Currently, doctors must invest time and money to implement EHR systems, but it’s the insurers and payers who ultimately benefit, thanks to a reduction in unnecessary tests and medications.

Source

Couldn’t have said it better myself. Now, how do we change this? Will the current EHR stimulus fix it?

UPDATE: Check out this post I did updating the Big Winners from the HITECH EHR Stimulus Incentive Program.

Whenever government decides to spend $20 billion, there are bound to be a lot of winners. The money has to go somewhere. I previously posted how I think that EHR adoption won’t significantly increase because of HITECH. However, there will be some BIG winners from this legislation. Lets’s take a quick look at a few of them.

• EHR Vendors – I don’t think there’s any doubt that vendors will benefit from $18 billion of investment in EHR.  The legislation was signed yesterday, and I’ve already seen ads for Allscripts talking about learning about the EHR stimulus.  Marketers for every “certified” EHR are going to beat this stimulus like a dead horse.
• Health Care IT Consultants (ohhh…maybe I should become one) – Business should be just fine for EHR and health care IT consultants despite the current economic crisis.  I didn’t think there were enough before.  Even a small increase in EHR adoption will mean higher demand for health care IT consultants.
• Existing EHR Users – Despite my feeling that this stimulus won’t stimulate EHR adoption, I do think that already implemented EHR users should benefit from this EHR stimulus.  I didn’t read any “first time home buyer” provision in this legislation.  This could mean a bit of free (minus a little paperwork) cash for those who find themselves already using a certified EHR.
• CCHIT (if they get chosen) – This is a big IF, but I believe that CCHIT’s survival hinges on them being chosen as the certification required to receive stimulus.  It would say a lot if they weren’t chosen.  Let’s hope HHS has the guts to not choose them despite the incredible lobbying efforts I’m sure they’ll receive.
• Hospital Systems – I’m familiar with one hospital system that has over 100 multi specialty clinics with many of them using a centralized EHR.  Seems like a great investment to pay someone to make sure they meet the required standards.  100 clinics X number of doctors in a clinic X $40k = a lot of money
• Health and Human Services (HHS) – Even just the $2 billion in discretionary funding is a huge boost to that organization.
• Obama’s HIT Donors

Anyone else I should add to the list?

The Health Information Technology for Economic and Clinical Health Act’s (HITECH) major goal is to increase EHR adoption. The major questions are “Is it enough?” and “Will it work?” Let’s take a look at each of these questions.

Is it enough?
Background:
The Health Information Technology for Economic and Clinical Health Act (HITECH) provides $18 million in incentives through Medicare and Medicaid reimbursements. Starting in 2011, physicians who show that they are “meaningfully” using health IT would be eligible for $40,000 to $65,000, and hospitals would be eligible for several million dollars. The incentives would be phased out over time, with penalties in place by 2016.
Answer:
$40,000 seems like a large chunk of money for EHR. Of course, we have to remember that it’s spread out over 5 years, but $40k isn’t insignificant. Sure, many EHR out there cost $200k plus to implement. However, not all of them are this expensive. In fact, I’d say that the EHR market has shifted from mostly high priced EHR to more moderately priced EHR with unique pricing structures.

The possible problem with the HITECH legislation is that we still don’t know how HHS will interpret what a certified EHR will be. If they say it’s a CCHIT certified EHR, then $40k might not be enough reimbursement. If they create a better standard for certification which will include specialty EHR and smaller but effective EHR software, then $40k is probably enough for many doctors to turn the corner and implement an EHR.

Will it work?
My simple answer is No.

Let me explain my reasoning. I think we all underestimate the biggest reason why most doctors don’t want to implement an EHR. Many doctors just don’t want to change. Sometimes this is related to fear (see colleagues failures). Sometimes it’s related to retirement pending. Most significant is they just don’t see how it benefits them (the doctor). Throwing a little cash at them isn’t going to change their desire not to change. They’ll just find another excuse. They’re preferred EHR isn’t “certified” might be a good one.

We also have to remember that this isn’t cash up front to pay for the EHR. It comes in the form of Medicare and Medicaid reimbursements that you hope you’ll qualify for after having spent money, time and energy (the oft forgotten element in an EHR implementation) implementing an EHR. If this was cash up front I might have a different point of view. However, far too many doctors have been screwed over (excuse the descriptive language) by Medicare and Medicaid reimbursement. Let’s not be surprised if many doctors don’t believe that they’ll ever see any of this extra Medicare and Medicaid reimbursement. If you still think this is far fetched, just do some research on doctors’ experience getting this same type of reimbursement from the ePrescribing initiative.

Add in the increased “paperwork” otherwise known as reporting requirements to receive the reimbursement and hopefully you’ll have an idea of why I think this won’t work. Most doctors want to see patients. They don’t want to deal with extra paperwork which includes researching an EHR. This is government aid were talking about and that’s pretty much synonymous with red tape.

Conclusion
I’m not trying to be a pessimist, but I am trying to be realistic. I just don’t see this new stimulus package having the desired effect on EHR adoption. More importantly, I hope that doctors take their time in selecting an EHR properly and aren’t swayed by the dollar signs EHR vendors will certainly be waving for them. Another set of poorly selected and implemented EHR will set back EHR adoption for years to come.

Luckily, I’m optimistic that most doctors have seen enough failures around them that they’ll tread lightly and not rush into EHR implementation.

Today the following videos came across my Twitter feed and I was interested in video being used to discuss health care IT and in particular the health care IT stimulus package. Props to HealthTechnica for stepping in front of the camera and trying to share some knowledge about health care IT with the world.

The videos are a little long for me. The audio was a little soft too, but not too bad. I would have also liked a short intro of who was at the table speaking. I of course don’t agree with everything they said in these videos and would have liked a little more depth on some subjects, but I do like to point to people doing creative things online with HIT.

The Obama HIT Stimulus Package Video by Health Technica Part 1

The Obama HIT Stimulus Package Video by Health Technica Part 2

Best thing I heard in these videos. “Technology isn’t meant to fix things.” I’ve said this a hundred times when I’ve said, applying an EHR to a poorly run clinic just exposes all the weaknesses of that clinic.

I predict that “meaningful EHR user” will become the most overused term in EHR and Healthcare IT adoption over the next year.  Since the term seems to be the cornerstone of receiving a part of the $20 billion EMR stimulus package, then I thought it might be a good idea to understand how HHS might define what a “meaningful EHR user” will need to do.

Luckily Patricia King, a health care attorney in Illinois, posted the criteria for being a meaningful EHR user on NetDoc as follows.

To be a “meaningful EHR user”, the physician must satisfy three criteria:

• The physician must use “certified EHR technology” in a meaningful manner, including electronic prescribing. The law calls for creation of a health information technology (HIT) Policy Committee, and an HIT Standards Committee. The HIT Policy Committee will focus on development of a nationwide health information infrastructure, while the HIT Standards Committee will recommend standards, implementation specifications and certification criteria. The Office of the National Coordinator for Health Information Technology (ONCHIT) is to adopt an initial set of standards, implementation specifications and certification criteria before December 31, 2009.
• The physician must demonstrate that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination.
• The physician must submit information on clinical quality measures specified by HHS.

Sound confusing enough?  Well, it’s going to be confusing until HHS is able to define what a certified EHR will look like (let’s all hope that it’s not synonymous with CCHIT certification) along with defining how the EHR should be able to exchange information.

I’ll be very interested to watch how HHS plans to implement these things.  I wonder if the frenetic pace that President Obama is basically requireing will end up being good or bad for health care IT and EHR adoption.

One thing we know for sure is that we’re in for an interesting ride.

UPDATE: Many of you will find my presentation on the ARRA EMR Simulus money of interest.

Today, “The American Recovery and Reinvestment Act of 2009” was signed by Obama. In this bill, $59 billion was allocated for health care with approximately $20 billion designated for EHR adoption. Of course, any doctor interested in EHR wants to know how they can get their piece of the $20 billion.

The bill was just published and can be read in it’s entirety online. I’d suggest part 2 of 5 for the health care portion of the Stimulus Bill. However, it’s not light reading so I’ll leave that to someone braver than I. It does seem like much of the bill remains intact from what was written about previously by Patricia King on NetDoc. Here’s my short layman’s summary (I’ll update this page as points are clarified):

The government is not just going to cut you a check. Instead the $17 billion will be incentives paid as increased Medicare and Medicaid payments. Incentives will start in 2011 and be paid over 5 year for a physician who can show “meaningful use” of an EHR system (we’ll be hearing about this meaningful EHR use a lot more in the future).

Physicians who do not show “meaningful use” will be penalized in the form of declining Medicare payments. Hospital physicians won’t be affected.

Those wanting the stimulus money will also have to be using a “certified EHR.” Both the terms “certified EHR” and “meaningful use” are still yet to be defined by the government.

The maximum a provider can receive is $41-$44k over the 5 years and paid in lump sum or payments as determined by HHS.

That’s the basics of the EMR stimulus package. I’ll follow up this post tomorrow with a look at what it takes to show “meaningful use” of an EHR and some thoughts on what effect this stimulus package will have on EHR adoption.

Editors Note: Please let me know if changes were made in the final bill so that I can update them on this page. Thanks.

I’ve been thinking a lot about the legislation that’s about to hit the fan in regards to investment in healthcare IT and in particular EHR and EMR softare. My biggest fear in this whole process is that the underlying assumptions being made will turn out to be wrong.

The following is a list of assumptions I’ve seen made in regards to the government’s investment in healthcare IT and EHR and its possible benefits. I’ll also offer a few comments on each assumption for people to consider.

Cost savings – The largest savings I’ve seen a medical practice receive from EHR implementation is in saved transcription costs. There’s some small savings from charting supplies and the like. Otherwise, where are the cost savings occurring? My guess is that if you polled those using an EHR you’d find very few cost savings. You would however find a number of new costs related to investment in technology. There must be some long term cost savings that the government sees that I’m missing.

Cut waste – I guess this has some minimal “Green” benefit. It just seems rather minimal to me.

Reduce the need to repeat expensive medical tests – I can’t wait for this benefit to be realized. Unfortunately, I’m afraid that the technology and more significantly the policies are in place to make this happen. Long term this benefit will be awesome, but we’re so far from realizing it that it’s hard for me to use this as a strong justification for the investment.

Save jobs – Health care has been relatively immune to lost jobs, but this investment will help save some jobs. We’ll just have to see if the money ends up going to big EHR companies who will just get richer in the process or whether this investment will do something significant in regards to saving and creating jobs.

Save lives by reducing the deadly but preventable medical errors that pervade our health care system – I’ve seen far too many research articles on both sides of this argument. Some say it helps prevent medical errors and others suggest that it may cause other errors. I’m not sure which way to think on this. In a perfect world it would certainly prevent medical errors. Unfortunately, a computer can only think so much. I’m afraid that an EHR isn’t the secret elixir we’d all hoped to use to solve medical errors.

I’m sure that I’ve missed other reasons. Feel free to add comments and other reasons I’ve missed in the comments.

I think I better work on a follow up article on the reasons why Obama should invest in health care IT. I think there are good reasons to invest in this area. Otherwise, I wouldn’t be writing about the subject. However, I think it’s interesting and valuable to have a realistic picture of why EHR implementation is important. I really am an EHR and EMR optimist.

One of the key facets of any EHR investment by the government will look at ways to award money for usage of an EHR. The hard question they’ll try to answer is how do you define an EHR that’s implemented.

This discussion is not new. Every study you can find on EHR implementation has struggled with the idea of defining when an EHR is actually implemented. I think that most surveys I’ve seen usually allow the user to define whether they’re EHR is fully implemented or partially implemented. The problem with this is that each person is likely to define a fully implemented EHR in different ways.

If a researcher has a problem defining an implemented EHR can you imagine how much fun the government will have defining this same thing. Not to mention when you start to attach money to the definition it gets really hairy.

Let me propose a simple definition of a fully implemented EHR using 2 main factors.

1. Paper Charts are no longer created or passed around the office.
2. Patient data can be transferred amongst EHR using a standard such as CCR.

The first factor is easy to measure. Take a look at the paper charts and see how many were created during the past year. Also, look at how a practice handles a patient who already has a paper chart. As long as a practice is relying on a paper chart, they are not full EHR. I should clarify that paper charts can exist in the practice, but they just should only be used for sending out records for past patients.

The second factor is easy to measure, but I’m just a little afraid that the CCR standard is just not quite fully defined. I hope that having Google Health and Microsoft HealthVault will help to establish this standard in an effective way across the industry. Some sort of medium for sharing important information is needed. Even if it’s simply allergies and medications for now would be fine with me. It can always be expanded later.

Should be simple enough. The problem is that it’s probably too simple for government work.

I haven’t really commented in the past about Tom Daschle’s appointment as HHS Secretary.  However, today it was announced that Tom Daschle has withdrawn his name from being HHS secretary.  I don’t know Tom Daschle that well, but from what I’ve read, it seems like Tom Daschle would have been more focused on implementing changes too health care not related to IT.  This guest post by Tom Daschle on the Huffington Post seems to indicate this feeling I have.

One thing is certain, it’s quite shameful that Tom Daschle could somehow have missed $128,203 in additional tax and $11,964 in interest.  Considering the amount of money Obama is planning on investing in EMR, I’m not sure I would have wanted Daschle involved in the process.

Of course, you have to wonder if there exists a politician that isn’t tainted in some serious way or another.  Whoever Obama appoints as HHS secretary, I hope it’s someone who will invest appropriately in HIT.  I also hope they’re as transparent and open as past HHS secretary Mike Leavitt was in his blog.

UPDATE:

I just found this interesting set of quotes and media put together by Alborg about Daschle and various special interests that he might have had.

I’m so happy that Daschle was forced to resign. He was one of the major HIMSS representatives on Obama’s team. From the HIIMSS website:

“HIMSS has arranged for members to personally add their support for Senator Tom Daschle to be confirmed as the next Secretary of the Department of Health and Human Services (HHS). “

In fact, he was paid off by HIMSS members, including speaking fees from Misys Healthcare Systems ($12,000) and GE Healthcare ($12,000) on 8/2008. Quote from article “Tax Cheat Daschle Favors Federal Reserve for Health“:

“GE Healthcare, one of several healthcare companies that paid Daschle tens of thousands of dollars to speak to their organizations, stands to profit if Daschle is confirmed and pursues Obama’s plan for more federal involvement in the health care field. Indeed, a part of the Obama plan, which is a specialty of GE Healthcare, is the electronic processing of medical records.”

Another quote from the recent media:

“While the tax cheating is getting some attention from the media, the $220,000 in speaking fees that Daschle collected from special interests in the health care field seems to be getting more coverage because of the fact, as noted by Kenneth P. Vogel of Politico.com, that many of these firms “stand to gain or lose millions of dollars from the work he would do once confirmed as secretary of Health and Human Services.” A front-page headline in the Washington Post, “Health Sector Enriched Daschle,” captures the obvious conflict of interest problem for the nominee. One of those firms is GE Healthcare, but chances are you won’t hear much about it from GE’s media properties…”

About Dashle’s book which includes HIT references:

“Daschle’s book, “Critical: What We Can Do About the Health Care Crisis,” published in early 2008, notes that “we are years, if not decades, behind European nations in harnessing health care information technology’s potential.” It calls for removing much health care policy-making from the political arena but states that at the same time the executive branch of the federal government should promote creation of an IT infrastructure for health information.”

The only question I still have is whether anyone exists that isn’t as bad or worse than Daschle.  At least maybe his replacement will know how to file his taxes.

I think it’s reasonable to consider some of the reasons why health care IT won’t be able or willing to have $20 billion of government money invested in health care IT.

Not Enough Healthcare IT Professionals – It’s been widely suggested that the number of health care IT professionals might not be sufficient to support this type of invesment in health care IT.  I hope my fellow IT professionals from every field can easily make the transition to health care IT.  Certainly many will without a problem.  However, the question remains if enough will be able to do so.

Other Reasons Not to Adopt EMR – I’m certain that a study on why doctors haven’t implemented an EMR yet would not show money as the main factor preventing adoption of EMR.  There are many other reasons a doctor chooses not to implement EMR and money isn’t going to resolve those concerns.

CCHIT Requirement – Of course, this assumes that the government chooses to make CCHIT a requirement for receiving funds.  Doing so will limit the choices a doctor has in selecting an EMR.  I think it’s very likely that many doctors will forgoe government funding in order to use a non CCHIT EMR.  This could be especially true for specialists who would rather select a non CCHIT certified EMR that focuses on their specialties needs.

Paperwork Required – The government won’t just be going around handing people checks.  We’ll have to wait and see how much paperwork and reporting will be required to obtain these government funds, but many doctors will shun the paperwork and beuracracy associated with receiving the government funds.

EMR Vendor Selection Process – With over 400 EMR companies to choose from, it will take doctors some time to decide which EMR they like best.  Even if you narrow the list of EMR companies to CCHIT certified companies, you’re still looking at a lengthy evaluation process.  Most doctors want to practice medicine not learn about software.  So, evaluating EMR software often gets pushed down on their list of things to do.

We’ve all seen or heard it said that it’s harder to spend $20 billion than you would think.  This couldn’t be more true when it comes to investment in health care IT and electronic medical records.  Let me know in the comments if there were any other reasons I might have missed on why the spending in health care IT might not occur.