New federal rules may spur switch to electronic systems
Anxious to link inpatient and outpatient data, some hospitals seize chance to help fund EHR conversion
From the November ACP Observer, copyright © 2006 by the American College of Physicians.
By Janice C. Simmons
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What used to be one hospital's pipedream—connecting information from inpatient and outpatient settings—is getting a trial run, thanks to new federal rules that allow hospitals, group practices and other specified health organizations to help physicians get new data-related technologies at reduced or no cost.
After the new rules came out, Akron General Medical Center in Ohio felt it could finally give a hand up to its physicians, who have been looking for ways to finance their own systems, and simultaneously follow through on its own data vision: fully integrated electronic health records (EHRs) that include e-prescribing.
As part of the trial, 50 of the hospital's physicians in internal medicine and family medicine practices began in early October to link their patients' secure outpatient clinical data with inpatient and emergency department data.
"It is sometimes frustrating to get the information from one setting into the other quickly and efficiently," said Richard J. Streck, ACP Member, the medical center's vice president of medical affairs. "And I think this roll-out will allow us to do that."
Rebecca Fallis, RN, and Richard Streck, MD test an EHR system developed by McKesson Corp. for physicians affiliated with Akron General Medical Center.
The new exceptions to the Stark rules and anti-kickback safe harbors that took effect Oct. 10—protections that were heavily backed by the College—now permit the hospital to help physicians and other providers get EHR software at reduced costs. Last August, the Centers for Medicare and Medicaid Services (CMS) and the Office of the Inspector General (OIG) each published separately two final rules on e-prescribing and another on EHRs in the August 8 Federal Register.
Although the downsides are daunting—high costs of hardware plus maintaining and using EHRs and concerns about too-close ties to hospitals—some predict physicians will welcome an easier entry into the world of EHRs and e-prescribing, which promises fewer medical errors and administrative hassles. While BCC Reports states that fewer than 20% of American physicians have electronic records capability, nearly three-quarters of physicians want it, 91% within three years, according to a Harris Interactive poll conducted last summer.
Plus, advocates emphasize that the new self-referral exceptions and safe harbor goals go beyond software and hardware to include uniform interoperability, product certification standards and a national electronic health infrastructure that will be in place by 2014, all of which is expected to add up to better-quality care.
How it works
Under the EHR safe harbor, organizations that provide patients with health care items or services covered by the federal healthcare programs—such as Medicare—may cover up to 85% of the cost of covered technology—specifically, EHR-related software and training services.
The approved donor organizations include:
- hospitals
- group practices
- pharmacies
- health plans
- community health services
- laboratories
Under the e-prescribing safe harbor, hospitals, physician groups, prescription drug plan sponsors or Medicare Advantage organizations may donate the full value of the software and training.
EHR protections do not include hardware. So physicians will likely have to come up with a total of $15,000 to $40,000 (including the software costs) to revamp their systems if they choose to adopt new EHR technologies.
To offset those costs, the College has said Medicare should offer incentives for adding EHRs. Those incentives, which have been examined in Congress, include grants, loans, tax credits, and even add-ons tacked on for Medicare usage.
"We are supportive of what HHS has done. We thought they did a relatively good job," said Patrick Hope, ACP's legislative counsel. However, this may not be enough to promote widespread adoption of EHRs. "It doesn't make any sense that this is really the only vehicle to incentivize physicians."
Imperfect solution...
While many, including ACP, applaud what has been done so far to encourage physicians to acquire EHRs, they cite several problems:
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Other costs. In addition to start-up costs, physicians embarking on a new EHR system need ongoing training, maintenance and updating for the new system.
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Hospital resources. Hospitals may balk at the start-up costs. "Most hospital systems that I know of barely can afford IT improvements for their own hospitals and for their own hospital staffs," said Peter Basch, ACP Member, who has used electronic health technology for 10 years in his private Washington, DC, practice and is also medical director for e-health of the non-profit hospital group, MedStar Health.
"MedStar is investing as aggressively as it can in quality initiatives, but we don't have extra money to support tens of millions of dollars investment in IT for affiliated physicians at this time," Dr. Basch said. "And I think that's true for many hospital systems."
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Ties to hospitals. Some physician offices may "be very skeptical or hesitant to allow a hospital to underwrite 85% of their costs because of the chains that could be applied—even though they're not supposed to be," said Justin T. Barnes, vice president of marketing and government affairs with Greenway Technologies, a Carrollton, Ga.-based company that sells EHRs and physician practice software
Hospitals, though, are interested in "helping the flow of information and improving connectivity to support patient care," said Chantal Worzala, the American Hospital Association's senior associate director for policy. She noted that under the regulations, donations may be made to any physician—even those who are not on staff. This is because changes in the way physicians practice—such as the use of more hospitalists—may mean that fewer primary care physicians are seeing their patients in hospitals but nonetheless want to obtain the information.
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Exclusions. The government excluded several types of organizations under definitions of donors, including research and manufacturing organizations such as pharmaceutical and biotechnology companies.
Also excluded were regional health initiative organizations (RHIOs), which include hospitals, physician practices, insurers and public health departments. RHIOs could be used to help broker the donation of EHR or e-prescribing software providers, said Tom Leary, director of federal affairs for the Healthcare Information and Management Systems Society (HIMSS).
But a start
Despite the concerns about how the new rules will play out in physician offices, some are optimistic about at least having some federal teeth behind the push for EHRs.
In fact, laboratory companies, who did get the go-ahead as donors, are already expressing interest in getting involved, said Scott Wallace, JD, CEO of the National Alliance of Health Information Technology (NAHIT) in Chicago.
Since many physicians do not have the means to transmit electronic messages—faxes are still often used to send information—many lab companies could realize significant cost savings with greater physician use of EHRs, he explained.
Plus, the issue of interoperability—donated EHR software has to be classified as "able to communicate and exchange data accurately, effectively, securely and consistently with different information technology systems, software applications and networks," according to the OIG—is starting to be addressed.
"A lot of systems are not going to satisfy that definition now," said Peter Hoffman, JD, a partner with Garfunkel, Wild and Travis in Great Neck, N.Y. However, in July, the Certification Commission for Healthcare Information Technology (CCHIT), a voluntary private sector organization with a three-year HHS contract to certify health information technology products, announced the first ambulatory EHR products to attain CCHIT certified status.
It is now looking at criteria for certifying 2007 inpatient EHRs and ambulatory EHRs which include laboratory, imaging, clinical documentation and chronic disease management/patient communication.
And, if the new incentives make it easier for even one doctor to get the technology, it's worth it, said Mr. Hope. "But we still have to think administratively and congressionally of what other vehicles are out there to get this in the hands of doctors."
Making it happen
Some physicians have already evaluated the pros and cons and made decisions to go forward—in their own way. Longview, Texas-based Diagnostic Clinic, which has 65 providers, for example, has decided to spend $2.5 million of its own money on an EHR system. "We want to work with the hospitals, but we don't want to be totally integrated with them," said James W. Sawyer, FACP, an internist at the clinic. "We have found ... that what works for the hospital EHR may not work so well in an ambulatory EHR."
The EHRs will help the clinic's physicians follow patients with just one chart as they move among primary care providers and specialists. "We think it's the right way to go, it's the right thing to do and it will improve medical care," Dr. Sawyer said.
Akron General is hoping for the same response from its physicians. The physicians are realizing that the only way they can effectively participate in some pay-for-performance initiatives is by having an electronic medical record in the office, Dr. Streck said.
The hospital's EHR will include e-prescribing, order management and results, charting, and a complete clinical data repository; computerized physician order entry will be added later. After completing the pilot in mid-2007, Akron General plans to offer the EHR to the 200 to 250 hospital-employed and independent physicians in the community. Physicians will pay around $400 per month for software and support.
"Our goal is to enhance patient safety and increase physician efficiency and productivity," said Dr. Streck. "Hopefully at a cost that's affordable."
Dr. Basch acknowledged that convincing physicians to use EHRs means focusing on not just having affordable or even free software and training but on improving the quality of health care. Because physicians may just see EHRs as more unreimbursed work, he emphasized what he believes is the compelling reason to take the plunge: "Using the technology to enable, improve and [provide] more effective and more efficacious health care."
What to know before you sign up for EHRs
If you are considering working with a hospital to set up your electronic health record (EHR) or to receive e-prescribing software and training services, here's what you should ask, according to Peter Hoffman, JD, a partner with Garfunkel, Wild and Travis in Great Neck, N.Y:
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Are the donations non-monetary in nature?
For the EHR rules, for example, the donation needs to be something like the software itself or training services related to the software. -
Is the use, compatibility or operability of the donation limited in any way?
"What the government doesn't want is a closed system—a hospital saying, 'We're giving you [this tool], but it only allows you to communicate with us,'" Mr. Hoffman said. -
Is the e-prescribing component compliant with Medicare Part D?
The e-prescribing provisions are statutorily mandated under the Medicare Modernization Act of 2003, while the EHR rules come under the regulatory authority—meaning they can be somewhat more broadly interpreted. -
What is the cost?
Under the government provisions, physicians must share at least 15% of the cost for EHR software and services. -
Are other physicians or practices being excluded?
A hospital can't pick who is eligible and can't pick practices based on the volume of business that they may generate. -
Do you have a written agreement?
You should have an attorney make sure "both the letter and spirit of the law are being complied with," Mr. Hoffman said. -
Do you plan to use the software on an ongoing personal basis?
If so, it will not be covered under the safe harbors.
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