During the next five years, the Obama administration plans to ante up serious money to encourage doctors and hospitals to adopt certified electronic health record (EHR) systems. The bet is that the money will set up a foundation for health information sharing, a requirement for lowering the cost and improving the results of patient care.
Some big healthcare providers, such as Oakland-based Kaiser Permanente and Intermountain Healthcare in Salt Lake City, have won praise for the productivity gains they now enjoy from their own decisions to invest heavily in EHR systems prior to the Obama team's big push.
Considering the economic climate, you would think there would be widespread enthusiasm among the healthcare industry's rank-and-file to take the incentives and upgrade. Among big hospital chains that's generally the case, according to healthcare executives and managers.
What's worrisome though are signs of resistance among small and independently-owned healthcare practices, the backbone of the U.S. medical system, to put up with the costs and commotions of adopting new IT systems to manage patient data and provide clinical support.
"We are seeing a number large hospital systems that were once reluctant [about EHR systems] now starting to ramp up," says Dr. Kip Webb, who heads up Accenture's clinical operations practice from San Francisco.
But for small hospitals and practices with five or fewer doctors, there are big concerns about the fixed costs of running digital medical record systems and the disruptions to established ways of caring for patients. "Many look at electronic health record systems as interfering with their livelihoods," says Webb.
It's not that the incentives to promote investments in IT aren't generous. Doctors who invest in EHR systems and can show "meaningful use" in their operations starting in 2011 are eligible for payments of $44,000 over five years from Medicare and $65,000 over six years through Medicaid. Meanwhile, those who cling to paper record systems in many cases will see their reimbursements from government health plans shrink, starting in 2015.
Not so fast
What has some healthcare professionals on edge, particularly those working at small clinics, is what they view as an aggressive timetable for "meaningful use" benchmarks that must be achieved to qualify for funding. At the end of 2009, the Centers for Medicare and Medicaid Services published a set of meaningful use guidelines that range from basic data capturing metrics to more elaborate clinical support functions expected from certified electronic health record systems.
Back in September, during a comment period on the then-proposed regulations, some 40 percent of the hospital surveyed (70 out 165) complained that the 2015 deadline to meet all of the meaningful use guidelines was "too aggressive," especially given the weak economy. Dr. David Blumenthal, the national coordinator for health IT, seemed to concede as much. In a letter posted on his agency's Web site, he said: "To some providers, particularly small or already stretched physician practices or small, rural hospitals, the path toward meaningful use may still seem arduous."
In October, a survey by the Medscape Business of Medicine's Web site confirmed that concern. In a poll of 3,700 doctors who work in practices of fewer than 100 physicians, 37 percent expressed no plans to invest in or use an EHR system. That's a disturbing finding given that small, independently-owned practices in the United Statesprovide about three-quarters of all walk-in patient visits at clinics in the nation, according to the National Center for Health Statistics.For small practices, maintaining even a modest digital medical record system can be a high-wire act. "In order to implement EHR in your practice you're going to need servers; you need somebody to do back up, you need full time network connectivity; it's a big deal," notes Dr. Marc Overhage, CEO of the Indiana Health Information Exchange. Many practices in Indiana never make a successful transition to the digital world. "We still have a 50 percent failure rate of implementation," says Overhage.Yet big hospital chains, such as the North Shore University Health System that operates hospitals in the northern suburbs of Chicago, have the kind of scale and IT budgets to absorb the costs of going digital.
North Shore started investing heavily in its system back in 2001, and today has an annual IT budget of about $45 million. The hospital chain is also offering access to its EHR system to physicians affiliated with its hospitals but not on staff."If you look at the number of hospitals with 50 beds or under, it is really hard to do these things," says Tom Smith, chief information officer at North Shore. In fact, the penetration rate for EHR systems among hospitals with 100 beds or fewer is around 4 percent to 10 percent, says Dr. Webb with Accenture. "These hospitals in general are under tremendous financial pressure these days," he says. "A lot of hospitals are in the red operationally."
So what will it take to get smaller practices enthusiastic about the conversion? IHIE's Overhage believes it may take a "disruptive technology," perhaps "a good enough EMR that is Web-based," he said. "Then all I need is hardware and an office network." John Thomasian, director of the National Governors Association's Center for Best Practices, said he thinks most small providers will eventually get on board, but it may take "pressure by the state and by their own plans" to do so.
Add it all up, and this much seems clear: The digital transformation of U.S.healthcare will be a fits-and-starts process that will carry on well into the next decade. The financial incentives being offered to smaller practices will help. But succeeding will be more about changing everyday ways of doing things, and that won't happen easily.
