Curbside Consult with Dr. Jayne 10/3/11

Last month I mentioned that the AMA had recently released its 2010-2011 Health Care Trends Report. The report’s “Science and Technology in Medicine” section includes items summarized from other sources, including MGMA data. Surprisingly, MGMA noted that independent practices were “more likely to have fully implemented and optimized EHR systems than hospital-owned practices.”

They noted that nearly 20% of EHR-owning independent practices felt they had optimized use of their systems, while another 50% had completed implementation and were moving to the next stage. In contrast, one-third of owned practices were still in the beginning stages of EHR adoption.

As far as quantifying how many physicians are using the system, only 43% of hospital-owned practices reported that all physicians used the system, where 72% of independent groups claimed that all of their physicians used the system.

I’ve spent a significant portion of my career toiling in the CMIO trenches, including oversight of ambulatory EHR implementation. Although this was largely in hospital-owned practices with employed physicians, I’ve had experience with private practices under hospital-subsidized arrangements as well as truly independent physicians. I’ve definitely noticed a difference in how the two groups do with EHR adoption and have a couple of thoughts on why they’re different.

My first theory involves the idea of free will. In a typical independent practice, the physicians have to come to at least some kind of consensus prior to purchase of an EHR. They’ve often been active participants in the selection process and in determining how a system will be implemented. Physicians may be active in system setup and customization of workflow and template screens.

In contrast, hospital-owned physicians are generally told which EHR they’re going to implement, as well as when and how. There are typically limits on how much autonomy physicians have with workflow, and customization at the provider level is taboo. It may be the system’s way or the highway. It’s always easier to get people to do what you’re asking when they think it’s their idea or when some reward is involved. It’s awfully easy to rebel when someone is trying to force change.

Speaking of reward, my second theory involves having the proverbial skin in the game. Because employed physicians typically have contracts which include the EHR and implementation as part of their employment agreements, they’re not paying much (if anything) out of pocket for the transition. Often employed groups are committed to keeping their physicians’ compensation stable as an EHR is implemented. Those physicians aren’t really incented to rapidly adopt or to change behaviors.

My colleagues who have had to pay their own IT bills (many of whom can also tell you exactly how much they paid for their EHR systems, down to the penny) have a different view of things. Trainers report that independent physicians are less likely to skip training sessions and tend to be more engaged. I’m sure those value-conscious providers know how much they’re paying for training hours and also how much they’ll be hurt if they can’t return to full productivity as quickly as they’d like.

My final theory revolves around the glacial speed of decision-making within hospital-owned practices. Physicians have given up a degree of autonomy (often for good reason – they’re lured by the promise of practicing medicine without having the pressure of dealing with staff, OSHA, CLIA, credentialing, vendors, and other distractions). Decisions are made among multiple levels of mangers, regional administrators, and hospital presidents.

There are often meetings to discuss the meeting before the meeting, not to mention the obligatory meeting after the meeting. Committees (and subcommittees, action groups, and departmental fiefdoms) have to sign on prior to things actually being decided. The ability to move forward with EHR adoption in a nimble fashion is seriously compromised. Each time the cycle repeats, adoption declines.

For those of you in the ambulatory arena, what’s your theory? E-mail me.

E-mail Dr. Jayne.