Schiff writes, “I have experienced firsthand the benefits and challenges that come with taking what is a ‘leap of faith’ and completely changing not only the documentation of care, but the very mechanisms by which care is provided and communicated.” He continues, “Ultimately, however, the future of care is dependent upon these challenges.”

Schiff writes, “It’s only by joining electronic health record technology with voice recognition that we can ensure patients are able to fully understand and participate in the digital care process” (Schiff, Huffington Post, 2/1).

Above article publish on http://www.ihealthbeat.org/articles/2010/2/2/opinion-physician-ehr-adoption-key-to-patientcentered-health-care.aspx

North Shore Hospital System on Long Island in New York recently announced that it will pay an incentive of up to $40,000 to each physician in its network who adopts its electronic health record (EHR) — paying 50% of the cost to physicians who install an EHR that communicates with the hospital and 85% of the cost if the physician also shares de-identified data on the quality of care.1 This payment would apparently come on top of the $44,000 incentive that the American Recovery and Reinvestment Act of 2009 (ARRA) has authorized Medicare to pay each eligible health care professional who uses certified EHRs in a meaningful manner. “Meaningful use” is still being defined, but the overarching goal is to improve the population’s health through a transformed health care delivery system with the use of EHRs to improve local processes, foster quality measurement, and increase communication. North Shore’s announcement is a sign of the continuing acceleration of EHR adoption by physicians’ offices2 and hospitals.3 Support for information systems is exempted from the Stark amendment to the Omnibus Budget Reconciliation Act of 1989, which prohibits hospitals from offering physicians incentives for providing referrals or admissions. The exemption for information technology acknowledges that the likelihood of additional referrals may be part of the motivation for hospitals to form closer links with community physicians through EHRs. Another benefit to hospitals from supporting the use of EHRs by physicians who are linked to them by geography, academic appointment, or practice pattern is the enhanced ability to manage the quality and outcomes of care. For example, if financial penalties and incentives are to be imposed on the basis of rates of readmission, then the more closely aligned a hospital is with the physicians who provide its patients’ postdischarge care, the greater the benefits it will reap.

The cost–benefit calculus behind physicians’ adoption of EHRs is also changing. Financial incentives are one element. The prices of EHRs have come down as the volume of software licenses being sold has increased. A second factor is that the time investment associated with data entry, which has long represented a major obstacle to adoption, has been reduced as systems have improved in performance and become more flexible with regard to individual preferences for data entry, including free text, templated data entry, dictation, speech recognition, and freehand graphic input. System usability has also improved, thanks to competition and customers’ resistance to cumbersome products. Third, the addition to EHR systems of capabilities beyond documentation, including coding functions, the ability to create and export bills, the automated creation of consultation and patient letters, electronic prescribing, and task tracking, now translates into greater time savings for users. And a fourth factor is the increasing emphasis on quality of care, since payment for quality requires documentation of quality.

Other trends favoring EHR adoption include the emerging consensus that alignment of hospitals and physicians is necessary to provide higher-quality care and service for patients as they move among providers and traverse levels of care, as well as the recognition that information transfer is an important component of care given by multiple providers. Younger physicians — and some older ones — are more comfortable and function more efficiently and effectively in an electronic-information environment than in a world of paper records.

Some obstacles persist, of course. EHR products remain expensive to install and maintain — cost issues that should not be underestimated. The decision by North Shore to provide a financial incentive as well as the software license suggests that many physicians still do not believe that current-generation EHRs will offer a return on investment directly to physicians.

Wide dissemination of EHRs requires public trust. The sharing of patients’ information — which has been common practice for decades for the purposes of billing, treatment, and public health — has come into the public eye because of the risks associated with vastly expanded sharing and the newfound ability to easily and quickly transfer many patient records simultaneously. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) created a framework for defining privacy, breaches of privacy, and penalties. The ARRA further defined privacy breaches and increased the penalties for them. One of the challenges to setting policy in this area is that electronic privacy and its relative importance are still being defined. The capability of providing a secure electronic environment for patient data — like the capability of providing reliable data storage — is beyond the reach of most individual physician practices. Truly secure and reliable EHRs are currently feasible only for larger organizations with centrally supported technological capabilities. This may be one reason why the rate of adoption has been much higher among large practices (see graph).

Rates of Adoption of Electronic Health Records According to Practice Size.

The percentage shown above each bar is the proportion of physicians who work in a practice of the given size. The green portion of each bar represents the percentage of physicians in a practice of a given size who have adopted at least basic electronic health records (EHRs), and the yellow portion represents the percentage of physicians who have not adopted EHRs.2 For each practice size, the percentage of physicians who have not adopted EHRs relative to the total number of physicians in practice is shown at the bottom. Physicians in the smallest practices account for more than 50% of those who have not yet adopted EHRs, whereas physicians in the largest practices account for only about 3%.

Exchanging information requires that EHRs share common standards. Work is ongoing at organizations for standards development and facilitation such as Health Level Seven (HL7), which have been providing practical standards for decades. The ultimate in interoperability would be a single EHR for all health care providers, but the disadvantage of this model would be a loss of competition among vendors — a factor that has presumably contributed to increased usability and lower cost. Moreover, interoperability among disparate EHRs may actually increase competition and innovation if it makes it easier for health care providers to change vendors by populating a new system with an old system’s data. Innovation is not predicated on competition alone, however. Increasing funding for EHR research and development — as opposed to implementation and evaluation — may produce evolutionary and revolutionary improvements in EHRs.

The next major step in EHR deployment is a concrete definition of the requirements — in terms of meaningful use, information sharing, and reporting of quality measures — for physicians to receive ARRA incentives. The federal Health Information Technology Policy Committee has submitted recommendations4 to the National Coordinator of Health Information Technology; the Centers for Medicare and Medicaid Services published draft rules on December 30, 2009, and this publication will be followed by a period for public comment before a final set of rules is issued. Clarity on federal incentives for physicians to adopt EHRs will allow these incentives to be aligned with those offered by state governments, provider organizations, and commercial payers. Poorly aligned incentives may have unintended consequences, such as increases in health disparities or incentives for specialty-specific silo systems.

Electronic interaction between hospitals and physicians is just the beginning. Patients are also interacting electronically with the health care system, exchanging information with providers through secure patient portals and patient-based health records. More active transactions, such as remote case management by nurses for patients with chronic diseases,5 may occur through telemedicine. Some possibilities that will be advanced by phys   icians’ adoption of EHRs include the use of cell-phone technology for messaging, the capability of moving data from home monitoring devices to cell phones and upstream to EHRs, yet-to-be developed software capabilities that will allow EHRs to manage these uploaded data streams within clinical workflows, and the effective provision of out-of-office care.

Above article publish on http://healthcarereform.nejm.org/?p=2839&query=TOC

The latest findings suggest that EHR adoption has increased significantly during the past decade, up from 18% in 2001.

Survey Details

For the report, NCHS interviewed 3,200 physicians and sent mail surveys to an additional 2,000 doctors (Walker, MedPage Today, 1/8).

Researchers used the surveys to estimate that 43.9% of office-based physicians were using EHRs in 2009. Of those, they note that:

• 20.5% reported having EHRs that included basic features such as clinical notes, laboratory results and prescription orders; and
• 6.3% reported using fully functional EHRs that included additional features such as digital reminders, drug interaction alerts and electronic order transmissions (Merrill, Healthcare IT News, 1/11).

2008 Survey

In 2008, the survey found that:

• 17% of physicians had basic EHRs; and
• 4.4% had fully functional systems (MedPage Today, 1/8).

The report notes that the number of physicians using any EHR system increased by 18.7% between 2007 and 2008. During the same period, the number of physicians using basic systems increased by 41.5% (Healthcare IT News, 1/11).

Above article publish on http://www.ihealthbeat.org/articles/2010/1/11/43-9-of-officebased-physicians-used-ehrs-in-2009-cdc-finds.aspx

PwC’s Health Research Institute publishes the annual report on key issues in the health care industry (Manos, Healthcare IT News, 12/17).

For 2010, the report contends that the health care industry will move toward:

• Adopting electronic health record systems and other health IT tools in order to qualify for federal incentive payments;
• Advancing telemedicine through the integration of health care technologies and broadband connectivity;
• Attaining greater electronic connectivity and stability as physicians develop closer relationships with health systems; and
• Expanding alternative care delivery models such as home health services, telehealth and remote patient monitoring.

The report also noted that the coming year likely will focus primarily on curbing costs and creating greater value in the health care system. Other emerging issues will include adapting to new health care regulations and tightening fraud protections, according to the report (Clark, HealthLeaders Media, 12/18).

Above article publish on http://www.ihealthbeat.org/articles/2009/12/18/report-ehr-adoption-telehealth-among-top-health-issues-in-2010.aspx

EHR adoption and finances remain the top challenges facing medical practices, according to a new survey from the Medical Group Management Association.

For the second year in a row, medical practice professionals sounded off to the MGMA about a variety of challenges faced while safeguarding their practices’ financial solvency.

The 2009 survey “Medical practice today: What members have to say” reveals the three top challenges of running a group practice remain the same as in 2008.

• Dealing with operating costs that are rising more rapidly than revenues;
• Maintaining physician compensation levels in an environment of declining reimbursement; and
• Selecting and implementing a new electronic health record.

After those top three concerns, the other priorities changed somewhat from 2008.

This year, respondents listed collecting from self-pay patients and those with high-deductible health plans and health savings accounts as the fourth-highest challenge. In 2008, the fourth-ranked challenge was recruiting physicians, which ranked sixth this year. Managing finances in the face of uncertain Medicare reimbursement rates rounded out the top five for the second year in a row.

“Medical practice managers have one of the most difficult jobs in healthcare,” said William F. Jessee, MD, the MGMA’s president and CEO. “Running a successful business that provides medical care is an incredibly difficult task in these economically challenging times. But the professionalism that MGMA members bring to their work enables them to persevere.”

The MGMA asked respondents to rate and listen to lead MGMA researcher James Margolis’ podcast. The organization also asked how the recession is affecting their medical groups and how they are responding.

Ranked by average score, the participants indicated the most probable effects of the recession on their practices are:

• An increase in uninsured patients;
• Improved billing and collections and/or denial management processes;
• Decreased revenues;
• Postponed capital expenditures;
• Operating budget cuts; and
• Staff hiring freezes.

Many respondents said they are experiencing the effects of the recession on their practices:

• 36.6 percent said they have postponed capital expenditures;
• 34.7 percent are seeing a rise in uninsured patients;
• 34.5 percent have implemented a staff hiring freeze;
• 33.9 percent have cut operating budgets;
• 33.3 percent have improved billing and collections processes; and
• 33.1 percent have witnessed a decrease in revenue.

“At their core, medical practices are small- to medium-sized businesses, and the recession has affected them in many of the same ways as other businesses,” Jessee said.

On the positive side, nearly 82 percent of respondents said there is a zero probability that their group will file for bankruptcy protection and nearly 80 percent said there is a zero probability their practice will close because of the poor economy.

The MGMA conducted the online survey Feb. 2-26, It received 2,077 responses, a rate of 13.4 percent.

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Successful electronic health record (EHR) adoption not only improves quality of care by making patient information easily accessible, it also provides valuable clinical decision support. In addition, organizations benefit from streamlined operations — enabling physicians to spend less time on charting and documentation, and more time engaging in face-to-face interactions with patients.

Despite these obvious advantages, however, many physicians are resistant to adopting EHR systems.

A number of factors account for this resistance. First and foremost, organizations are leery of the cost and disruption that can sometimes accompany the conversion from manual to automated processes. Second, a portion of older physicians — who often serve as the leaders in an organization — are typically less comfortable with new technologies than their younger counterparts. And finally, some physicians believe that taking the time to electronically document patient visits will negatively impact patient interaction because it means spending time in front of a computer screen rather than with the patient.

Kittitas Valley Community Health Information Network is an electronic information-sharing partnership linking 30 providers — about 90 percent of all primary care providers in the county — from seven locations. When we implemented our EHR system in 2007, we utilized several strategies that proved instrumental in overcoming anticipated obstacles and ensuring successful adoption:

1. Locate a physician champion. When identifying champions, we looked for those physicians who had a track record of adopting new technologies, were able to maintain positive attitudes despite occasional setbacks and, most importantly, were well-respected by their peers. These champions could clearly articulate the goals and enthusiastically promote the benefits of a fully functioning EHR system to other physicians — helping to encourage even initially skeptical providers to get onboard.
2. Set honest, realistic expectations for physicians and their staffs. The more complex and sophisticated an EHR system, the more challenges a practice might experience in the early stages of implementation. However, we found the potential productivity gains and cost savings ultimately outweighed any inconveniences. By ensuring that everyone understands that there will be a learning curve and that they will experience some growing pains on the front end, you can alleviate frustration and set a positive tone post-implementation.
3. Ask each location to designate a physician, nurse and administrative user to participate in several days of training with the EHR vendor. These “super users” were then available to help others navigate the EHR system, reducing the need for support while building staff camaraderie.
4. Prepare for the transition. In our case, each location went to an abbreviated schedule for two weeks — scaling back patient volume so that physicians and administrative staff would have adequate time to train on the new system. In hindsight, we would recommend that organizations allow a full month for staff to get comfortable and then gradually add back patient visits each week. For example, a practice might take four patient slots out of both the morning and afternoon schedules during the first week, three slots during the second week, two during the third week, and so on. Providing staff members with the opportunity to use the system while performing their daily routines enables them to learn at a comfortable pace.
5. Use a staged rollout. We did not do this during our initial implementation, but have used it several times with processes and changes adopted since. Within each location, two to three physicians, who were committed to the EHR system and willing to work through any stumbling blocks, were selected for initial implementation. Working with fewer physicians at the onset enabled the implementation staff to provide a strong support system, and helped ensure that any issues or concerns were resolved early in the deployment process. Once the first few physicians went live in each location, other providers were added two at a time. That way, each successive group of physicians could seek guidance from colleagues who were already using the system and could witness firsthand the successful utilization of an EHR system.

As an increasing number of health care organizations take advantage of the dollars offered by the American Recovery and Reinvestment Act to deploy EHR systems, it will become even more important to ensure timely and successful adoption of these systems. By setting realistic expectations among key stakeholders, identifying hurdles early and putting plans in place to proactively deal with any challenges that may occur, the likelihood of a smooth transition is significantly increased.

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