May 2009 FEATURE ARTICLES

Thought Leaders

From Talk to Walk

By John C. Joe, M.D.

Healthcare industry and government leaders have been talking about electronic medical record (EMR) systems and their vast potential for decades.

However, many professionals at provider organizations are afraid that the technology won’t live up to the clinical, operational and bottom-line benefits hyperbole. Worse yet, many healthcare organization leaders simply don’t want to — or don’t have the wherewithal — to plunk down the cash to implement an EMR.

As such, EMR adoption remains relatively low. I believe real progress will occur only when the industry makes healthcare leaders more comfortable with EMR decisions and the bottom-line impact they’ll have.

Clearing the Start-up Cost Hurdle

To start, the initial cost — often cited as the No. 1 barrier to adoption — needs to be made easier to swallow for healthcare organizations. Fortunately, there is movement in the industry to address this initial barrier. Simply consider the following: The Certification Commission for Healthcare Information Technology (CCHIT) has identified 90 public and private programs designed to subsidize the adoption of healthcare IT. According to the CCHIT Incentive Index, these programs offer more than $700 million worth of incentives to all types of healthcare organizations through a variety of government and non-government initiatives.

In addition, Stark law exceptions also are making it easier for large systems and hospitals to corral physician practices into their healthcare IT initiatives. With the U.S. Department of Health and Human Services’ Stark law technology exception and IT safe harbors to the anti-kickback statute, hospitals are explicitly allowed to subsidize as much as 85 percent of the upfront and ongoing costs of EMR software for physicians. Under the regulations, hospitals only can subsidize an interoperable EMR that can communicate with a wide range of systems, not just those of the subsidizing hospital. Products that have earned a stamp of approval from CCHIT comply with such standards.

Some states are forging ahead and mandating the use of healthcare IT. For example, Minnesota now requires hospitals and healthcare providers to have interoperable EMR systems in place by 2015. Minnesota also is requiring that all providers, group purchasers, prescribers, and dispensers establish and utilize e-prescribing systems by 2011. Massachusetts has tied implementation of healthcare IT to state licensure. Its legislation calls for hospitals and community health centers to implement and use a full EMR system by 2014 and requires hospitals to utilize a computerized physician order entry (CPOE) system by Oct. 1, 2012.

State Government Efforts

According to "Health Information Technology, 2007 and 2008 State Legislation," a report from the National Conference of State Legislatures, state strategies for achieving a critical mass of healthcare IT adoption must address the current misalignment of incentive in the healthcare sector. The bulk of benefits from EHRs often accrue to payers, while providers are responsible for purchasing and maintaining the systems.

Some states are, in fact, encouraging EMR adoption by offering financial incentives such as: linking medical school loan repayment to healthcare IT competency (Massachusetts SB 2863); offering tax credit for providers who purchase EMRs (Wisconsin SB 40); offering incentive payments for providers who use EMR systems (New York SB 6808); and, providing medical assistance program reimbursement for home and community services delivered via telemedicine (Colorado SB 196). But the industry, as a whole, still must do more.

For example, payers must actively encourage technology adoption. Current Medicare payment policies act as a disincentive for physicians to acquire and use healthcare IT. Separate payment for clinically-appropriate e-mail and telephonic solutions, add-on payments for office visits supported by EMRs, and reimbursement for care management services supported by IT would, indeed, help healthcare organizations get into the act — according to a call for the realignment of incentive issued by the American College of Physicians.

Priority Criteria

Once financial obstacles are cleared, the road to EMR success will be much easier to realize. Healthcare leaders, however, will still have to make informed choices — to avoid the much-feared buyers’ remorse. As such, leaders should choose systems that:

Offer the ability to access data and communicate across inpatient and outpatient settings. For example, an affordable, integrated system that offers doctors access to inpatient and outpatient data from a single database can enable hospitals to strengthen their ties to community physicians and realize increased inpatient and outpatient volumes.

Are easy to use. For many years, EMRs have been cast aside by clinicians simply because they are too difficult to use. With systems that are built with physician needs in mind, gaining clinician buy-in shouldn’t be difficult.

Hospital leaders should work with physicians to more accurately define their EMR needs and determine the relative importance of various clinical functions such as decision support, drug interaction checking, e-prescribing and physician documentation.

In addition, leaders should assess how an EMR can improve hospital finances and operations. A truly useful EMR must facilitate charge capture, coding of services, compliance with regulations, pay for performance reporting, quality and outcomes improvement, and risk management.

Are easy to maintain. The earliest EMRs from more than twenty years ago were mainframe-based applications. Surprisingly, many popular EMRs on the market today are still run on mainframes. Most newer products are based on client-server architecture, requiring expensive "server farms."

Aligning Incentives, Implementing IT

Web-based systems, on the other hand, can be hosted within a hospital’s firewall or at a third-party data center for economies of scale and support. Additionally, no client software is needed except a current, standard operating system and Web browser. As a result, hospitals can run Web-based systems without having to dedicate human and financial resources toward system upkeep.

In essence, what’s needed to turn the EMR promise into a reality is the alignment of initial and ongoing financial incentives and the implementation of technology that actually helps organizations easily accrue the many benefits associated with clinical automation. When all of these elements come together, healthcare organizations can purchase their EMR solution, implement, and realize significant clinical, organizational and bottom-line benefits.

John C. Joe, M.D., is assistant professor for Family & Community Medicine at Baylor College of Medicine, and chief executive & medical officer of Prognosis Health Information Systems. Contact him at jcjoe@prognosishis.com .