A Message to America’s Physicians: Purchasing EHR Technology A Shaky State of Affairs

By Brian Klepper and David Kibbe

Much of the conversation and debate about physician EHR adoption has centered on the single issue of the (high) cost of purchase.  However, we’d like to suggest that the situation is much more complex and involves several more subtle variables.

Consider, for example, uncertainty about the future.  In a recent speech, Lawrence Summers, Director of the White House’s National Economic Council for President Barack Obama, related the following analysis about decision-making under conditions of uncertainty in the marketplace, which he had first heard from Ben Bernanke, current Chairman of the Federal Reserve, in a speech Mr. Bernanke gave over 30 years ago:

“If you as a business were considering buying a new boiler, and if you knew the price of energy was going to be high, you would buy one kind of boiler.  If you knew the price of energy was going to be low, you’d buy another kind of boiler.  If you didn’t know what the price of energy was going to be, but you thought you would know a year from now, you wouldn’t buy any boiler at all.  And in exactly that way, it is illustrated that the reduction of uncertainty, through the resolution of disputes, is, I would suggest, all important, if we are to maintain confidence.”

Let us paraphrase both of these eminent economists, while applying the same set of ideas to the purchase of electronic health records:

If you as a physician were considering buying a new EHR technology, and if you knew the reimbursement rates for your practice were going to be high, you would buy one kind of EHR.  If you knew the rates of reimbursement were going to be low, you’d buy another kind of EHR.  If you didn’t know what the reimbursement rates were going to be, but you thought you would know a year from now, you wouldn’t buy any EHR at all.

We’ve substituted “reimbursement rates” for the “cost of energy” here because, especially for physicians in small practices with under ten clinicians, the amounts they are paid per encounter by health plans, Medicare, and Medicaid are what determines how much money net of expenses will be available for significant investments such as EHRs at any given period of time.

And there is enormous economic uncertainty for physicians now.  A 21 per cent cut in fees from Medicare is looming overhead, set to go into effect January 1, 2010.   An arcane system known as the SGR determines annual Medicare payment rates by using a formula that aligns actual spending rates with specified targets. Medicare rates are crucial as they are the benchmark rates by which private sector health plans set their payment schedules. In the past several years, spending has exceeded targeted rates, triggering steep reductions in physician payment rates, which have been averted only by last minute Congressional intervention. What’s worse is that recently the so-called “Medicare-fix” of the SGR has become a political football, with a Democrat-led effort to revamp the system as part of the health reform legislative package failing to reach the Senate floor for a vote on October 14, 2009.  This only adds to the uncertainty regarding what physicians will earn in 2010 and beyond.  No cut? A 5 per cent cut? A 21 per cent cut?  The prudent physician or practice administrator, like the prudent business, would be wise to delay major purchases like an EHR until knowing if there will be capital available to pay for them.

Enter the ARRA/HITECH incentive payments of as much as $44,000 for “meaningful use of certified EHR technology” over a 5 year period starting in 2011, intended to stimulate physician and hospital adoption of EHR technology, uptake of which has been anemic at best.  Currently, only somewhere between 15-20 per cent of physicians are using EHRs, and the number among small and medium size practices is even lower.   Clearly, Congress and HHS believe that a stimulus of approximately $10,000 per doctor per year should be enough to induce a significant number of America’s doctors to change their minds and acquire and use EHR technologies in their practices by 2015.

But only if the doctors can make a reasonable calculation as to the net costs of such a purchase, and right now there is too much uncertainty to make such a calculation.  Not only do they not know the federal government’s definition of a “certified EHR technology”  — which will determine which products currently on the market, or on the market sometime during 2010-2011, will qualify their practices for incentives, if purchased.  They do not know yet which particular “meaningful uses” of such technology will be rewarded, if such a “certified” technology is purchased.   They also don’t know how to apply for the incentive payments, when to make such application, or in what time period to expect a reply.   (To be fair to ONC and HHS, the regulations sorting all this out are expected to be released in December, 2009.  However, as we understand the process, final versions are unlikely to be read into the Federal Register until mid-2010 or beyond.)

Furthermore, many physicians with whom we’ve spoken believe that the $44,000 being offered by the ARRA/HITECH incentives would cover only a quarter to a third of the actual total costs of ownership during those five years, leaving them with expenses of roughly an additional $100,000 per physician that must come out-of-pocket in order to implement one of these software programs.  This may be why one hospital recently offered to add an additional $40,000 per physician, over and above the ARRA/HITECH payments, as incentive to get their system’s doctors to utilize one of the more popular EHR products. (“Popular” may be a stretch.  When only 15 per cent of doctors have chosen to acquire an EHR from any vendor, none of them can really be considered the people’s choice.)

Thus, there exists a significant “uncertainty gap” between what Medicare or Medicaid is willing to pay a physician to adopt an EHR technology, and what the actual costs to each physician will be.  Physicians buying now must either a) accept the possibility of a significant out-of-pocket expense, or b) have confidence that health care payment reform will provide significant additional payments beyond those of ARRA/HITECH to doctors will make up the difference.
However, confidence among physicians in incentive payment programs from HHS and CMS is probably at an all time low.  Many thousands of physicians who complied with the Physician Quality Reporting Initiative, or PQRI, by sending CMS quality and performance data from 2007 to 2009, have yet to receive a penny for their efforts. Some report they haven’t even gotten responses from CMS as to the nature of the problems!   The bonus payments are just 1.5-2.0 per cent of Medicare billings, or between $1,000 and $2,000 for the average family physician or general internist.  But according to many physicians, the work that has to be done in order to qualify for these payments  routinely uses nearly as much office staff and IT consulting work as the bonus is worth.  The many snags encountered by physicians who have tried to participate in PQRI have added insult to injury, significantly tarnishing the reputation of CMS and putting into question, in the minds of many physicians at least, the government’s ability to operate the ARRA/HITECH incentives, without question a much more complex endeavor than has been PQRI.

Finally, physicians lack confidence in broad payment reform of the kind that would actually create a return on investment for health IT used to improve quality and monitor costs of care.  Beyond the issue of Medicare incentive payments for EHR technology not yet specified, to be used in ways that haven’t yet been defined, doctors are manifestly not confident about the longer term issue of whether short-term incentive payments will be converted to sustainable economic returns, as through pay-for-performance, after 2015.   This concern is perhaps more relevant to the reduction of uncertainty and the build-up of confidence than the narrow issue of ARRA/HITECH incentive payments, which are, after all is said and done, a faux business model for investments in EHR technology that comes to an end in 2015.

So, what should America’s doctors do?  Well, we’re not in the business of advising people about how to spend their hard earned money.  But we do believe that it’s human nature to be conservative and to withhold investing when uncertainty about income, expenses, and returns on investments is high, and doubly so when confidence in the people and organizations making the decisions that effect those variables is low.  That this is precisely the situation in which most doctors in America who work in small and medium size medical practices now find themselves may be more determinative about the future of the EHR market place and adoption of EHR products and services than any advice we could offer.  This interplay of uncertainty, confidence, and money for health IT investments may also create challenges and give direction for Dr. Blumenthal and his staff at ONC as they operationalize the policy and regulations mandated by ARRA/HITECH.  For one thing, as Ben Bernanke so wisely pointed out many years ago, resolving disputes will be key to ending uncertainty and returning confidence to this shaky state of affairs.   But we’re not sure that even Congress has the will to resolve the disputes that would set our health care system on a reasonable course and reduce the uncertainties we’ve discussed here.

Brian Klepper, PhD is a health care analyst based in Atlantic Beach. David C. Kibbe MD MBA is a physician and
Senior Advisor to the American Academy of Family Physicians.

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31 replies »

  1. Nice post. Seem tree on most accounts but I also think that today medical practitioners are looking to avail of this federal incentive by trying to comply with the definition of meaningful use but at the same time EHR providers are looking at their own set of profits.
    This misunderstanding is mostly I believe as a result of wrong interpretation of the federal guidelines. The EHR providers need to look at these guidelines from the prospective of the practitioners who deal with different specialties.
    Each specialty EHR has its own set of challenges or requirements which I believe is overlooked by in most EHR vendors in a effort to merely follows federal guidelines. This is resulting in low usability to the practitioners, thus less ROI, finally redundancy of the EHR solution in place.
    I think ROI is very important factor that should be duly considered when look achieve a ‘meaning use’ out of a EHR solution. Though one may get vendors providing ‘meaning use’ at a lower cost, their ROI / savings through the use of their EHR might be pretty low when compared to costlier initial investment. Found a pretty useful ROI tool that is pretty customizable and easy to use. It also accounts for the different specialty EHR’s too.
    Some of the other useful resources on this topic:
    REC’s putting EHR’s to meaningful use
    Certification criteria for EHR
    Also the introduction of REC’s through the HITECH act. is a great way to avail of quality EHR solutions at competitive prices. The stiff competition among not only these REC’s but also among EHR vendors ( to become a preferred vendor of a given REC) will result in lot of positives to medical practioners.
    Looking the funding provided to the REC’s, the staggered grant allocation system also promises to be an unbiased way of allocating funds. It will also help in the concept of REC’s helping out each with their own unique business models. It can be one of the possible answers to the
    ’safe vendor challenge’ as discussed by many critics.

  2. As a practicing Pediatrician in New York State, let me recap some of the issues touched upon above in simpler form:
    1. Forcing Electronic Medical Records on doctors with the hypothesis that it is a good thing for healthcare in this country, is a mistake. From my perspective, it can be good, but it can be bad. Most doctors I know use EMR to make it easier to code higher and get higher reimbursements from insurance companies. There is little proof that we should be forced into this boondoggle. Most doctors who convert complain bitterly of the adjustment they have to make in their office for a year period or more, the financial expense, the training, the time it takes to enter old info into a new system. And in the end, we can play the insurance game better, where is the benefit? It may be there, but it is not being looked at correctly.
    2. Its been said before, but 15% of medical care costs can be cut by installing good malpractice reform. EVERY practicing doctor plays the “watch out for the malpraqctice lawyer game”. We all order more tests,usually with absurd costs to the system. Specifically, extra radiological tests and blood tests, which have their own outrageous costs. Doctors dont care, they have to be ready for that law suit from any given patient. Lets build in practical ways to deal with our overlyh litiginous society in order to improve health care. It only takes some reasonable laws to reform this system!
    3. The disparity between specialists, and the primaryh care doctors is absurd. I can spend an hour diagnosing a brain tumor in the office and get paid $60,while the specialist can spend the same hour in an operating room and charge $15,000. When is there going to be some reasonable moves towards parity on this issue. Ignoring this problem is like continuing the $300 million dollar bonuses for CEOs.
    4. Finally, remember that only 15% of medical dollars go to doctors,, the rest go to insurance companies, administration, hospitals, therapists, medical equipment makers, pharmaceuticals, etc. I am not sure there has been much build into the new reform laws to even touch most of these issues.
    Maybe a few doctors should have been consulted before passing new legislatures. We know the problems pretty well!
    Dan Cohen, Pediatrician, New York

  3. David, let me try and explain, but it will end up a bit long….
    First of all let’s define what costs $5000. I am referring to traditional EHR, the way ONC is defining it and the way meaningful use is restricting it to be. This is software capable of meeting meaningful use criteria, i.e. connectivity to pharmacies, labs, other providers and patients, reporting all those very complex measures to Federal Agencies, collecting and documenting patient encounters, submitting claims electronically and verifying eligibility with payers, satisfying all security and CDS measures.
    This can be one monolithic application, or a number of smaller applications functioning in harmony.
    I’ll start with open source which is often being mentioned as a panacea to highly priced software. I am an avid believer in open source and harnessing volunteer work to create good software. However, open source is great for technology savvy companies that use free components to build either their infrastructure or their own software. This usually reduces the cost to build and support the product. The non-technical end consumer, or customer, is very rarely able to capitalize on the fact that the product is open source.
    In the case of EHR technology, there are several open source options, but they are so complex that a user cannot just go to the website, download something and start using it. He/she will very likely need to purchase a support package and pay for the creation of various interfaces.
    Even in a SaaS model, connecting to a lab for example requires custom work for each and single practice. This is beyond the software vendor’s control and it costs money in the form of labor.
    Interfaces require extensive maintenance, whether they are web services based or TCP/IP based. For example payer or intermediary interfaces require constant changes based on the ever changing payor rules and edits. That costs money and it’s custom work.
    Free open source software does not come with clinical libraries that by themselves require licensing fees. For example, First Data Bank is not free. You must have FDB or MediSpan to perform the meaningful use requirements of DDI and allergy checks. These clinical databases are expensive and there are other ones that are needed too.
    The fact is that the open source EHRs out there all come with a hefty support package that amounts to about $5000.
    I agree with you that bits and bytes should be free, or nearly free and SaaS models get closer and closer to that elusive free. Interoperability, however, is not at all free and Clinical Decision Support is not free either. A concrete example would be the open source interface engine called Mirth. Great product. You can download it and use it (if you are a techno geek). However, even an IT shop finds itself in need to purchase support, which runs at about $7000 per year for the basic stuff. This is a fraction of what the commercial engines cost, but it is not free.
    Unlike software, the services required to support it are not converging in price to zero.
    So now the question is why do we need such big software that we must charge for so much support. The answer to that is that the requirements, now from ONC (not just CCHIT), are for very complex functionality. Whether you buy one monolithic software for $5000, or multiple small ones for $50 each, your expenses will add up in a hurry if you want to meet the standards.
    As to the iPhone and Android platforms, those are great. However, I don’t think a small screen device can replace the paper chart. It is not feasible to expect physicians to do their work on an iPhone. It’s too small and docs have lousy vision. We need to differentiate between cool, small applications that add convenience and large business management software that is needed to run a clinic. Meaningful use, even for 2011, requires the latter.
    Another way to provide all this for “free” to physicians is to generate revenues in a different way. Note that the word “free” is now in quotation marks.
    Google supports all its apps and freebies with revenue from advertisement. Your use of their “free” apps is promoting and supporting their main line of business, so basically all the freebies are loss leaders.
    A well known model in the EHR industry is to provide “free” EHR to billing customers. The very nice revenue stream from managing medical billing more than covers the bits and bytes. So here you go, as good as Google 🙂
    There are EHRs that are at least partially supported by ads too, but there’s a very fine line here. Physicians I spoke with shuddered at the idea of having pharmaceutical ads in their work flow and I do too. So ad supported EHRs will probably need some other way to generate revenue. There are various other revenue sources associated with electronic medical records, as I’m sure you know, and I’m pretty sure they will be used in the future.
    Finally, David, here is my suggestion if we want completely free, or as close to free as possible, honest EHR technology.
    Most of the costs associated with EHRs are in interoperability and clinical content.
    So maybe HHS would set aside some change to build a national drug database that has all the functionality of FDB and build a good general CDS database that will grow and expand with new evidence and let the vendors access it for free.
    Have the Feds spend money on an interoperability infrastructure that anybody can connect to with a few clicks of a button. Build the clinical information highway for us, and let the vendors build the cars. I can assure you that the docs that insist on a horse and buggy today, will quickly change their mind when they realize that 10 mph is not the speed limit anymore and the cars, lo and behold, are less costly than old Mr. Ed chewing hay in the barn.
    I knew it was going to get too long and I really tried to be brief too….. 🙂

  4. Margalit: Good points. But I think that $5,000 per physician is still too high a price to pay for these SaaS EHR technologies, given the appropriate platforms and open APIs to encourage developers to build good apps, and lots of them. I think we must consider not only the price, but the disruptive innovation that delivers good-enough products at much lower pricing, through innovative technology and innovative business models.
    And it’s not only Google. It’s happening all over.
    You mention Salesforce.com. They disrupted the CRM business, and might do so for health IT if they tried. What about Amazon? Again, massive cloud architecture, open platform, huge ability to scale. The Apple iPhone already has some interesting EHR-lite applications, and more are on their way, costing only hundreds of dollars a licencse. And the Android open-source operating system for cell phones is potentially an EHR technology platform, too. Mobile, scalable, cloud-based, open source. A powerful combination, no?
    Why protect the “conventional vendors?” Let them compete on features, service, and cost, so that physicians — and their patients — can decide which tools to use and how best to communicate, make decisions, report lab results, access online content, etc.
    I remember the days when a “stereo system” cost thousands of dollars and was placed in my living room, from where it could not easily be moved. It had an amplifier, tape deck, speakers, etc.
    Now, I carry my music collection on a relatively inexpensive little device, connecting it to lots of sound systems at will, e.g. in my car, and — oh by the way — it also takes photos, has maps, records voice messages, and is a telephone.
    So…explain to me again why an EHR app ought to cost $5,000 per physician, when it can’t even do email?
    Again, thanks for your comments. dCK

  5. David, It’s not at all sacrilege to question today’s business models. However, hardware costs money and even the sassiest SaaS company must be profitable somehow or it will not stay in business. Salesforce.com, arguably the pioneer of such model, is not free. It’s very low priced compared to its competition, but not free.
    You can achieve efficiencies with SaaS that allow you to manage costs down significantly if you have a very high volume of easy sales. However, as I said above, unless you have a secondary means of obtaining revenues, not necessarily from the primary software, as Google most definitely does, you will have to charge something for the second S in SaaS.
    What I was calculating above was the minimum cost that an efficient SaaS vendor with no secondary revenue stream can aspire to, and that is about $5000 per year for a full fledged EHR.
    Maybe Google should offer EHR tools. I’m pretty sure they could offer those for next to nothing and monetize the access to both physicians and patients so the EHR costs are more than covered. That’s how all the other Google freebies work. No conventional vendor would be able to compete with Google in the small practice space if they decide to do this.

  6. Dear Margalit: Thanks for your always good and thoughtful comments. I guess one has to ask: why should any physician pay $20k for an EHR technology in the era of Google Docs and PracticeFusion? The stark reality is that business models for software in the cloud have refashioned our thinking about the cost of this functionality. I now pay 99 cents or less per song, and $9.99 per book on Kindle, and nothing at all for Google Docs and Gmail. Would I pay something for the latter if I had to? Probably, as I depend upon them, it’s software that works well for me, and there are social benefits to writing and sharing that way.
    Why should doctors and patients pay for online software that helps them to manage care and make good wellness and health care decisions?
    I know I’m committing sacrilege, just by asking this question. But think about it. Is there any EMR or EHR software out there worth $10,000? How about $5,000? Give me a reason to pay that kind of money, or to advise physicians to do so.
    Kind regards, DCK

  7. Unless you have a secondary means of getting revenue, prices will not come down much lower than $5000 – $6000 per provider/per year. That’s for EHRs that can meet meaningful use.
    There are basic license fees that have to be paid per user like FDB or MediSpan, patient information, CPT, any decent decision support like Isabel, maybe order sets, interface engine maintenance, server OS, database and .NET dev tools are not free either.
    Hardware to run the software on costs money and depreciates every year. Data center is another big expense.
    Then there is cost of software maintenance and upgrades, all the interfaces and web services maintenance, support and general SG&A.
    Stuff like that adds up in a hurry.
    On top of that the office has to purchase tablets and other computers, pay for good internet service and network setup, maybe a fax server. You’re looking at another $10,000 for one doc, a nurse and an office manager. Probably have to buy new stuff every 2-3 years.
    Add another $5000 for data migration, training and go-live.
    It’s much less than David’s numbers up there, so I guess it’s good, but you are looking at about $20,000 in the first year, for a solo practice. That’s not counting physician time.
    I don’t know…. Is that reasonable?

  8. I’m inclined to believe that 4 things will happen to make this a somewhat moot point
    1) Price of EMRs will come down, driven by the SaaS model
    2) Medicare and private payers will start demanding PQRI type reporting as part and parcel of their payment–which will require some part of this (e.g. registries, outcomes measurments)
    3)Patients and other purchasers will start demanding the outputs of physician office workflow technology(e.g. online appointments, access to test results) that will get enough doctors’ offices to being “close enough” that we’ll call the problem solved in 8-10 years.
    4) tools like the iPhone and more advanced interfaces will make it easier for the younger generation of docs to insist on this
    No question that this will be messy!

  9. Margalit,
    Thank you for the engagement and your response. I respect and understand some of the points you make. While I would like to give you counter points to consider, I will rather keep this posting short and make a clarification that I think many of us should bear in mind and that this article and everyone’s responses helped me to remember. That is, we keep referring to EHR as a technology but I think we should consider expanding that. It is not simply a technology. It is a whole new process, a whole new system, a whole new way of documenting and reporting and accessing patient care. It takes a dramatic shift in thinking, and I suppose I can understand how something so largely different can make some people hesitate.
    I will say one more thing – can’t help myself. Part of scientific prudence is about going out and finding the information necessary to make a fair assessment, with a critical eye (knowing that you can never really prove a hypothesis, only disprove it). I see too many people eager to criticize, rather than question, and then with the grumbling attitude of “come back when you have something better” and label that attitude as scientific prudence. So even if you yourself are being scientifically prudent, I hope those who, without doing much research and then simply say “I haven’t seen anything that shows me an EHR will be of any benefit” aren’t thinking they are scientifically prudent. Because, as you say, many have seen benefits and the information on those benefits is out there for all to find and consider, along with the challenges.
    In addition to Practice Fusion, there are other free, open source EHR solutions:
    http://www.youtube.com/watch?v=pBe1WiMxLV4 – Introduction
    http://www.youtube.com/watch?v=o-mEht-SRLs – OpenEMR – Setup Your Clinic (Part 1)
    http://www.youtube.com/watch?v=UbKCB_GqUzM – OpenEMR – Setup Your Clinic (Part 2)
    http://www.youtube.com/watch?v=NXW28Rk69lQ&feature=player_profilepage – OpenEMR – Setup Your Clinic (Part 3)
    I do not know anything about the ease of use or functionality of them though.

  10. Computers are tools and software is a service. If you put the tools in the hands of a master, the tools can perform amazing services. They expand human abilities in all kinds of ways. EMR/EHR systems can provide many valuable and useful services that can enhance the way a physician does his job. There are free EMR/EHR systems ( check out: http://www.practicefusion.com/ ). The real cost is not money, but time. A good set of software services should improve a physicians abilty to engage with his patients and automate the workflow processes. Quality software in the hands of a master, will always have better cared for patients and a physician who spends less time in the office and more time in life.

  11. Gennady,
    I think most people would agree that modern technology could be beneficial to a medical practice or any other business for that matter. The question is what should that technology be. The current technology, marketed and sold under the product name of EHR, has not proven to provide significant, across the board, benefits commensurate with the investment. In many cases, it has created adverse effects for both physicians and patients. It is true that there are success stories out there as well.
    However, if we compare EHR technology to any other technology used in the medical field, like devices, medications or equipment, it sort of makes you wonder. Would you be supportive of pushing a line of medications to the general public if some trial users reported benefits, but others reported adverse effects? Would you even promote any medication that purported to cure all ailments with no clarity as to exactly how this would be accomplished, except “try and see for yourself”.
    If you answered no to the above, and requested that more tests and trials should be done, it does not define you as “anti-medications”. Just scientifically prudent.
    As to CCHIT, even if we understand what meaningful use will be defined as, buying a certified EHR, does not automatically qualify you for the incentives. You still have to use it in a certain way and provide proof that you did. Since setting complex goals is much easier than achieving them and measuring that achievement, I suspect we will run into all sorts of problems trying to correctly qualify the “winners”.
    I also have a problem with the “fire sale” tactics of frightening customers into buying now instead of waiting at least a few months. Why would it be too late to buy something a year from now? Does it take three months to master the product enough to be able to use it meaningfully? Are you sure you want to use something that takes so much time to learn and fine tune? Do you plan on three months waiting time after you buy Quicken, or Microsoft Office, or Quick Books, or any other software aimed at small business use? We’re not taking SAP or Oracle Financials class software here. Or are we?
    On a personal note, I know quite a few happy users of those integrated monolithic EHRs, but I also know folks that are struggling and folks that can’t even afford to try. The big EHRs, will absolutely work for some users, but there has got to be a choice for the others and government regulations should not obstruct those choices.
    The more I think about this, the more I agree with David, that we should provide an easier path to technology adoption, instead of leaving behind all that are adverse to gamble and big bangs, which as it turns out, are most doctors.

  12. I appreciate the point of this article but I was hoping for some more open minded thoughts from the commentators. I am also very glad to see the clarification from Dr. Kibbe that he is not “anti-EHR” because it seemed like that is where people were heading. I have this picture of the commentators to just be content to sit on the sideline with arms crossed and eyes shut, being dragged somewhere they don’t want to go. Please do not misunderstand, I do not mean to criticize but I fear these negative and somewhat stubborn attitudes may be leading towards sacrificing a higher level of care. There will never be a good time to invest thousands of dollars. Moreover, most things worth investing in will have a recovery period. I mean just think of your educations. Was that worth the enormous investment? Probably, but it took awhile for you to pay off those loans I bet. So, yes it will take a very long time for an EHR to be useful and to see benefits in finances and even patient care but please take care to keep a more open mind to the potential benefits.
    Also remember that the current incentive period is just a period; how long will it be around? The Certification Commission for Health Information Technology (CCHIT) states that “Providers and hospitals who wait until Fall 2010 to choose EHR technology will experience a high risk of failing to achieve meaningful use in time for the 2011-2012 incentives.” What will the incentives be after 2012? Will there even be one? CCHIT is an organization that is recognized by the Federal Government as a certifying body and their website has plenty of information regarding meaningful use, which can serve to reduce concerns about the lack of a final rule. Yes, CMS is very frustrating at times. It would be more logical to have the clarified and final definition of MU. However, note that CCHIT forecasts “Final 2011 MU requirements will be the same, or less stringent than current Committee recommendations”. There is uncertainty either way, you wait and risk losing or getting a decrease in the incentive OR you go for it and risk not meeting the MU requirement. My strong guess though is that if your EHR is certified by the CCHIT committee (a question that should be asked of all your potential EHR vendors – I am not employed by any EHR vendors by the way), there is little chance it will not meet MU requirements.
    I have great respect for the work that most physicians do. Prioritize my care over cost is the expectation. There are plenty of well done studies on the benefits of EHR systems. For example, there is a study entitled “Clinical Information Technologies and Inpatient Outcomes; A Multiple Hospital Study” authored by Ruben Amarasingham, MD, MBA; Laura Plantinga, ScM; Marie Diener-West, PhD; Darrell J. Gaskin, PhD; Neil R. Powe, MD, MPH, MBA. The conclusion is “Hospitals with automated notes and records, order entry, and clinical decision support had fewer complications, lower mortality rates, and lower costs.” I have a copy, contact me if you would like it (gbira2@yahoo.com). I will not try to convince you on the potential benefits of an EHR, my hope is that you research that yourself and do it first without thinking about the investment. If you think an EHR can help, be creative in raising the money. I understand those in small practices have greater issues. Are you good at what you do? If yes, you probably have a committed patient base. If so, perhaps some of the committed would be willing to help subsidize an EHR, thereby affecting their own care. Develop some literature on what you think the benefits would be to you and thereby, your patients. Then, on each persons visit, ask for a small donation – perhaps the same as a co-pay or ½ the co-pay – offer to charge it directly to their credit card, make it easy is the point. Make one of those barometers showing people how close you are to the goal. Even if you don’t raise much, at least your patients will know you are active and looking out for their care now AND in the future. And if you do raise some funding, it may make your patients feel more engaged with you as their provider – how nice for both of you. Whoever makes a donation will feel more committed and connected than ever.
    Lastly, the article mentions that there are currently 15-20 percent of physicians using EHR’s. Who are these physicians? I don’t know, perhaps the authors have more detail but my guess is that they are the ones who are most progressive and I want my physician to be on the cutting edge and brave enough to invest into technology that will help me and my loved ones’ health – that’s your ROI.

  13. Robert: I agree with you completely! One of the reasons that I am a proponent of modular or component EHR technologies gaining some play in the market, is that I think the de-coupling of clinical information management from the revenue cycle/billing system, may help restore an emphasis on the use of the IT for quality, safety, and efficiency. This is hard to do in a care environment where fee-for-service dominates, and physicians are rewarded for doing more, not doing better.
    If we can get in the habit of talking about the jobs/tasks that the component applications are intended to do, e.g. e-prescribe, management of populations of patients with specific conditions, communicating with patients/other providers to coordinate care, management supply inventories — whatever — we may free ourselves from this poisonous idea that an “EHR” is a single-vendor, monolithic suite of applications.
    However, this is an uphill struggle, to be sure. The money and power lies with the big providers and their big HIS and HIT vendors, and they will do just about anything to maintain their positions of power, influence, and market share.
    In light of this situation, I think it’s important to support physicians who choose NOT purchase a 2001 truck or minivan, even when part of its cost is subsidized, and even if you can’t yet purchase the 2010 hybrid or electric vehicle you may want. I think this is the voice of the small medical practice in America, which isn’t being heard much in places like Washington.
    Kind regards, and thanks for your comments.

  14. Dr. Kibbe:
    I don’t think anyone who has posted here is innately “anti-EHR.” However, we are scientists, and we looks for evidence to support the claims made on behalf of drugs, procedures, and equipment. The claims made for EHRs have been wildly over-stated and lacking in supporting data. Many of us are particularly frustrated that our professional organizations have not seemed open to a serious discussion of the pros and cons of EHRs.
    My personal feeling is that EHRs devoted EXCLUSIVELY to better patient care could be designed and would be valuable. However, our medical records in this country have been so corrupted by coding issues, counting bullets, procedure codes, billing guidelines, liability protection features, HIPAA, etc., etc., that, when translated into electronic format, the chaff so overwhelms the wheat that the end-result is unusable.
    Again, thanks for the discussion.

  15. Thanks for all the good comments. I’m very glad to see that our post has met with some approval and interest. Please note, we’re not “anti-EHR” in our approach or thinking. As we’ve written many times before, we believe that effective, useful, and affordable EHR technology is absolutely essential to the practice of quality medicine, and to participatory medicine that involves patients as partners in decision making.
    Our goal here is to help get peoples’ thinking straight about where and why the market for these products — purchasers and manufacturers — is out of alignment. We support physicians who would like less risky, better designed, and less expensive products. And we encourage companies to offer lighter weight, safer, and less complex products. Even free ones if possible. Finally, we’d like the policy setters and regulators to be realistic about what they can achieve, and to “do no harm.” Harm will be done if they by set policies and promote standards that have no chance of achievement with the majority of the nation’s medical practices.
    Very kind regards, DCK

  16. I second the suggestion of FDA approval. Some parts of computer systems are classified as medical devices already but not enough. The higher-ups need to seriously think about this. I think some of these systems (and their disastrous implementations) are killing people.
    (yes, I’m repeating myself from Dr. Wachter’s post, but sometimes it’s necessary…..)

  17. Wonderful report on the financial aspects and practice disruption from purchasing electronic care record equipment. Do not forget the maintenance of the machine and the training of new employees, if the learned ones leave the employ.
    After years of seeing promotion of these devices, the wake up call is heard. Holy cow, who has approved these devices as being safe and efficacious and who is interested in the adverse events caused by them? Who will fix latent flaws in the devices and when?
    It appears to be in the interest of assuring patient safety that Senator Grassley has (recently) expressed an interest in a few of these concerns.
    As doctors become typists and data coordinators, the devices create a requisite emphasis away from individualizing patient care. There is shift in labor. Doctors were “fed” data that enabled them to spend time thinking about and interacting with patients. Now, the patient is the computer.
    Until the devices are made to be user friendly and are approved by the FDA (as they need to be in Sweden and Canada), the best advice is DO NOT BUY.

  18. This is a superb article and so timely too. It seems that many physicians are sharing David & Brian’s assessment of the situation. http://tinyurl.com/ylla7sc
    Unfortunately, this should have been expected. As I wrote here over six months ago, practicing physicians were not at all consulted when the HITECH policies were formulated and nobody should have expected them to blindly comply.
    I suspect a significant amount of backpedaling will be necessary in order to avoid serious embarrassment.

  19. ” I was under the impression that EHR might also have something to do with improved patient care and better outcomes.”
    Unfortunately that’s another promise, like return on investment, that was made without any supporting evidence, and that hasn’t panned out so far.

  20. Any time a physician has to touch a computer he/she is being a secretary. Very unproductive. All of the documentation requirements just to get paid are artificial and bogus posturing to give the payors reasons to pay less. It is not about quality of care. It is intended to slow down care, thereby decreasing capacity.
    If you want better quality and more capacity, then free doctors and nurses from keyboards.

  21. Uh, excuse me. As an outside observer and layman, I was under the impression that EHR might also have something to do with improved patient care and better outcomes.
    Maybe not.

  22. Excellent Post, here is a perspective that is continually FAILED to be addressed by the likes of a variety of Heath IT organizations (yea the ones attempting to charge all of those exorbitant fees as mentioned above) . For more on the dismal state of affairs in Primary Care read this physician’s foundation study…
    There are multiple practice issues that traditional HIT fails to address for us docs who see patients, namely running faster on that same treadmill of insurance that threatens to further deccimate the physician patient relationship.
    Talking about reform and traditional HIT is boring.
    Let’s talk about solutions that put physician’s and patient’s back into the driver’s seat of health. Here is ours.
    Want house calls? Fill out our brief survey…
    Integrated ecommerce, marketing, HIT, solutions for mobile medical practice, reducing physician overhead by 80%.
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  23. As with any IT project, the decision has to be based on two factors: if EHR is eventually going to make user’s life easier and (2) whether it provides ROI. Targeting the ARRA incentives don’t make much sense unless there is a proper place for EHR in the practice workflows. The ROI part is all but clear at present, to say the least…

  24. Guys:
    Practice Fusion turns this calculus into an elementary math problem: Free EHR, free upgrades, free eprescribing, free lab look-up, free training, free everything.
    Physicians can have their EHR, pocket their stimulus checks, and save their ammo for the upcoming battle on Medicare payment reform.
    Glenn Laffel MD, PhD
    Sr VP Clinical Affairs
    Practice Fusion
    Free Web-based EHR

  25. Well said. The EMR mandate on the surface appears to make a lot of sense, but is nearly fiscally impossible for primary care physicians, especially those in small practices, to implement. I especially appreciated the point about reimbursement–we as physicians are in a very uncertain time, and it is hard to justify the expenditure of an EMR right now.

  26. Excellent article David and very timely. Any solid ROI calculation has to be based on strong fundamentals. Most small-medium office docs today aren’t finding big-iron EMR implementations helpful for their bottom lines. And, the reform effort adds tremendous uncertainty to the equation with the most likely outcome being lower traditional reimbursemnt fee schedules.
    “But we’re not sure that even Congress has the will to resolve the disputes that would set our health care system on a reasonable course and reduce the uncertainties we’ve discussed here. ” Your post coupled with Roger Collier’s below do a great job explaining the ‘state of the union’ when it comes to Health IT.

  27. Drs. Klepper and Kibbe: Thank you for an excellent post. This is a very accurate description of the valid concerns physicians have about just the purchase price of EHRs, much less all the other issues surrounding them. This type of discussion stands in stark contrast to the evidence-lacking EHR cheerleading and sales schtick the AAFP has been feeding us for the past ten years.