Why are doctors afraid of moving to EHR’s? Fear of losing productivity, mainly

More scuttlebutt and chatter about the EHR adoption survey done by MGMA I mentioned a few weeks back. Below is a synopsis from a good resource I just learned about. But hey, Uncle Sugar knows that it will hurt to go from your paper and Word (or Wordperfect) patient record system to an EHR solution. That’s why the Feds are offering 44K now, and 39K if the practice makes the change 2013. Anyway:

Productivity was the pervasive issue. The only group that reported some productivity gains was the 16.3% self-proclaimed “optimized users” of EHRs—those who have had sufficient time following implementation to master the EHR. (The report did not define “sufficient time.”) Among this group, 41% reported that physician productivity has increased. What is disturbing about this statistic, however, is the implication of the converse—that even among these most accomplished EHR users, the majority of physicians (59%) are seeing a decrease, or at best no increase, in productivity. For the total population studied, 43% have just worked their way back up to where they were before implementation, and 31% of respondents are experiencing an actual productivity decrease.

Productivity was the major factor accounting for why 8% of survey participants are in the process of replacing their EHR with another, while anticipated productivity loss was reported as the most significant barrier to EHR implementation for physicians still using paper charts. Among these paper users, 78% fear productivity loss during implementation and 67% worry about the effect even after the transition to an EHR.

This data confirms past experience regarding productivity loss and raises these critical questions:

• Why do only 16.3% of EHR owners categorize themselves as “optimizing their use of an EHR”?
• While government incentives will certainly address the financing concerns expressed by small practices, how will this money address the productivity obstacle for all adopters?
• What accounts for the loss of productivity?
• When technology has replaced an antiquated paper process in other industries, it has always brought increases in productivity. How do we deliver the same results in healthcare?

EHR usability and quality assurance: do the Feds understand what is at stake?

So, 2011 is the year the checks for EHR get issued. The IT industry seems to me to be adopting a bit of a wait-and-see attitude about the Federal push to implement and integrate EHR, possibly because the standards for “meaningful use” are only now being rolled out. This is such heavily bureaucratized terrain; not every vendor wants to mess with it. A certain Zen-like patience is required for this market, what with business rules, such as they are, based on the sometimes inscrutable calculations of public-sector analysts and specialists who issue Federal guidelines. I used to work as an analyst for a Health IT company, tracking  state compliance to the Federal Medicare data transaction standards, and every time a bureaucrat put me on hold, one more little part of my youth expired, joylessly.

But after all the regulations and rules have been parsed, the rubber must hit the road. Whether doctors and nurses and admins can use the EHR systems being implemented remains the $100 Billion question, no?

From the January 18 PC World:

Dr. Tom Handler, a radiologist and analyst for the research firm Gartner, said one of the main barriers to adoption, “valid or not,” are concerns about the productivity and usability of EHR systems. Many physicians also believe that the data collected by the government through EHR reporting criteria will be used to decrease Medicare and Medicaid reimbursements, Handler said.

“Ultimately, what I hear doctors saying is, ‘Let me get this straight. You want me to spend money to put in a system that will be harder to use and slow me down, so I will earn less money, and that the end result is that someone else makes more money,” Handler said. “If you phrase it that way, it’s not illogical to see why they don’t want to do it.”

E-prescribing is another example. “Docs say, ‘I didn’t go to medical school to become a data entry clerk so Walgreens could hire one less pharmacy tech to enter the system.’”

Handler said current meaningful use criteria also doesn’t take aim with incentives that address what physicians consider some of the most critical reforms needed in healthcare today.

For example, Handler said, a computer-based patient record system can catch duplicate patient test orders, but the current meaningful use incentives don’t penalize physicians for ordering duplicate tests.

Ultimately, it’s the patient — the insurance company and then society — that pays for the duplicate test, and yet, its the physician who’ll have to foot the cost for the system that can prevent the duplicate tests, he said.

Dr. Harry Greenspun, chief medical information officer for Dell and a member of the Healthcare Information and Management Systems Society (HIMMSS), said resistance to EHR adoption can be as simple as a physician not wanting to add steps to a process that has worked for decades.

“It’s really easy to write a prescription; you just jot it down on note paper. On a computer screen it can take a lot longer,” he said. “If you go have to through a check list or a menu-driven program, it can be clunky, and a barrier to adoption.”

“On the other hand,” he continued, “If I can share [radiological] images, pull data from other systems, write a prescription all from one screen … and get valid prescription alerts and find out about public health threats, then the value is obvious.”

Everyone wants doctors and other medical professionals to interact with systems that are as intuitive as possible. The Feds know that usability is make-or-break, and they are developing appropriate usability and quality assurance standards…one hopes. But this is a non-trivial business folks, and there are issues lurking under the surface that give me pause. For instance, there is the crucial distinction between usability and learnability that Andrew Dillon highlights (scroll down to comments):

Distinguish between usability and learnability. Most usability tests are short run tests of people’s initial reactions to a technology. This privileges the earliest phases of human reactions, the making sense of something new. This is important but it is not the full story. I have shown repeatedly in my own work that people’s later reactions take time to emerge and often run counter to their initial ones.

Are your eyes glazing over with this inside-baseball arcana yet? Are you thinking, we pay good money so those nerds with advanced degrees in cognitive psychology or human factors have to worry about this kind of hair-splitting, not us. THAT’S THE WRONG ATTITUDE. Too-big-to-fail projects can fail, and with as much money is at stake with EHR, failure can mean the entire universe is sucked into a fiscal black hole.

Oh, and people can die if we don’t get it right.

New study: “harm to patients resulting from medical care was common”

The healthcare webs are buzzing with the results of a new study by Landrigan and cohort from the November 25 issue of the New England Journal of Medicine (read it here). The medical establishment is understandably never eager to see studies in prominent journals highlighting the dark side of medicine, where mistakes result in increased morbidity and mortality, ethical controversies (when to admit mistakes?), legal hassles, and resulting increased overhead at a level that would give Croesus pause. Of course problems are opportunities, and an army of specialists and managers have done a brisk business in recent years working on improving the situation. Doing well by doing good, perhaps? Researchers are getting interested as well: the relatively new field of medical cognitive science is making efforts to help hospitals cut down on errors. But when a study focuses on the lack of improvement in adverse event statistics after years of targeted investments, certain big-shots may be getting nervous. The Landrigan paper implicitly calls into question what return on investment patients and taxpayers are getting relative to the tremendous sums spent on quality assurance, risk management, error control, continuous improvement of safety, and so forth. The authors are careful to note that they sampled from a specific geographical region, and that in any event efforts to reduce adverse events from care should continue. Nonetheless:

In conclusion, harm to patients resulting from medical care was common in North Carolina, and the rate of harm did not appear to decrease significantly during a 6-year period ending in December 2007, despite substantial national attention and allocation of resources to improve the safety of care. Since North Carolina has been a leader in efforts to improve safety, a lack of improvement in this state suggests that further improvement is also needed at the national level.

And this:

In a statewide study of 10 North Carolina hospitals, we found that harm resulting from medical care was common, with little evidence that the rate of harm had decreased substantially over a 6-year period ending in December 2007. Although there was a modest reduction in the rate of preventable harms on the basis of external reviews, the reduction did not reach statistical significance in adjusted analyses. This apparent reduction was not substantiated by the internal reviews, which by all measures were of higher quality than the external reviews (i.e., higher within-team reliability at both primary and secondary review stages and higher agreement with experienced reviewers).

Our findings validate concern raised by patient-safety experts in the United States and Europe that harm resulting from medical care remains very common. Though disappointing, the absence of apparent improvement is not entirely surprising. Despite substantial resource allocation and efforts to draw attention to the patient-safety epidemic on the part of government agencies, health care regulators, and private organizations, the penetration of evidence-based safety practices has been quite modest. For example, only 1.5% of hospitals in the United States have implemented a comprehensive system of electronic medical records, and only 9.1% have even basic electronic record keeping in place; only 17% have computerized provider order entry. Physicians-in-training and nurses alike routinely work hours in excess of those proven to be safe. Compliance with even simple interventions such as hand washing is poor in many centers.

 

 

A poll on adoption of EHR’s

We are at the stage now where Federal writ must be interpreted and scrutinized by those planning budgets and personnel decisions. Institutions and organizations such as Regional Extension Centers face serious financial and logistical challenges concerning EHR’s. While these challenges certainly present opportunities for those of us in the healthcare informatics/healthcare IT world, the history of implementing complex upgrades to institutions that must provide mission-critical services during the upgrade is daunting. Healthcare CIO’s and CTO’s and directors must proceed with caution as the Feds operationalize the logistics of the ARRA EHR meaningful use provisions.

Houston Neal from www.softwareadvice.com/ passed along a note that they are running a poll on an important issue concerning the adoption of EHR’s and how the Feds are structuring incentives to do so.

One of the major components of the the American Recovery and Reinvestment Act of 2009 (ARRA) was the allocation of $19 billion to jump start the adoption of electronic health records (EHRs). One of the major uses of those funds was the establishment of Regional Extension Centers (RECs) to support EHR adoption by primary care physicians.

The entity spearheading this effort, the Office of the National Coordinator for Health IT (ONC), is specifically charged with helping 100,000 priority primary care providers become “meaningful users” of EHRs in 24 months. Eight months have passed since the ONC began funding RECs, and we’re skeptical that they will deliver.

Don’t get us wrong. We’re big advocates of EHRs. We’re glad to see such an energized EHR market. We’re just skeptical that throwing money at the problem will lead to efficient and successful adoption of this important technology.

In our opinion, there are five fundamental flaws with RECs:

1 Doctor’s aren’t moving as fast as the money is flowing
2 The market already delivers on what RECs promise
3 “Preferred vendor lists” limit choice and free markets
4 RECs won’t get doctors to “meaningful use” fast enough
5 The REC model leads to under-staffed, ephemeral entities“

What do you think about how electronic health records (EHRs) will be imlemented in the key category of Regional Extension Centers ? Take the poll at : http://www.softwareadvice.com/articles/medical/five-reasons-we-think-recs-are-reckless-1092310/#survey#ixzz10rpWUNdV

What is Microsoft’s strategy for getting deeper into the healthcare IT game?

My friends at Software Advice, a web site that profiles electronic health record software, forwarded me a really interesting article about what the “Beast from Redmond” is up to as it hungrily eyes the multi-billion dollar healthcare information technology sector. I am not at all convinced they are going to make good on their efforts. Their core competencies in Windows, Office, and server products do not make them obvious candidates for dominating the EHR /EMR markets, though the SQL Server product line I believe to be robust enough to support EHR/EMR applications on top of it. On the other hand, the contracts for building EHR/EMR systems are so lucrative, and the regulations around their deployment so vast, it might be that only the few companies with the resources to lobby regulators and politicians, and to put up capital and resources to secure multi-year commitments with hospitals (and their third party vendors of legacy and proprietary applications) can compete.

Earlier I analyzed the efforts of Dell to penetrate the EHR/EMR space, and the article I am excerpting below performs a similar, though more in-depth, analysis of what we might expect to see from Microsoft’s efforts in this sector.

from http://www.softwareadvice.com/articles/medical/microsoft-emr-it%E2%80%99s-not-just-a-matter-of-when-it%E2%80%99s-a-matter-of-who-1040510/

Setting its sights on the medical market, Microsoft is starting to squeeze its way in with a few smaller acquisitions and developments of its own, mainly Amalga and HealthVault. However, these current medical offerings are on the periphery of the market and do not really target the sweet spot: electronic health records for physician practices. An intelligent acquisition of a large EHR player would provide a key piece of the puzzle for Microsoft’s entry into the medical market.

Acquired by Microsoft in 2006, Amalga provides information connectivity and interoperability to large healthcare networks. It is the primary Microsoft healthcare offering in the industry at this point, although it is not available in the United States. Microsoft may be planning to offer it domestically, as it did with Navision Damgaard, or may be looking to acquire a domestic vendor to complement it. Regardless of Microsoft’s strategy, Amalga still would not address the physician practice EHR market.

On the other end of the spectrum, HealthVault is a patient-managed, centralized health records solution. It is essentially designed to be a reference point for consumers, not a substitute for medical records. If Microsoft were able to introduce an EHR to the market and enable its users to make records accessible to patients, labs, specialists and pharmacies via HealthVault, then they would really be on to something. This synergy with its other products would just be an added bonus to having its own EHR.

So what would Microsoft prioritize as its key acquisition criteria when evaluating EHR targets? They would certainly want target vendors who possess the following:

1. Large market share and name brand recognition. Microsoft usually likes to be the largest name in the business, so they would definitely want to sell a “big-name” system with which most buyers are already familiar.
2. A scalable product for small and large practices. Microsoft would need to be able to cover a wide range of medical customers. While its bread and butter is always in the small and mid-size market, they would want scalability into the largest organizations.
3. A .Net architecture to drag along infrastructure sales. Reinforcing the position of .Net in the medical software marketplace would be important because it would drive further sales of Microsoft infrastructure while squeezing out Unix, Oracle and IBM.
4. An established, indirect sales channel. Microsoft historically favors selling through partners, including the existing Dynamics dealer network. An EHR vendor with a large dealer network would provide Microsoft an easily transferable sales channel and process.

Discussing ARRA’s “meaningful use” provision: how to define it?

Picking through the July print edition of Healthcare Informatics, and surfing the blog, I see the debate by analysts over what constitutes “meaningful use” of Electronic Health Records/Electronic Medical Records is reaching a crescendo.  “Meaningful use” refers to the criterion for accessing some of the massive funds allocated by the American Recovery and Reinvestment Act for development and implementation of Electronic Health Records/Electronic Medical Records. As Woodward and Bernstein (allegedly) said: “follow the money“.

There is lots of good discussion and fine-grained debate over the definitions and implications of the “meaningful use” provision at http://www.meaningfuluse.org/ . I see at Health Data Management.com a nice summary:

“The federal HIT Policy Committee has approved revised recommendations of a workgroup for an initial definition of “meaningful use” of electronic health records systems. Among the changes made in the recommendations are refinements in computerized physician order entry criteria and a shorter timeline for implementing personal health records.

The definition is important because providers must demonstrate meaningful use of EHRs to qualify for Medicare and Medicaid incentive payments starting in 2011 under the economic stimulus law. The recommendations now go to the Office of the National Coordinator for Health Information Technology and other units of the Department of Health and Human Services. HHS officials will use the recommendations for guidance as they develop rules to implement the incentive programs. A proposed rule is expected by the end of this year.

The policy committee’s Workgroup on Meaningful Use recommends that 2011 criteria apply not just to 2011, but also to a provider organization’s first adoption year. That means if a provider cannot be ready for incentive payments until 2012 or 2013, the organization still will start with 2011 criteria. In other words, 2011 criteria would be considered Adoption Year 1 criteria.

Consequently, 2013 criteria would be in effect in 2013 or in an organization’s third adoption year.

The workgroup’s adopted definition of meaningful use is a matrix of more than two dozen requirements that have been revised to some degree since it first was unveiled a month ago. The workgroup made several clarifications, particularly in the area of requirements for adoption of CPOE. But many of the details remain to be fleshed out during the administrative rules process.”

Meanwhile, over at Modern Medicine, an analyst writes:

“The first public draft of the “meaningful use” definition, the linchpin of the $44,000, five-year Medicare incentive for improving electronic health record adoption, includes too many requirements for physicians to comply by the 2011 deadline, according to a healthcare technology analyst.

“The bar has been set too high, and the recommendations put forth will be virtually impossible to implement within the aggressive time schedule of the HITECH Act,” says John Moore, managing partner of Chilmark Research of Cambridge, Massachusetts, in reference to the EHR incentive legislation. “Simply put, it appears that not enough attention was paid to the processes/workflow changes that are required as part of a successful HIT rollout to meet these recommendations.”

Ephraim Schwartz: Financial and technology issues make Obama’s EHR push not so easy to execute

from www.infoworld.com/article/09/03/11/10FE-electronic-medical-records_1.html

Up until now, the benefits of electronic medical records that have occurred accrue to just about everybody — patients, employers, state and federal governments, and medical insurers — but the actual health care providers. Doctors get the least benefits, especially in small practice groups (those with fewer than five physicians) that make up most medical practices.

But even those who might benefit from electronic health records don’t, says Homer Chin, associate medical director for clinical information systems at Kaiser Permanente Northwest. Why? Because there is little incentive to share information, the core of an electronic health record (EHR; also called an EMR for “electronic medical record”). For example, hospitals make money by doing tests. But once EHRs are up and running, a doctor ordering a test electronically might immediately receive an alert saying the test was unnecessary because the patient had the same test or procedure at another location. “There is not much revenue and profitability in putting in an EHR. There is little financial incentive,” Chin says.

An ironic consequence of EHRs is that, by helping raise the quality of health care, they penalize doctors and other medical providers for success, says Wes Rischel, a vice president at Gartner. The bottom line: Doctors will see fewer patients.

Beyond the income factor, the high cost of EHR systems today — not only the systems, but the setup and training — also dissuades adoption by doctors, especially those in small groups. Physicians have been unwilling to invest anywhere from $20,000 to $50,000 in an EHR system where the economic benefits tend to go to someone else. Today’s EHR systems are not as easy to use as they could be, so there is a large learning curve required, Chin says: “There is something intuitive about paper chart and prescription pad.”

Recognizing these factors, the stimulus package tackles these financial challenges head on by offering money to health care providers. Hospitals submitting via EHR systems to Medicare and Medicaid will receive up to $6 million a year in additional payments for sending data electronically. This incentive will remove much of the adoption inertia seen so far, says Richard Archer, a principal in the health care IT advisory practice a KPMG.

<snip>

But now Microsoft, Google, and AOL founder Steve Case’s Revolution Health are looking at entering the health care information exchange market. All three offer individuals a personal health record, which puts the patient in control of his medical information. But the business aspect is in giving health care providers access to a person’s complete health record from a single site.

There are two major questions around the reliance on health records from these providers, say industry analysts. One is whether users will trust a for-profit organization to care for the most personal kind of information. The second is whether each of us can be trusted to manage and keep such a life-and-death record up to date or if it’s safer to leave that responsibility to organizations whose only job it is to keep the health data updated.

The prognosis for EHRs
EHR providers are, not surprisingly, bullish on the future of EHR efforts. Greg Mancusi-Ungaro, a senior director at Exigen Systems, says deploying an EHR system is just like implementing any big enterprise application, only the enterprise in this case is bigger and the stakes are higher. “The technology exists today and despite the fact that we lack some core standards, we are enabling the development of a flexible infrastructure to stay in tune with requirements. I can visualize a successful national system,” he says.

As Kaiser’s Chin points out, there is a convergence occurring around health care technology regarding how to share it and use it to assist delivery of services and treatment. But the challenge of orchestrating and satisfying so many stakeholders remains. Plus, even if the solutions are mandated rather than eventually negotiated, the task of gathering the many pieces that are still in flux, then integrating them remains a complex technical and process task.

Over time, both industry representatives and analysts expect that every U.S. citizen will have an EHR available nationwide. But to make it happen will require a great deal of cooperation, innovation, and an investment in health-oriented IT. This shift will likely start at a less ambitious level than the political rhetoric suggests, with local practitioners sharing patient information in a local health care ecosystem.

Wal-Mart’s Electronic Health Record plan “could be a game-changer”

from  www.iht.com/articles/2009/03/11/business/11record.php

The company plans to team its Sam’s Club division with Dell for computers and eClinicalWorks, a fast-growing private company, for software. Wal-Mart says its package deal of hardware, software, installation, maintenance and training will make the technology more accessible and affordable, undercutting rival health information technology suppliers by as much as half.

“We’re a high-volume, low-cost company,” said Marcus Osborne, senior director of health care business development at Wal-Mart. “And I would argue that mentality is sorely lacking in the health care industry.”

The Sam’s Club offering, to be made available this spring, will be under $25,000 for the first physician in a practice, and about $10,000 for each additional doctor. After the installation and training, the continuing annual costs for maintenance and support will be $4,000 to $6,500 a year, the company estimates.

Wal-Mart says it had been exploring the opportunity in health information technology long before the recent presidential election. About 200,000 health care providers, mostly doctors, are among Sam Club’s 47 million members. And the company’s research showed the technology was becoming less costly and rising interest among small physician practices, according to Todd Matherly, vice president of health and wellness at Sam’s Club.

The financial incentives in the administration plan — more than $40,000 per physician over a few years, to install and use electronic health records — could accelerate adoption. When used properly, most health experts agree, the migration from paper to digital records can curb costs and improve care.

But especially among physicians in small offices, many doubt the wisdom of switching to electronic health records, given their cost and complexity. Only about 17 percent of the nation’s physicians are using computerized patient records, according to a government-sponsored survey published last year in The New England Journal of Medicine. The use of electronic health records is widespread in large physician groups, but three-fourths of the nation’s doctors work in small practices, of 10 physicians or fewer.

But Wal-Mart has the potential to bring not only lower costs but an efficient distribution channel to cater to small physician groups. Traditional health technology suppliers, experts say, have tended to shun the small physician offices because it has been costly to sell to them — a large market in total, but scattered.

“If Wal-Mart is successful, this could be a game-changer,” observed Dr. David Brailer, former national coordinator for health information technology in the Bush administration.

Weekly Healthcare Reform Update from Healthcare Information and Management Systems Society

Healthcare Reform Update – This Week’s View From Washington, D.C.

from  www.himss.org/ASP/ContentRedirector.asp?ContentID=69003&type=HIMSSNewsItem

Originally, it was estimated that $19.2 billion in health IT was included in ARRA ($2 billion for the Office of the National Coordinator and $17.2 billion for incentives through Medicare and Medicaid).

The Congressional Budget Office (CBO) now indicates that approximately $23 billion is included for health IT through the legislation ($2 billion for the Office of the National Coordinator and $20.819 billion for incentives through Medicare and Medicaid). A new CBO report estimates that enacting the ARRA legislation would increase federal budget deficits by $787 billion over the 2009 – 2019 period. ARRA authorizes and appropriates $2 billion for the Office of the National Coordinator for Health IT. Of the $2 billion, the CBO projects that $300 million will be spent in fiscal year 2009, $1.28 billion in fiscal year 2010, $360 million in fiscal year 2011, and $40 million in fiscal year 2012. (See page 5 of the PDF.) In addition, the CBO now estimates higher projections for eligible providers that demonstrate a meaningful use of certified EHR technology at a new net cost of $20.819 billion. $20.819 is derived from the sum of the total costs of the incentives in fiscal year 2009 – fiscal year 2015 ($36.368 billion) and the total savings that are achieved in fiscal year 2016 – fiscal year 2019 through the incentives ($15.549 billion).

More on Google Health supporting sharing of personal health information with trusted others

hat tip http://geekdoctor.blogspot.com/

According to the official Google Blog at http://googleblog.blogspot.com/2009/03/google-health-helping-you-better.html, Google Health users can now have family, friends, a doctor access a read-only view of  their medical records and personal health information.

“Log into Google Health, click on “Share this Profile,” and type in the email address of the person with whom you’d like to share your profile. Google Health will send an email to them with a link to view your profile. The link will only work in connection with the email address of that person — your profile can’t be accessed if the link is forwarded on. You can stop sharing at any time, and you can always see who has access to your information. Those who are viewing your profile can only see the profile you share — not any other one in your account. We’ve also built in some extra protections to make sure your health information stays safe, private, and under your control:

• The sharing link in the email expires after 30 days, but the sharing access itself does not expire — it will stay in place until the user decides to stop sharing
• Viewers can only see — not edit — your Google Health profile
• You can review a user activity report to see who has viewed your profile