Govt. Tries Multiple Strategies to Boost Electronic Record Use

Although recent research indicates that the adoption of electronic health records (EHRs) by physicians nationwide is proceeding slowly, federal officials are confident that the pace will pick up and that clinicians will soon be using the technology in sufficient numbers to meet the national implementation target date of 2014.

In recent interviews with Psychiatric News, federal officials said they were not surprised by findings of a national physician survey that showed relatively few clinicians extensively use health information technology.

The national physician survey, published in the July 3 New England Journal of Medicine, found that only 4 percent of physicians have“ an extensive, fully functional electronic records system,” and 13 percent have a basic system. Psychiatrists were one of several medical specialty groups not included in the survey.

The survey was designed to identify the extent of adoption nationwide because no definitive national study has provided reliable estimates of physician adoption of EHRs. Previous estimates ranged widely from 9 percent to 29 percent.

Usage Low but Trending Upward

“We have known for some time that we have been pretty low [in number of physicians] in terms of any EHR adoption, and the first step was to get a good handle on what those levels were and how they have been changing recently,” said psychiatrist Robert Kolodner, M.D., National Coordinator for Health Information Technology, in the Department of Health and Human Services (HHS), in an interview with Psychiatric News. “So it's not news that they are low, but depending on how you look at the data there does seem to be some movement upward.”

The physician survey and a Government Accountability Office (GAO) report issued in May agreed that the start-up and ongoing costs of electronic health information systems have greatly impeded adoption by many clinicians, especially those in small and solo practices. Other barriers to the use of health information technology (HIT) that physicians identified were their concerns that the various commercially available EHR systems are not interoperable and that they could face increased legal liabilities from the use of the technology.

Karen Bell, M.D., director of the Office of HIT Adoption in HHS, told Psychiatric News that it has been clear for some time that costs continue to be the biggest obstacle to physician use of various aspects of HIT, including EHRs.

“However, there are a number of other barriers as well, and we have been working across all of them to find ways to push the adoption agenda forward in physician offices,” Bell said.

Federal Commission Appointed

Among the federal efforts has been the creation of a certification process through the Certification Commission for HIT, which provides annually upgraded standards for commercial HIT systems to ensure they provide physicians with needed functionality, system interoperability, and state-of-the-art security.

“Purchasing a certified system is the first step in knowing that you are headed in the right direction,” she said.

The Centers for Medicare and Medicaid Services (CMS) also has launched an effort to get HIT information out to physicians through its Doctors' Office Quality Information Technology (DOQ-IT) program, which CMS states was“ created to promote [EHRs] in ambulatory care.” It presents every process that a physician would need to do his or her job. Bell said her office is trying to make this information more widely accessible by physicians.

Once physicians have some idea of what systems they want to buy and know that those systems are certified for compatibility, some also may need help overcoming the start-up costs and the ongoing financial burden of purchasing HIT system upgrades or add-ons, according to the recent research.

Help in overcoming these cost obstacles can come from evolving business approaches, such as application service providers, also known as providers of on-demand software, which offer software over a network. The application service providers reduce the complexities and costs of HIT software by providing continuing performance and security updates over a network connection.

Costs of HIT systems also are being addressed by many of the large health insurers, including the federal government, which sees computer technology as an imperative ingredient for improving the efficiency and quality of the nation's health care.

The leading federal effort to provide clinician cost support is the CMS EHR demonstration project. The Medicare Care Management Demonstration provides financial incentives to physicians who use an EHR system certified by the Certification Commission for HIT and who regularly submit performance data electronically to CMS. Another CMS pilot project announced in October 2007 will make bonus payments to small physician practices that use certified EHRs.

These approaches are based on the understanding that physicians need upfront financial support, as well as ongoing financial incentives to cover the long-term costs of HIT.

“That is one particular area where the government has taken a stance in terms of helping to address the business case for physicians,” Bell said.

Other federal efforts included CMS's creation of an exception to the“ Stark Law” in October 2006 that allowed hospitals to provide some financial support to help physicians adopt HIT. Another financial effort by federal officials may come through discussions with malpractice insurance companies to provide malpractice-premium credits to physicians with good records who are using certified systems, Bell said.

One physician concern that federal officials are not addressing directly is physicians' desire for stronger legal protections for potential liabilities stemming from their use of HIT, such as in instances of theft and misuse of patient records.

Legal opinions from outside lawyers indicate that the liability risk from electronic records is the same as physicians already face with paper records, Bell said. Although the risk of faster dissemination is much greater with electronic records, federal officials said they would have to wait for legal cases to know what additional protections are needed for clinicians.

“We've been talking about [enacting additional legal liability protection] but we're not clear that it can be done at this point, at least that is what we hear from external legal counsel,” Bell said.

It remains unclear whether federal efforts to encourage physician HIT adoption will be sufficient to meet the Bush administration's goal of making an EHR available for most Americans by 2014.

Despite the low number of clinicians using the technology, Bell and Kolodner said that there are indications that there will soon be a large increase in physician adoption, including a large number of doctors who have purchased systems and are only waiting to start using them.

“We are going to see a fairly large uptick fairly soon. So I have no concern that we won't be reaching our goal,” Bell said.

Information about the national physician survey is posted at<http://content.nejm.org/cgi/content/full/359/1/50.> Information on DOQ-IT is posted at<www.cms.hhs.gov/PQRI/Downloads/Vendor_Notification_082707.pdf>. Information about the CMS HIT demonstration project is posted at<www.hhs.gov/news/facts/20080131c.html>.▪