EHR Adoption for All – Now and Not Later!

The American healthcare system is fragmented, costly, hence underperforming. Despite significant islands of excellence, overall demographic measures position the U.S. far from the top of the developed countries, while health expenditure is the highest, and rising at an accelerating rate. There is a broad consensus that these trends are unsustainable and a change is mandated.  And while the type of change is still open for debate, the current law is threatened with repeal, and incentive payments may be cut or scaled down, it is generally agreed that health information technology (HIT) must play a significant role.

Despite playing a leading role in the development of health information systems and healthcare informatics research, such advances were slow to trickle down to the rank-and-file physicians in the US, and the adoption of electronic health records (EHR) lags significantly compared to other nations. Among the many reasons for this gap are lack of orchestrated effort and cost.  In the last several years we have witnessed a major change.  Government initiatives endorse and mandate the use of HIT across the continuum of care. The flurry of activities is accompanied by numerous new regulations that are difficult to comprehend and to comply with, especially by the providers that are supposed to implement them. They also result in higher development and implementation cost of new HIT systems and sustain a large and costly echo-system, thus maintaining a significant barrier to wider adoption.

Coupled with the technology initiative, there is also a move towards more comprehensive, integrated, community-based care delivery systems. ACO (Accountable Care Organization) is the new buzz word that describes a population-based, yet patient-centric, approach that promises to deliver cost-effective, comprehensive care. This has been long overdue. For many decades, healthcare delivery has been moving away from the community-based Primary Care Physician (PCP) model towards the partialist/specialist model coupled with healthcare consumerism.  Unique to the government’s ACO approach, is the combination of HIT and reporting measures to ensure quality of care and measure population health improvements. This initiative is attractive to practices and healthcare organizations since it promises to split any realized savings with the ACO.

Reviewing the draft regulations for ACOs, it appears that relatively small groups of physicians can form such an ACO. After all, this is a community-based approach, and a minimum of 5000 Medicare beneficiaries is required. However, a high bar is set by requiring appropriate administrative and clinical systems to be in place. Since only about 10% of physicians have even the most basic form of sanctioned EHRs, the cost of the required technology is likely to exclude many community physicians from participating in this community-based initiative.

The most basic building block of the HIT initiative is a compliant EHR whose data is standardized, potentially sharable, and can be queried in any meaningful way. The government EHR adoption incentive programs mostly address eligible providers. There are many physicians who are not eligible for participation. Thus, with or without incentives, the cost of EHR technology is still a significant barrier, most likely to postpone wide spread adoption, at levels such as in the Netherlands or Great Britain, for many more years. In turn, reduced levels of adoption will reduce and delay the effectiveness of many initiatives such as quality measures and ACOs.  As CMS and ONC ratchet-up the technology and compliance requirements, it is even more important to ensure faster and wider adoption of EHR technology by all physicians.

For effective delivery of coordinated healthcare in the community, there are many more participants than the physicians. Care coordinators, dietitians, social workers and many others are involved. Most are not eligible providers, but require supporting technological solutions that are not covered by current initiatives. It is quite likely that initiatives such as the adoption incentives and shared savings for ACOs will not cover the cost of the initial investment in technology required for effective population-based community healthcare. Perhaps it is the time to reassess our current approach, and focus more on wider adoption of EHRs and other first-line support systems for all providers (physicians and non-physicians) rather than follow, at this time, increasingly sophisticated schemes.

Gai Elhanan, MD is Chief Medical Information Officer at Halfpenny Technologies, Inc., a leading provider of clinical data exchange solutions.

What is the Right Connectivity Strategy for My Outreach Program

and how about them U of A Wildcats; I think they have a real chance this year in the NCAA!

Let’s review the environment. In many areas of the country, the penetration rate of physician of EHR/EMRs will drive from a lowly 20% to nearly 80%. This adoption rate is fundamental to the changes necessary to drive more effective and efficient healthcare. But let’s also be honest, too; it is also driven by funding from good old Uncle Sam. These physicians and physician groups will also want to comply with meaningful use criteria to qualify for stimulus funding to underwrite their costs of entering the new electronic medical record and health record era.

Meaningful use criteria, as many already know, in stage one, two and three begin and then accelerate sophisticated use of these systems. Early stages mandate the storage of discrete data like lab which comprises nearly 80 to 90% of the potential data within an EMR. Let also not be modest; laboratory diagnostic data represents probably the largest data source for diagnostic efforts of physicians. No bias here! Later stages mandate Order Entry so drug-to-dug, drug-to-disease interactions can be checked, and – drum roll, please – laboratory ordering which eliminates errors, reduces manual data entry, (there is a solid ROI behind clean orders and getting paid, but that’s another blog) and promoting quality and efficiency across the spectrum of care.

It only makes sense. Reality check number one; there are at least 375 different EMRs out there that we know about. We are learning about new ones on the pace of a couple per month. It is the Wild West, and it sort of feels like a there is a stampede coming over the hill doesn’t it?

If you are one of the 75% of hospitals laboratories in America with an outreach program or are a reference lab, you could be facing this stamped and that’s actually not the worse part. The worst part is they are all DOCTORS!!!!! (By the way, I hope our Chief Medical Information Officer does not read this blog, but I couldn’t help throwing that analogy in. You should see him when he is mad; he turns all sort of funny shades of red and purple! Anyway…) So, you are facing the stampede and wondering what’s the right strategy. Okay, let’s start with the options.

Option 1. My IT department controls an Interface Engine. Why can’t I just connect my orders and results to it, and let them connect to all the different EMR’s? Sounds simple, right?

Here are a couple questions to ask yourself.  Does your IT department have a lot of extra time on their hands? Have they already completed the ICD9 to ICD10 and 4010 to 5010 conversions? Are they prepared to handle the stampede? Can they deal with 375 different EMR systems? Are they good with doctors?

Option 2. I could use the physician access system/portal vendor I am currently doing business with! Sounds good, doesn’t it? If you are using one of them, they probably already have some connections out there. You have used them for quite some time. You like them or maybe not.

Okay, here are a couple questions to ask yourself. Are they prepared to handle the stampede? Can they scale to the demand you have and all of their other customer’s needs, too? Is EMR connectivity a sideline or are they really in this business with both feet? How is there service now? What might it be like when things get really crazy?

Option 3. Use the local HIE. This one usually comes from corporate. “We don’t want you wasting time building interfaces to EMR’s, because we have that covered with this here strategic relationship with the state’s HIE!”

Okay, you have got my pattern figured out. Here are some questions to ask yourself. Who is faster at building interfaces to my clients’ EMR, the HIE or my competitor? Can you afford to wait? Does the HIE initiative take care of the special requirements and workflow of lab order and result processing? How are the specimens going to be received? Will I be able to get paid with the information they are sending? How will MRN, Event, Episode or Account Numbers be associated with the order when transmitted to the LIS? Will the physician be presented with ask-at-order-entry-questions? Will an ABN get printed, signed and will the transaction contain an indicator of same? Is the HIE technology biased in any way that might prevent it from interfacing really well to all my customers EMRs?

(Note to reader: some HIE technology vendors are also EMR vendors and may not play nice with other EMRs or heavily influenced by your competitor. You get the picture. Their goals may not coincide with your goals to protect and grow your business.  At the worst case, you might want your own strategy in place or at least a backup!)

Option 4. Find a vendor who does this for a living: just this.

Big Finish – I hope you find the rather weak attempts at humor and analogy not too distracting. There is merit within each option and other’s I haven’t mentioned, but I pick on each pretty hard for a purpose. There is a are large demand for connectivity now and we expect it to grow.  Your strategy and options deserve careful consideration and potentially a multifaceted approach. If you already have a strategy, great, what’s your back up plan? If you don’t have a strategy, it’s probably time to start the process.  I welcome any and all comments, thoughts, concerns as long as they are positive and constructive, for the rest I’d like to introduce you to our CMIO; he’d love to hear from you!!!!!

(Note to reader: Our CMIO, Dr. Gai, is actually an incredibly smart, nice, and visionary individual. His face doesn’t turn red when he gets mad either. I’ve never actually seen him mad, and I enjoy his company. I just made all this up to see if he would read my blog!)