Giving a patient medications in the ER, having them pop positive on a test, and then withholding further medications because…
Being John Glaser 1/29/09
The current version of the Health Information Technology for Economic and Clinical Health (HITECH) Act, which is part of the larger economic stimulus legislation, will alter the HIT industry and the IT plans of our organizations.
For outpatient electronic health records, the Act puts some non-trivial money on the table. A provider who uses a certified EHR can get a maximum (through Medicare) of:
| $15,000 | In 2011 |
| $12,000 | In 2012 |
| $8,000 | In 2013 |
| $4,000 | In 2014 |
| $2,000 | In 2015 |
This totals $41,000. This will clearly increase interest in adoption and could represent a lot of revenue for a provider organization.
To get this money, a provider must demonstrate that they are meaningfully using health information technology. What does "meaningfully" mean?
- Using e-prescribing
- Connecting through HIEs to improve the quality and coordination of care
- Submitting information on clinical quality measures.
While we might be more or less clear about what e-prescribing means, clarification is clearly needed about what we mean by the second and third criteria.
It is anticipated that HHS will spend 2009 providing specifics and clarity about what providers have to do to demonstrate meaningful use. This means that most providers will have one year – 2010 – to finish EHR implementation and put in place the infrastructure, applications, training, etc. needed to get the as much of the incentive money as possible.
This is a tall order. And it means that providers should start moving now (if they aren’t already) even though the dust has yet to settle on the specifics.
John Glaser is vice president and CIO at Partners HealthCare System. He describes himself as an "irregular regular contributor" to HIStalk.
Mr. Glaser raises good points. But the greater issue is productivity. By most accounts, deploying a traditional EMR in a practice can result in each doctor seeing about 15% fewer patients…up to 15% of revenue is lost. Some say that is only the first year…but there is no data to substantiate that. If the impact is only 5% but is permanent…for a doctor that does just $600,000 per year in revenue, 5% means an annual revenue reduction of up to $30,000, or $150,000 over 5 years. That certainly negates the $41,000 the doctor receives from this funding, even if all the “meaningful use” criteria are met.
Traditional EMR and the functions required to be certified by CCHIT may be at odds with what most physicians want. They can’t be slowed down, they can’t afford long learning curves and training sessions that close offices for days. And many find it hard to use hardware devices and point-and-click templates while providing patient care.
EMR adoption will only get traction when these aspects of traditional EMR’s are minimized. That’s why a “hybrid EMR” may be the answer. Fast learning curve, high success rate, no productivity loss.
Funding should be aimed at what clearly works. Perhaps we should look closer at the market to see just what that is. There is no clear consensus (or landmark study) that suggests it traditional EMR.
Thank you for sharing and commenting. I’ve been looking for information that better describes motivations (incentives) for providers to adopt the “Health IT Shuffle” from paper to electronic records.
There are many who speak of the lack of “this or that” piece of the puzzle that purportedly will inhibit adoption of electronic records. There will be negatives as well as positives, but that only means we must quickly iterate through the process to achieve the goals of improved productivity in the practice (at lower costs) and improved patient outcomes (resulting from better information).
It will be tough, but we can prevail.
RE: criterion 3 in your post (submitting information on clinical quality measures): it always comes back to the difficulty in capturing data. Partners’ own Mass. General Hospital Psychiatry Dept. found outcomes measurement compliance jumped from 63% to 95% (over 50% improvement) when they started using a digital pen system to capture the results directly from paper forms. Disclosure: My company provided technology for that initiative.
With the Obama cash infusion, oft-cited #1 reason for not using an EHR (cost) will be de-fanged a bit. That may promote the old runner-up biggest problem to the lead position: poor usability and lost efficiency (depending on who you ask). But if we just throw more money at deploying systems that work poorly, we’ll have… more poorly-working systems. In the rush to cash in, I hope the industry won’t just throw checks at the familiar players and hope for the best.
The keyword here is “maximum” of $41000.00. In the most recent P4P program, last I read 60% of providers didn’t get anything, and those that did got an average of $600.00.
For this paltry, unreliable payment, you will need to buy a CCHIT-certified EHR which will cost you about $100000.00 in EMR, yearly updates, training, and hardware. You will also need to hire another staffer to do the required reporting and data gathering (i.e. another $30000.00). You will most likely need to change your workflow (i.e. see less patients, costing 3 less per day x 200 work days x $70 a visit = another loss of $42000.00 per year). And this is if everything goes right; if your office is one of the 20-40% estimated failed installations or one of the eventual 8% deinstallations, then you are totally at a loss- you lose your tens of thousands of dollars, and then you get NOTHING from Medicare.
This is why doctors don’t want EHR systems and don’t want HIT forced onto them by politicians that are beholden by vendor lobbyists. In particular, President Obama recently nominated Glen Tullman, CEO of the HIT outfit Allscripts-Misys Healthcare and a heavy Democratic contributor, to the position of his personal HIT advisor/czar. In the 2 years prior to Obama’s nomination Mr. Tullman contributed $144000.00 to Obama.
So we get HIT pushed on already poorly paid, overworked physicians. All for what? Increased quality? Yeah right. What is going to happen is that if Medicare continues to push HIT they will lose their providers en masse, many to retirement just when President Obama wants to bring on universal healthcare in the era of already large primary care provider shortages.
HIT will bring on the “perfect storm”…
Al
For citations, download my most recent PPT slide presentation, “HIT in the USA Under President Obama”, from my website at http://www.msofficeemrproject.com/Page3.htm.
A couple of corrections to what Dr. Glaser states. If you don’t get it ready by 2010 (gov’t fiscal 2011 I think), you do not lose the money completely, it just pushes out your start date for your first bonus. The text of the law as actually like “first payment year – $15,000”, etc.. What does happen is that if you wait too long, though, you don’t get anything, so you need to start somewhere between FY 2011 and 2015 to start receiving the bonus, and if you wait until after 2015 to qualify then you lose all the bonus.
Also, there is effectively a penalty provision where if you don’t have anything in place starting in 2016, you start losing about 1% of your total Medicare payments every year up to 5% max. So even if you miss the bonus, there’s pain awaiting you if you don’t join up.
In other words, this is unlikely to be “stimulating” because the capacity doesn’t exist to ramp this up in one year, but the other provisions will help build that capacity over time (e.g., regional training centers) and eventually it will drive HIT adoption by 2015 or so.
Of course, the cynic in me could point out that the e-prescribing incentives haven’t done much at all to drive that into providers’ laps, so I’m not sure how this will change anything significantly, given that the $41,000 won’t cover the costs of most EHRs (particularly the certified single-vendor ones that are required) and there’s a huge chunk of doctors who won’t be too concerned about getting 5% less Medicare payment in 2021, particularly because we go through an annual cycle where that is threatened and at the last minute changed. Most doctors over 50 now will be close to retirement by then anyway.
Were focusing on the economic benefit to the clinicians.
Should we not be focusing on quality and patient safety? Could we not call the economic stimulus something more noble, such as, Quality Stimulus? How can we get the Obama administration to align the ‘handouts’ with Quality Improvement?
I have always kept the business of health care well in focus, however, at the core, we as health care IT professionals are doing this to make care, “safer for patients and easier for clinicians”. Isn’t that the ultimate charge? Personally, I would not want my care provider to look at me as a math equation.
The confusion part about this is the seemingly conflicted definitions of certified EHR and qualified EHR. I am assuming that CCHIT wins-out and provides the “certification” criteria. Is this the same read everyone else has?
Dr. Glaser – Do you believe you will need to CCHIT certify your EMR to qualify for the incentives?
>>> Should we not be focusing on quality and patient safety?
CCHIT-certified EHRs:
— HAVE NOT been shown to increase quality
— HAVE NOT been shown to increase patient safety
— WILL NOT decrease costs
— WILL make a great 3 page note whether or not you see the patient
In several studies they have been shown to do the opposite. In the past 3 months both JACHO and the US Pharmacopedia writtten about new data input errors brought on by EHR software… errors which can and will end in worse outcomes.
The HITECT Act is a purely political bill, “giving back” to those that have supported candidates that contributed heavily so that their EHRs are forced onto the physician population. Take the recent HHS secretary pick Dashle- just recently, on 8/2008 he gave 2 lectures, each paying $12000, one for GE and the other for Allscripts. Take Obama’s personal HIT advisor, Glen Tullman (CEO Allscripts)- his company donated $144000.00 to Obama to pay for this position of power just 2 years prior to Obama’s election.
The HITECT Act stinks and is a waste of taxpayer money. For more information, I have 2 slideshow sets that discusses these issues from my humble point of view (total ~130 slides of data which obviously Obama doesn’t have):
— “What is Wrong With HIT in the USA?” and “HIT in the USA Under President Obama”, http://www.msofficeemrproject.com/Page3.htm
— (for information on HIMSS member lobbying) http://www.emrupdate.com/forums/t/18099.aspx?PageIndex=1
Cheers,
Al