April 2009 Issue

10 Tips for Making the Transition

AN ELECTRONIC MEDICAL record will very likely be a part of your practice sooner rather than later. Here are 10 tips for making the transition to paperless as effortless as possible:

1. Make sure you have 100 percent affirmation and cooperation from all practice partners to commit to the installation. It’s too traumatic an ordeal to start out with any ill will or second thoughts.
2. Upon making an EHR software purchase, read the educational materials you’re given, listen to the training sessions—and practice. Then practice a little more. This isn’t like upgrading your canned waiting room music service or installing computers with color monitors. One doctor calls EHRs “the most radical change in medicine since public sanitation, the development of the hospital, antibiotics and the nursing profession.”
3. Don’t have a negative attitude. It will only make the experience worse.
4. Assign a principal decision-maker to establish timelines and finalize protocols. Toes may be stepped on, but everybody needs to focus more on the practice goal of a successful EHR installation than on their own parochial concerns.
5. Make sure that decision-maker establishes an achievable timeline. Good, but unrealistic, intentions can make everyone’s life really miserable.
6. Dedicate adequate time for researching competing systems. You’re way better off installing the right system 60 later than planned than the wrong system on time.
7. Establish a drop-dead “D-Day” when all records going forward will be entered into the EHR only. No. Questions. Asked.
8. Schedule light for first week after start-up, and try to make it part of your software agreement that you have continuous on-site support for the first three weeks of the implementation. Assume there will be glitches.
9. Make sure you understand your practice’s workflow, and remember that different specialties have different needs, and different patients need different levels of support. The system that worked so well for your colleague may not be what your practice needs.
10. Make sure staffers are all on the same page. They can make or break the process.

EVERYONE IS EXCITED about the healthcare IT incentives in President Barack Obama’s economic stimulus package. Organized medicine is abuzz, and the educational offerings are already proliferating. If there’s a physician anywhere in Southern California six months from now who doesn’t know how to get his or her hands on a chunk of cash, it’s not the county, state and national associations’ fault. And the software companies, naturally, can’t wait for doctors to upgrade their electronic health records—or buy new ones—in an effort to take advantage of the cash that will soon be available. And the early adopters and EHR fans are tickled to death to get some of their investment back, and they’re looking anxiously forward to the day when their less-technology-friendly colleagues join them in the 21st Century.

Everyone is excited about the incentives, it seems, except the holdout physicians who are the very people expected to take the bait. Doctors appreciate the effort, and they know that an EHR-only world may be just a few years away. And, of course, nobody’s saying they’ll refuse to take the incentive payments. But the amount of the payments isn’t as jaw-dropping as many small practices and solo practitioners need for it to be to make them worth the expected hassle of transitioning to a paperless office, and besides, the incentive program misses the point of their hesitation, many doctors point out. The cost can be huge, of course, but it’s not the reason so many physicians have yet to take the digital plunge. The deeper problems for those providers are questions about interoperability, about standards for coding and for data transmission, about ongoing technical support for expensive EHR products and more. Because so many of the details of the digital future as envisioned by the Department of Health and Human Services remain fuzzy, a lot of doctors are understandably reluctant to change the way they practice just for a few grand a year for the next few years.

Details, Details, Details
The financial details of the incentive program have emerged, and the bottom line is this: Medicare and Medicaid physicians stand to receive as much as $65,000 over the next few years if they can show “meaningful use” of a qualified EHR. If that’s not a big enough carrot, doctors who treat those populations may be motivated by the stick that accompanies the orange veggie. Providers who can’t show the required “meaningful use” by 2015 will start to see their Medicare reimbursement cut. What does “meaningful use” mean? That hasn’t been determined yet, although early word is it entails using an electronic record with e-prescribing capability that meets the Department’s current standards, connectivity to other providers and, of course, the ability to report its use to HHS. Pretty much what you’d expect. So far. What’s a qualifying EHR? That hasn’t been determined in detail yet, either. It must, generally, be able to trade information with other sources, support order entry by doctors and provide decision support. And it must contain demographic and clinical information.

Just about every aspect of the program except the dollar amounts and the timeline remains uncertain, to be figured out between now and 2010—with some details due by the end of this year—by a standards committee that will be convened by the soon-to-be-created Office of the National Coordinator for Health IT, or ONCHIT, in the lovely language of federal healthcare policymaking. There will also be changes to the Health Insurance Portability and Accountability Act. Action that defines a breach, for example, will be detailed and civil money penalties for violations of the Act will rise. Also, new restrictions on how the data are used will be imposed. As well, patients will be allowed access to an accounting of the disclosures involving their medical information if they want one. State attorneys general will enforce the Act under the measure.

Just about every aspect of the program except the dollar amounts and the timeline remains uncertain, to be figured out between now and 2010—with some details due by the end of this year—by a standards committee that will be convened by the soon-to-be-created Office of the National Coordinator for Health IT, or ONCHIT, in the lovely language of federal healthcare policymaking. There will also be changes to the Health Insurance Portability and Accountability Act. Action that defines a breach, for example, will be detailed and civil money penalties for violations of the Act will rise. Also, new restrictions on how the data are used will be imposed. As well, patients will be allowed access to an accounting of the disclosures involving their medical information if they want one. State attorneys general will enforce the Act under the measure.

Physicians can, however, avail themselves of as much as $44,000 over five years if they treat Medicare-eligible patients and if they’re not hospital-based. They can up their take by an additional 10 percent payment each year if they also work in federally designated Health Profession Shortage Areas. Payments start in 2011, or the first year a doctor proves he or she is using a qualified EHR in a qualified way. The plan is to pay $18,000 for the first year of incentive eligibility, $12,000 for the second, $8,000 for the third, $4,000 for the fourth and $2,000 for the fifth. But if you’re not on the bandwagon by New Year’s Eve 2012, it won’t be a Happy New Year. You get lower incentive payments, plus they stop in 2015, just like everybody else’s. If you still haven’t gotten on board, Medicare will cut your reimbursement by 1 percent, then by 2 percent in 2016 and 3 percent a year forevermore. Actually, the reimbursement cut can go even deeper, at the HHS Secretary’s discretion, up to 5 percent, if 75 percent of eligible providers aren’t using EHRs by 2018. Nurse practitioners and nurse mid-wives are also eligible for incentive payments.

Hospitals also qualify for bonus payments, but they’re paid separately from the direct-to-physician incentives. Hospitalbased doctors—anesthesiologists, pathologists and emergency department providers, for example—aren’t eligible.

Medi-Cal providers who are not also Medicare providers can receive up to $65,000 from 2011 to 2015, monies that will be paid directly through the various state programs. You make the Medi-Cal cut if your practice is at least 30 percent eligibles—that’s 20 percent if you’re a pediatrician. Doctors in Federally-Qualified Health Centers or Rural Health Centers qualify for incentives if 30 percent of their practices are “needy,” which means they’re eligible for Medi-Cal, SCHIP or sliding-scale fee schedules or are uncompensated care patients. Medi-Cal providers receive $25,000 the first year, then up to $10,000 a year for the next four.

Medi-Cal providers who are not also Medicare providers can receive up to $65,000 from 2011 to 2015, monies that will be paid directly through the various state programs. You make the Medi-Cal cut if your practice is at least 30 percent eligibles—that’s 20 percent if you’re a pediatrician. Doctors in Federally-Qualified Health Centers or Rural Health Centers qualify for incentives if 30 percent of their practices are “needy,” which means they’re eligible for Medi-Cal, SCHIP or sliding-scale fee schedules or are uncompensated care patients. Medi-Cal providers receive $25,000 the first year, then up to $10,000 a year for the next four.

HHS will spend $300 million to beef up the nation’s HIE network, both by establishing more of them and by expanding existing exchanges. Another $20 million has been set aside to ensure consistent standards across care settings. The Secretary gets to divvy up the rest of the separate $2 billion that’s available right now. Nothing’s set in stone, but priorities include interoperability standards and privacy standards development, bulking up the infrastructure required for more advanced and more widespread telemedicine and providing grant money to a variety of organizations to help even sooner than 2011 with the costs of transitioning to a paperless office. That’s all supposed to be wrapped up—including “meaningful use” standards and those for qualified EHR systems—by the end of the year. Physicians will report their EHR use by attestation, by submitting claims with appropriate coding, by responding to a survey or by other means that HHS has yet to devise. Reporting standards development is another ONCHIT function.

The Act is designed to provide the boost needed to move America into world-class status in the HIE rankings. So where are the hurrahs? Software companies are understandably happy. Indeed, tales already are making the rounds about doctors receiving calls and emails from EHR software vendors the very day the bill was signed. E-prescribing software leader OA Systems Inc., in fact, expects some spillover effect because of a generally increased focus on information technology, That and the fact that it’s offering a full practice management and EHR product in the near future. OA spokesperson Omar Ahmed says his company saw a nice uptick in business after e-prescribing got a federal government boost and expects the healthcare IT sector overall to see a similar bump soon. Individual doctors are also into the incentives. Some former physician hold-outs, in fact, especially those for whom cost has been a key obstacle to EHR adoption, concede they’ll take another look at a digital future because of the incentive payments.

On the Bright Side
Some doctors are excited about the change. And some have already jumped on the bandwagon. Stephen F. Tarzynski, MD, chief of service for pediatrics, West Los Angeles area, for the Kaiser Permanente Medical Care Program admits that when Kaiser famously switched to digital patient records a couple of years ago he had to make changes to his practice style. (See “At the Subatomic Level” on the next page).

Yet, Dr. Tarzynski embraces the change because he believes it is a move in the right direction. Advances in medical care aren’t supposed to make physicians’ professional lives easier, and they’re not supposed to lower their costs or facilitate their staying in the practice rut they established right out of medical school. Advances in medical care are supposed to improve patient care, and few of even the staunchest opponents of digital transition would argue that it won’t do that. “The good far outweighs the minor annoyances,” Dr. Tarzynski enthuses. “That’s the bottom line. It’s worth it because it’s good for the patient.”

The fact is, EHRs can be awesome. Doctors can illustrate points with graphics, sometimes even moving pictures, and can, with a mouse click, show in a graph the progression of a patient’s weight, say. That has a lot more impact than telling the patient, “Your weight fluctuates too much.” And the level of detail in lab results and other components of the patient’s individual record is legendary. EHRs are also invaluable to public health physicians, for population care management, and, in fact, to any physician who wants to know, for example, which pediatric patients are late for immunizations. Click once, then one more time to print a reminder card for each one. That’s why physicians who love EHRs really love EHRs. Plus, as Dr. Tarzynski adds, “in terms of coding and billing, Kaiser’s EHR has brought in income we were leaving on the table.”

But Worries Remain
Take the case of patient we’ll call “M” Mary is a 74-yearold< widow with multiple conditions including hypertension, sleep apnea, spinal stenosis, Felty Syndrome and more. Her secondary insurance is a Blue Cross-Blue Shield plan issued through the government that she receives as a benefit after the death of her husband. Mary was doing fine and living a healthy life as long as she received her medications.

Plus, there has been very little evidence to date that an EHR will either pay for itself or improve the quality of care. In fact, some studies demonstrate just the opposite—an EHR has little or no effect on quality of care. For example, a 2008 study published in Circulation, a premier cardiology journal, assessed the influence of EHRs on the quality of care of more thn 15,000 patients with heart failure and found “little improvement” compared with paper-based systems. Similarly, researchers from Brighan and Women’s Hospital and Harvard Medical School published an analysis in 2007 of some 1.8 billion ambulatory care visits and concluded that “EHRs were not associated with better ambulatory care.”

Many specialists are concerned about the dearth of EHR systems designed for them. Ophthalmologists, for example, often attach digital images to medical records. They must transmit perfectly; many products meet the high standards required for clear, sharp transmission of such specialized imagery.

Other concerns include issues surrounding data entry errors. For example, entering a patient’s weight incorrectly could cause the computer to calculate a incorrect prescription dosage. And what about service? George Ma, MD, an internal medicine specialist in Los Angeles implemented EHRs early on. But he’s only been able to do this because his son is an electrical engineer who maintains his computers via the Internet. “When I ask my colleagues why they don’t have EHRs,” he says, “they respond ‘because we don’t have your son!”

But a bigger concern for many physicians is obsolescence. And with good reason. ICD-10 adoption looms, for one thing, and it wouldn’t be the first time one software maker managed to convince the regulators developing the final standards to include details that its competitor’s product doesn’t feature. “That’s the nightmare scenario,” Ford says. Could it happen? “Possibly.” Indeed, the Healthcare Information Management and System Society says physicians should demand installation contract language to the effect that if future HHS standards exclude it from qualification as an acceptable EHR, the vendor will upgrade the system at no cost to the practice. “I do not use EHRs as I am wary of buying into something expensive that may change when a mandate comes down from the government,” says Los Angeles ophthalmologist Troy Elander, MD. “I understand we may all have to go with EHRs in the future, but I don’t see the need to jump in now. I can wait until a system has been chosen that will be universal.”

What’s Next?
That’s pretty much the consensus advice. Nobody’s advising doctors to slam the receiver when a software vendor calls and like it or not, EHRs are coming. But buying right now might not be a smart maneuver. Your time is better spent learning about what’s on the market and listening to the advice of your professional organizations (the CMA recently added a web page for HIT initiatives at www.cmanet.org/hit/) as to the emerging technological specifications of the incentive program—and then signing up once you know more about what is best for your practice.