ranked as the primary benefit, a benefit that can only be realized with an integrated EHR that reaches across care settings.

Hospital-centric Support
The example of Lynn Green represents a classic scenario of healthcare delivered via an outmoded model: one patient, one physician, one encounter. Each physician treating Lynn has a system that recognizes a one-to-one relationship between her and her doctor. The systems do not recognize her dependence on the many specialists, clinics and ancillary healthcare community members involved in her treatment.

Under the new model, the hospital would form the center of IT support that allows communities to automate in the way care is delivered: Primary care physicians refer to specialists who refer to other specialists and to hospitals. The hospital makes best use of its existing IT assets for the benefit of the patient. Also, this model shifts the burden of IT expertise and expense from the physician to the hospital, saving financial resources and increasing productivity. No matter which member of the healthcare team treats a patient, the information record resides with the hospital and is available for every treating provider.

The hospital provides integration and connectivity support. It connects the physician’s office with the inpatient setting and with payers, auxiliary healthcare providers, pharmacies and extended care providers. Shared data is consistently captured and used to support a wide variety of applications, such as chronic care management, reporting and, ultimately, quality-based reimbursement models. It also can integrate all clinical users, not just physicians, and support vital financial operations required to maintain profitable physician practices. It can create a vital linkage between financial and clinical processes to make sure that the right data is available for billing, collections and reporting.

Hospital IT systems also can offer new, secure communications solutions that allow independent physicians without a common shared IT infrastructure to share information via a Web-based platform. Once full-scale healthcare information communities are created, physicians can more easily start the electronic information-sharing process.

Hospitals can provide a powerful platform for incorporating consumer-driven healthcare applications. As consumers are increasingly required to manage information about their healthcare, both clinical and financial, they must be brought into the information network. Hospital-centric IT would support consumer queries about treatments, diagnoses, managing chronic illnesses, invoices and even electronic payment infrastructures to pay their increasing share of healthcare costs.

Many different models are emerging to help make EHRs a reality by 2014. Clearly, a number of innovative solutions will evolve based on a variety of needs. Today’s second wave requires a pragmatic, affordable approach.

A good start is a community-based information exchange that includes the hospital, staff physicians, affiliated physicians, clinics, auxiliary members of the health team and financial partners, all sharing a common platform to exchange information.

The real need today is to automate the entire healthcare community by first complying with emerging standards. It is time that we, as an industry, work together to meet the needs of the second wave and to make EHRs an affordable reality.

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