Tip­ping point

Na­tion’s EHR use tops 50%, stage set for next steps

Modern Healthcare - - THE WEEK IN HEALTHCARE - Joseph Conn

The na­tion’s health in­for­ma­tion tech­nol­ogy sys­tem passed a ma­jor mile­stone last month when the govern­ment an­nounced that more than half of all U.S. physi­cians now use elec­tronic health records.

“We have reached a tip­ping point,” said HHS Sec­re­tary Kath­leen Se­be­lius, adding that adop­tion of EHRs is “crit­i­cal to mod­ern­iz­ing our health­care sys­tem.” That adop­tion was ac­cel­er­ated by the mas­sive $22.5 bil­lion govern­ment in­cen­tive pay­ment pro­gram in the 2009 stim­u­lus act.

Ex­perts who’ve been in­ti­mately in­volved in get­ting providers to this point say the govern­ment ef­fort has set the stage for the next wave of health in­for­ma­tion tech­nol­ogy de­vel­op­ment, which will build on the wide­spread dif­fu­sion of EHRs. “I be­lieve that get­ting to this 55% level is truly trans­for­ma­tive,” said Dr. Kevin Fick­en­scher, pres­i­dent of the Amer­i­can Med­i­cal In­for­mat­ics As­so­ci­a­tion, a pro­fes­sional as­so­ci­a­tion of health­care data users and re­searchers. This pu­bic in­vest­ment “is just a down pay­ment.”

On their own, EHRs al­low hos­pi­tals and physi­cians to gather health­care data. “The next true chal­lenge is in how to take the in­for­ma­tion that ex­ists and do the proper an­a­lyt­ics to cre­ate, not just in­for­mat­ics, but knowl­edge,” he said.

To­day, mov­ing a med­i­cal ad­vance from hy­poth­e­sis to a com­monly used best prac­tice “is a 17-year time gap,” Fick­en­scher said. “With com­put­er­ized data an­a­lyt­ics, we can nar­row that gap sig­nif­i­cantly.”

Dr. Robert Kolod­ner agreed. Kolod­ner spent 28 years at the Vet­er­ans Af­fairs Depart­ment and served as the sec­ond head of the Of­fice of the National Co­or­di­na­tor for Health In­for­ma­tion Tech­nol­ogy at HHS. “The next 10 years are re­ally go­ing to be ex­cit­ing. We’re go­ing to dis­cover some pat­terns of care that we didn’t even know ex­isted.”

One of those new care mod­els will be driven by data-em­pow­ered peo­ple, act­ing as con­sumers, us­ing mo­bile ap­pli­ca­tions and home­based health de­vices, Kolod­ner pre­dicted. “The in­fra­struc­ture is in place for there to be a con­nec­tion be­tween this per­sonal health space, what I gather on the de­vices about my weight and my diet, and link­ing that to data from the health­care de­liv­ery cen­ters … I think the shift is go­ing to be the pa­tient de­mand­ing that data be de­liv­ered to them for what­ever they want to use it for,” he said.

This shift to pa­tient-cen­tered­ness “cre­ates the op­por­tu­nity for a more mar­ket-driven health­care sys­tem, and hav­ing this a more per­son-cen­tered, rather than pa­tient-cen­tered health­care sys­tem,” said Kolod­ner, who is now vice pres­i­dent and chief med­i­cal of­fi­cer at Vi­Tel Net, a McLean, Va., tele­health soft­ware and ser­vices firm.

The role of govern­ment spend­ing in spurring EHR adop­tion re­mains con­tro­ver­sial. Dr. David Brailer, named by Pres­i­dent Ge­orge W. Bush as the first ONC leader in 2004, said he had “ev­ery con­fi­dence”—even with­out fed­eral in­cen­tives—that the na­tion could achieve the goal Bush set then, that ev­ery Amer­i­can should have a per­sonal elec­tronic med­i­cal record in 10 years.

“It was very, very clear the pre­cur­sor con­di­tions were ripe for this to do it,” said Brailer, now the CEO of Health Evo­lu­tion Part­ners, a San Fran­cisco-based ven­ture cap­i­tal fund. “I was just, ob­vi­ously, the gaso­line. The tin­der was in the room and we were just wait­ing for the match.”

If the 2014 goal is at­tained—and it is much nearer, given the halfway mark achieve­ment—a foun­da­tion will have been laid for the ad­vance­ment of pa­tient care through in­creased elec­tronic com­mu­ni­ca­tion and data an­a­lyt­ics.

Ac­cord­ing to the CMS, more than 291,000 or 55.3% of the 527,200 physi­cians and other health­care pro­fes­sion­als el­i­gi­ble to re­ceive fed­eral in­cen­tive pay­ments for adopt­ing a cer­ti­fied EHR have been paid. The cal­cu­la­tion is based on data from monthly CMS re­ports through April, just 28 months af­ter pay­ments un­der the pro­gram be­gan.

“There is no go­ing back,” said Dr. David Blu­men­thal, the third ONC leader and now pres­i­dent of the Com­mon­wealth Fund, a New York-based not-for-profit. “Both of my kids

are physi­cians in train­ing, and I can’t imag­ine them prac­tic­ing in an of­fice with­out an elec­tronic record sys­tem.”

Dr. Farzad Mostashari, the cur­rent ONC chief, said, “A year ago, there were peo­ple writ­ing sto­ries about, ‘Oh, yeah, the peo­ple (re­ceiv­ing in­cen­tive pay­ments) are the ones who’ve al­ready adopted. You aren’t do­ing any­thing new.’ It turns out that wasn’t true. We’ve come past the early ma­jor­ity and now we’re mov­ing into the late ma­jor­ity.”

The in­dus­try sell­ing EHRs has come a long way since 1979, when Ju­dith Faulkner launched Epic Sys­tems Corp., which to­day is a lead­ing EHR de­vel­oper for physi­cians and hos­pi­tals. “We opened with a small bunch of cus­tomers, maybe four or five … I never thought, never at all,” that Epic would grow to be as big as it is now, Faulkner said. “I thought we’d have a good niche prod­uct.” Epic is the No. 1 provider of com­plete EHRs used in am­bu­la­tory care in the fed­eral in­cen­tive pay­ment pro­gram, hav­ing sold them to nearly 54,500 of­fice-based physi­cians, ac­cord­ing to CMS data.

But some ex­perts are ques­tion­ing whether there will be a fi­nan­cial re­turn on that in­vest­ment. A re­cent study in Health Af­fairs con­cluded that only groups of six or more physi­cians had a mod­est, $2,205, five-year pos­i­tive re­turn from their in­vest­ments in EHRs. Smaller prac­tices ac­tu­ally lost money buy­ing the sys­tems.

The aver­age loss per physi­cian to­taled $43,700 over the pe­riod, ac­cord­ing to the re­search team led by Ju­lia Adler-Mil­stein, an as­sis­tant pro­fes­sor in the School of In­for­ma­tion, with a joint ap­point­ment in the Depart­ment of Health Man­age­ment and Pol­icy at the School of Pub­lic Health at the Univer­sity of Michi­gan.

Even with the max­i­mum $44,000 fed­eral mean­ing­ful-use in­cen­tive pay­ment, only 41% of prac­tices could achieve a pos­i­tive re­turn-on-in­vest­ment for their EHR spend­ing, their study con­cluded.

Still, many fam­ily physi­cians were early con­verts to com­puter tech­nol­ogy as an es­sen­tial tool in cre­at­ing pa­tient-cen­tered med­i­cal homes, said Dr. Ja­son Mitchell, di­rec­tor of the Cen­ter for Health In­for­ma­tion Tech­nol­ogy, which was launched by the Lea­wood, Kan.based Amer­i­can Acad­emy of Fam­ily Physi­cians in 2003. “From a fam­ily medicine per­spec­tive, we’ve seen a steady in­crease in adop­tions.”

But for most health­care providers, the first decade of the 21st cen­tury saw EHR adop­tion ad­vanc­ing at a snail’s pace, which many at­tribute to the lack of fed­eral sub­si­dies. In 2009, the year of the stim­u­lus act, just 6.9% of of­fice-based physi­cians had adopted a “fully func­tional” EHR, ac­cord­ing to an au­thor­i­ta­tive sur­vey by National Cen- ter for Health Statis­tics at the Cen­ters for Dis­ease Con­trol and Preven­tion.

“I knew it was go­ing to take some­thing dra­matic to make this work,” said David Roberts, now a San Diego County com­mis­sioner, who rep­re­sented the Chicago-based Health­care In­for­ma­tion and Man­age­ment Sys­tems So­ci­ety in Wash­ing­ton as its vice pres­i­dent of govern­ment re­la­tions when the stim­u­lus act was be­ing drafted. He’d seen ear­lier health IT bills by Sens. Deb­bie Stabenow and Olympia Snowe, with $4 bil­lion in pro­posed health IT fund­ing, and thenSen. Hil­lary Clin­ton, with $655 mil­lion, fail.

But once Pres­i­dent Barack Obama signed the Amer­i­can Re­con­struc­tion and Re­cov­ery Act into law Feb. 17, 2009, it cre­ated a time-limited en­ti­tle­ment pro­gram for EHR in­cen­tive pay­ments. Through April, EHR pay­ments have ex­ceeded $14.6 bil­lion, in­clud­ing $5.9 bil­lion to physi­cians and other el­i­gi­ble pro­fes­sion­als.

Be­gin­ning in Jan­uary, the CMS posted four con­sec­u­tive months of record num­bers of ini­tial pay­ments made to physi­cians and other pro­fes­sion­als. Dur­ing the pe­riod, 103,000 EPs were paid, 34,000 in April alone, push­ing the na­tion over the 50% hump.

“The prob­lem of get­ting physi­cians to use elec­tronic health records is fun­da­men­tally solved,” said Glen Tull­man, the for­mer CEO of Allscripts Health So­lu­tions, a lead­ing de­vel­oper of EHRs for of­fice-based physi­cians. “You’d be hard pressed to find a hos­pi­tal or physi­cian” that doesn’t own or isn’t buy­ing an EHR.

Tull­man spent 15 years grow­ing Allscripts from a de­vel­oper of a hand-held drug ref­er­ence and e-pre­scrib­ing tool to the No. 2-ranked pro­ducer of “com­plete” EHRs for physi­cians in am­bu­la­tory care, ac­cord­ing to CMS data. He is now a Chicago-based in­vestor in health IT com­pa­nies. “We’ve put in place the in­fra­struc­ture that for the first time will per­mit us to im­prove the qual­ity of health­care ser­vices and re­duce costs.”

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