Small Medical Practices Don’t Find EHR Adoption Meaningful
Unhappy Camper (Vol. 1, Issue 12)
InformationWeek, an IT journal, presented a very interesting article Tuesday available at: http://www.informationweek.com/shared/printableArticle.jhtml;jsessionid=... entitled “Small Medical Practices Don’t Find EHR Adoption Meaningful”. Richard Gibson, president of the Oregon Health Network gave testimony before the US Congress about the many reasons why EHR adoption is difficult, at best, for the small medical practices. Gibson stated that, “CMS has estimated the five-year cost of acquiring and electronic health record for an eligible professional to be $94,000. EHR incentive plans through Medicare and Medicaid will cover 47% to 67% of that estimated cost.” It is definitely recommended reading.
Now, believe it or not, I am actually a proponent of EHR adoption, but I will continue to rant against the bureaucracies that spawned EHR and promote it unrealistically with Meaningful Use dollars. Yes, Meaningful Use has the potential ability to change physician behavior by showing real data of how adherence to quality measures can improve patient care. But Meaningful Use may also have an unspoken agenda in the social realm--that of controlling behavior to change how physicians interact in setting up medical practices. It used to be said that “Getting physicians to agree is like trying to herd cats—it can’t be done.” But, like an open can of tuna, all these physicians will apparently come running to feast at those Meaningful Use dollars.
I remember being told by some of these authorities in the 1990s about how the solo physician and small medical practices were doomed, and we had all better consolidate into larger groups or face extinction. Their reasoning was at the time that health insurance companies would favor larger groups and cut out the participation by soloists or small groups. Part of the underlying message was that we would all move to a system of capitation payments. The other part of it was that insurance companies could not negotiate effectively with such soloists or small groups and could cut ‘better’ deals with larger ones. It seemed that every medical conference I attended during that decade presented some featured speaker on those inevitabilities.
Those of us who saw through the diatribes and continued to practice solo or in small groups actually made out quite well, thank you. The hospitals all seemed to have heeded the message though, leading to the mass of medical conglomerates we witness today. Capitation never really made that big an inroad within our little state. Remember the Prudential & Travelers threats to disempanel us all if we did not accept capitation? I do. Along with US HealthCare and the others, the insurance companies eventually dropped their ideas. For the time at least, we had won.
Now up north, MassHealth may bring capitation back due to budgetary concerns forced on by their legislature. But so might the nationwide push to adopt EHR. The expense and ongoing efforts required of EHR really do tax the small medical groups severely. We cannot as easily afford the enormous start up costs. We cannot afford the full time IT support staff and ongoing related expenses that EHR requires, and are largely left alone to handle such daily things as computer boot-up errors or network failures, things they never taught us in med school, and really have no place in the curriculum to begin with.
So most of us must be left paying, and paying a lot, to the bevy of independent IT support companies that have grown to support the health IT market. I suppose there are certain economies of scale in joining together through organizations such as RI-REC to purchase such IT support and to brainstorm the common problems encountered. But the complexities and cost of EHR adoption will remain profound. And this time around, I truly do fear that those pressures have returned for small medical groups to consolidate into much larger ones, from a different angle to be sure, but by the same bureaucracies that threatened us all in the 1990s. And capitation, with its inherent abilities to, at whim, lower payments per patient will not be far behind
Implementing HIT should be done for the right reasons. Meaningful Use dollars should not be the key. I will be glad to accept the money, but I cannot imagine that physicians are lining up to do it for the Obama money. We have had a significant ROI from HIT, I expect that anyone can achieve a "meaningful" ROI if they do it well. There is a lot of funding out there - decreased malpractice rates, increased insurance fee schedules for those with EHR's, P4P programs, etc. These are viable options to improve revenue stream if you have an EHR. Aside from the outside funding sources, there is remarkable improvement in efficiency achievable in most (if not all) facets of running a medical practice - the doctor-patient interaction included. Those efficiencies contribute to the ROI, both financially and from a professional satisfaction perspective. Some may balk at the comment that the doctor-patient interaction can improve. With an EHR, health maintenance issues are on alerts, test results are organized and accessible, outstanding tests are clearly identifiable - these are some of the reasons that I can relax and interact easier with patients while in the office rather than scrambling to search through a paper record for notes/lists/test reports to piece together what may be due (or overdue). Also, the latest addition for our practice is the patient portal, an electronic tool that has been a win-win-win for patients-staff-providers.
I don't see small practices (solo, smaller partnerships) doing it on their own either - some may, but most probably won't. If I were doing it alone I would look to team up with other smaller offices to do HIT together. If you prefer to keep separate organizations, not merge practices altogether, I would expect (hope) that there would be a way to do some sort of venture with regard to HIT. Research and sign up with the same EHR vendor, seek out IT support together, etc. I think the REC is offering a great service - the consultants are likely available to small practices for a rate, probably an affordable rate. There are definitely up-front costs, but the ROI should be there if done correctly. The REC can help smaller practices get it done - I see the REC's primary objective as helping the small practices since the larger practices will have pooled resources to get it done.
I try to follow guidelines and standards of care the best I can. In saying that, I want to add that I receive reports on my patients from other providers, out of state, walk-in clinics, other PCP's on a frequent enough basis to see that there are others clearly not practicing sensible medicine. I don't want to categorize any particular type of practice or state, but will give a couple of examples. If you see a patient with a cold (and document that that is what you think it is prior to ordering tests), how can you justify running labs that include CBC, CMP, TSH, FT4, A1C, sinus x-ray, rapid strep test (that is negative) and provide Levaquin? (you guessed it - in a setting that gets reimbursed for in-house testing). If you are seeing a 94 y/o with chronic, stable CAD (notes indicate chronic, stable angina without change), how can you justify doing an ECHO, standard ETT, separate ETT Mibi and Carotid Duplex? (you guessed it again - in a setting that gets reimbursed for in-house testing). Not only that, how can you justify running these same tests yearly? Just to add - this was done despite the fact that the patient's primary cardiologist is in his home town, not where he visits for a few months a year to get away from the cold - and the provider doing all of these tests doesn't communicate with the primary cardiologist. Mind you, the same 94 y/o that convinced the urologist to continue to do PSA screenings. How many have heard from patients "let's get some tests, cost is not a factor, I have Medicare." I don't want to discount that there are excellent practitioners in smaller practices around the country, and that some in larger groups may be practicing outside standard of care. However, I do see merit in computerizing practices, incorporating standards of care into the EHR's so they are available at the point of care, doing peer review, looking at quality reports, etc. Smaller practice or not, we need to get the national health care system computerized and get it done right. Those that want to practice outside the standards of care should be held accountable. I know this is a slippery slope, if taken to the extreme we'll never have innovation, new approaches, etc. There is absolutely merit to the "art" of caring for patients, but there is a substantial amount of medical care that is "science" based upon research and sound guidelines. I am not suggesting that we all work in the same way at all times, but we have to reign in those that are clearly outliers with respect to sensible, cost-effective, medicine. If you think additional resources are needed for a patient, justify it, don't do it because the patient pressures you, or because it improves your own cash flow. The current administration's efforts are one approach to get it accomplished. It may not be the ideal approach for all, but providers should find a way to get it done.
Using an EHR? Yes - eClinicalWorks
Disclosure: Owner/practicing partner of Aquidneck Medical Associates, Inc. Contracted as the Case Management Physician Advisor at Newport Hospital (a Lifespan affiliate) and as an advisor for BCBS of RI to help facilitate HIT integration in community practices