A few years ago, my partners in AHITA.org ( a non-profit organized to help providers implement EHRs)  and I implemented an electronic health record in a physician practice. Along the way, we evaluated every major product and discussed with the physicians in the practice what they needed and how to examine their workflows to automate.  It was very effortful, took almost a year, and cost the physician practice about $50,000 in consulting fees.  At the end of the engagement, the AHITA partners decided in all good conscience that all the products sucked and wouldn’t help a small practice; we kind of drifted away from the idea of electronic health records. Our physician partner, who had written his own EHR, gave up in disgust because he couldn’t get anyone to buy it.

Now, Obama’s administration has given incentives that mandate EHRs. 2010 looks like it is going to be the year. And hopefully, many of the products have improved in their ease-of-use and financing programs during the past couple of years. There’s a lot of behavior change around implementing new technologies, and even practices that already own EHR technology need to learn to use it properly to qualify for the meaningful use incentives the government is offering. For most practices, this will mean an increased focus on workflows around ordering, e-prescribing, and clinical decision support and some attention to improving them, not just automating disfunction.

As far as I can discern from listening to the Allscripts webinar I just heard, many of the incentives revolve around seeing more Medicare and Medicaid patients.  All those physicians who were going to give up Medicare patients will be re-thinking that, because to qualify for the stimulus money they have to prove that 44% of their volume is Medicare, or 30% is Medicaid. And this is calculated by individual physician, not by practice.

For a physician, the Medicare part of the program starts this year. But this year you only have to prove that you used electronic records for 90 days during the year, and that at least 50% of your patient encounters have to be at a practice using a certified EHR. That goes up with every passing year.

Another interesting incentive: the physician’s payment will be based on multiplying his or her allowable charges  by 75%, so seeing a Medicare patient and using an EHR should make the patient (me) worth 75% more to the physician who sees me, especially if he delivers professional services, and doesn’t just send me for an MRI or to a lab. The incentive doesn’t count  fees for surgicenters or technical components of a doctor visit. This will be Medicare Part B services. (A physician aiming to collect $18k in 2011 has to submit allowable charges of $24k to Medicare and she will get paid $24k+$18k).

Physicians have to choose whether they want to participate in the Medicare part of the incentive program, or the Medicaid part. For a busy primary care practice, I bet Medicaid patients begin to look more attractive.

Now, away from the money and on to the part that benefits the patient:

Your doctor will now have to use five decision-support alerts in her software, and will have to give you electronic access to your records within 48 hours of your request. The incentives encourage the patient to become part of the conversation, and the doctor to communicate with the patient electronically. The government wants people to use personal health records, and for the physician to communicate with those PHRs, and that is going to happen FAST.

Here’s what the EHRs these physicians adopt will be required to do for the physician to get the subsidy:

• Electronically select, sort, retrieve, and output a list of patients and patients’ clinical information, based on user-defined demographic data, medication list, and specific conditions.
• Calculate and electronically display quality measure results as specified by CMS or states.
• Electronically submit calculated clinical quality measures
• Electronically generate a patient reminder list for preventive or follow-up care according to patient preferences based on demographic data, specific conditions, and/or medication list.
• Implement automated, electronic clinical decision support rules (in addition to drug-drug and drug-allergy contraindication checking) according to specialty or clinical priorities that use demographic data, specific patient diagnoses, conditions, diagnostic test results and/or patient medication list.
• Automatically and electronically generate and indicate real-time, alerts and care suggestions based upon clinical decision support rules and evidence grade.
• Automatically and electronically track, record, and generate reports on the number of alerts responded to by a user.
• Electronically record and display patient records and connect with other providers
• Patient information: electronic copy upon request in 48 hours80%
• Patient access to electronic information (i.e. lab results) within 96 hours of availability10%
• Clinical summary of each patients’ insurance eligibility, and submit insurance eligibility queries to public or private insurers

All the major products do this in one way or another. This doesn’t make them easier to deploy or train staff on, or use. Or make the change management any easier (that’s the part I do).

However, this sounds very promising for both the patient and the physician. And it’s not part of health care reform legislation, it was part of the stimulus, so we know it’s going to happen.

Makes me remember when electronic claims processing came into widespread use — which was not until Medicare mandated sending them electronically in order for physicians to get paid.  You’d be surprised how fast paper claims disappeared:-)

Any meaningful effort for health care reform has to include the participation of the IT community and continued progress toward electronic health records, streamlined claims procedures, and ability to disseminate public health information efficiently. The National eHealth Collaborative aims to partner the public and private technology communities to create a “secure, interoperable, nationwide health information network.”

From their press release:

The National eHealth Collaborative brings together these stakeholders to accelerate development of the health IT systems, infrastructure, standards, protections, participation, and education needed to create a secure, interoperable, nationwide electronic health information network. The Collaborative provides a needed and credible forum for stakeholders to transparently vet and prioritize national advancement efforts and leverages the value, resources and best practices offered by both the public and private sectors. The Collaborative works in close partnership with the Health Information Technology Standards Panel (HITSP), the Certification Commission for Health Information Technology (CCHIT), and the Nationwide Health Information Network (NHIN), as well as other health and IT member organizations.

The complete list of their directors is here.

Here is a list of their goals:

• Consistent standards to guide the development, sharing and updating of confidential individualized health information within a secure national network;
• Education, guidance and incentives for widespread adoption of electronic health records by health systems, health professionals and individuals;
• Creation of the secure, interoperable network that enables immediate, consistent, protected access to relevant personal health information at the point of care, anywhere and anytime it is needed;
• Collaboration among a wide variety of institutions and organizations to enable broad, efficient, seamless and confidential exchange of secure, individualized health information—leading to system-wide improvements in health outcomes, access, and quality of care, as well as reduced costs over time; and
• Partnership with members of the Nationwide Health Information Collaborative and others to develop a governance plan for the Nationwide Health Information Network.

While I view this as a positive movement toward health care reform, their board members seem to come from insurance companies and corporate interests, with no representation from the technology sector. Shouldn’t companies that actually create the platforms be a key player in the discussion?