Electronic Health Record Czar Sees Hurdles for Incentive Plan

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By Robert Lowes

Medscape Medical News 2009

April 9, 2009 — President Barack Obama's point person for digitizing healthcare says the plan to incentivize physicians to adopt electronic health records (EHRs) could falter if eligibility requirements are too ambitious in the April 9 issue of the New England Journal of Medicine (NEJM). EHR experts couldn't agree with him more. Keep it simple, they told Medscape Medical News.

Appointed last month as the national coordinator for health information technology in the Department of Health and Human Services, internist David Blumenthal, MD, will play a key role in implementing a portion of the American Recovery and Reinvestment Act dubbed the Health Information Technology for Economic and Clinical Health (HITECH) Act.

Under HITECH, physicians who demonstrate "meaningful use" of an EHR system can receive $44,000 over 5 years through Medicare or almost $65,000 over 6 years through Medicaid. The first year to qualify for these payments is 2011. Medicare reimbursements progressively shrink for physicians still using paper charts by 2015. The law creates bonuses and penalties for hospitals, too, as previously reported by Medscape Medical News. The law's goal is not just putting a computer in every exam room, but instead improving the healthcare of every patient who walks into the exam room, and cutting costs in the process — hence the emphasis on meaningful use.

Dr. Blumenthal, most recently director of the Institute for Health Policy at Massachusetts General Hospital/Partners HealthCare System in Boston, states in the NEJM article that one challenge for HITECH is a tight schedule. "The infrastructure to support HIT [health information technology] should be in place well before 2011 if physicians and hospitals are to be prepared to benefit from the most generous Medicare and Medicaid bonuses," he writes.

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Don't Force Physicians to Buy User-Unfriendly Systems

What those standards and policies will look like is Dr. Blumenthal's other big worry. According to HITECH, only a certified EHR system qualifies for a bonus, yet the law doesn't specify who will perform the certification. There's a contender in the wings — the Certification Commission for Healthcare Information Technology (CCHIT) — but Dr. Blumenthal writes that many CCHIT-certified programs "are neither user-friendly nor designed to meet HITECH's ambitious goal of improving quality and efficiency in the health care system."

Poor usability, along with high price, is a common gripe about CCHIT-certified products, said family physician David Kibbe, MD, senior advisor to the Center for Health IT at the American Academy of Family Physicians. "AAFP members complain about how much time they have to spend on documenting patient care with these programs," Dr. Kibbe said. "There are too many clicks." He attributes the complexity to the hundreds of software features and functions that CCHIT mandates.

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Meaningful Use, Meaningful Reimbursement

For many physicians and HIT advocates, the "meaningful use" requirements of HITECH represent another unsettling question mark because they have' not been fully spelled out. For example, physicians must use their EHRs to report how they perform on clinical quality measures that HHS has yet to select, but which will lean toward the management of high-cost, chronic diseases. Dr. Blumenthal warns in his NEJM article that the bar for meaningful use could be set too high, frustrating physicians and hospitals. Sam Karp recommends starting low, with quality measures as elemental as receiving lab results electronically, or reducing adverse drug interactions (made possible by automatic alerts that pop up during electronic prescribing).

All the EHR authorities interviewed by Medscape Medical News agreed with Dr. Blumenthal's assertion that physicians will feel more motivated to use EHRs if third-party payers reimburse them for improving the quality and efficiency of healthcare. Family physician Ben Park, MD, an EHR user for 30 years and CEO of a 200-physician network in Indiana and Ohio, said more pay-for-performance programs and their reliance on data collection would hasten EHR adoption, assuming payers put more money on the table. "Right now, it's peanuts for performance," he said.

Dr. Park's desire for higher pay also applies to the HITECH incentives, which he considers too low. Sharing his view is Micky Tripathi, president and CEO of the nonprofit Massachusetts eHealth Collaborative, which has helped some 600 physicians implement EHR systems. Based on his group's experience, Mr. Tripathi estimates that $44,000 in incentives under Medicare would cover only about two thirds of a physician's EHR costs over 5 years.

"The way this program is currently structured, the odds are quite low that EHRs will get high adoption," Mr. Tripathi said.

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