Psychiatrists assessing their interest in the huge $19 billion federal program that aims to entice clinicians and hospitals into adopting expensive digital patient record systems should first ask themselves the following questions:

Do I treat many Medicare patients? Is a large segment of my patient population enrolled in Medicaid? Is a large part of my practice writing prescriptions for psychoactive medications?

Psychiatrists who answered "no" to all three of those questions should approach the federal incentive program with caution, according to psychiatric experts on the information systems that federal regulators refer to as electronic health records (EHRs).

"The clinicians this [incentive program] impacts the most are people who see a lot of Medicare or Medicaid patients," said Robert Plovnick, M.D., M.S., director of the APA Department of Quality Improvement and Psychiatric Services, in an interview with Psychiatric News.

Beginning in 2011, the federal EHR incentive program will provide up to $44,000 to physicians who treat a large percentage of Medicare patients and who purchase a qualifying digital record system and use it according to federal guidelines. The program also will provide both individual physicians and group practices that have many Medicaid beneficiaries among their patients and who adopt qualifying EHR systems with up to $64,000 per physician spread out over five years.

The incentive payments and penalties for physicians and practices that don't adopt EHR systems, however, may ultimately pale in comparison to the cost of purchasing, training on, and maintaining the EHR system, which could range from thousands of dollars to hundreds of thousands of dollars.

But both federal incentives and potential penalties may prove less persuasive than private insurers who develop their own sets of penalties for physicians who lack EHRs, a possible scenario based on insurers' penchant for following practices established in federal programs, Plovnick said.

Physicians can qualify for the incentive payments under either Medicare or Medicaid, but not both.

Psychiatrists who treat large numbers of Medicare or Medicaid patients should ensure that their practice is a good fit for EHRs, which can be costly, complex, and initially disruptive.

"It really depends on the features of the EHR product and its degree of usability to the specific type of practice and the specific workflow in a psychiatrist's practice," Laura Fochtmann, M.D., chair of APA's Committee on Electronic Health Records, told Psychiatric News.

For example, psychiatrists who rely on psychoactive medications to treat a large number of people with complex illnesses may benefit from EHR features that allow them to e-prescribe and to track contraindications and allergies, Fochtmann said.

Conversely, psychiatrists whose practices focus on behavioral or talk therapy may find the EHR format not especially useful because of the time it takes to enter handwritten notes from sessions into a digital format and because they may perceive that there is little benefit to having computerized therapy notes.

The details about what types of psychiatrists already use EHRs—Plovnick estimates about 10 percent of psychiatrists do so—may emerge next year when APA polls its members about whether they use an EHR system and, if so, which type of system they have bought. Nearly half of APA's members are solo practitioners. EHRs are more likely to be in place in hospitals and large health care systems where physicians have little role in the selection or oversight of the EHR system, Plovnick noted.

Once solo practitioners and group practices decide that their practice and patient mix are good fits for an EHR system, they should compare the vendors and individual EHR systems that meet federal qualifications, because the federal incentive payments only are offered for the use of those specific systems. APA plans to provide advice and support through its Web site to its membership on choosing and implementing an EHR system as the incentive program continues to roll out.

The federal regulations governing various aspects of EHRs will continue to be finalized over the next five years, and only physician users of programs that comply with each new group of regulations will qualify for the incentive payments.

"It's really important to talk to the vendors and make sure they will upgrade [their EHR system] at each stage" of regulations, Plovnick said. "That's important because once you are locked in to a plan, it's really hard to change."

The first of those regulatory phases—focusing on basic design and usage requirements—is scheduled for completion by the end of this year. Subsequent phases will focus on inter-EHR communication, interoperability requirements, and, finally, comprehensive security measures—although EHRs will include some security provisions before this step.

APA's EHR updates are posted at <www.psych.org/ehr>.