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Group Practices Taking The I.T. Plunge
Health Data Management Magazine, October 2007
Many forces are compelling physicians to automate their clinical documentation. Ashby, who specializes in pain management and addiction treatment, felt he could no longer ignore the force that most pressed him.
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The force that most compelled Princeton (N.J.) Orthopaedic Associates to migrate to electronic records was the financial cost of not doing so. "We were using an awful lot of people to keep track of charts," says Rob Simpson, director of the four-site practice comprising 17 physicians and 120 staff members. "We knew what our costs were for the file room. Like any other information technology decision, it was a pretty easy decision and we have close to a one-year return on investment." The practice uses the document imaging and EHR applications of SRSsoft, Montvale, N.J.
Neither practice, however, felt pressure to go electronic from other market forces perceived to be influential. Patients weren't pushing them to automate, nor were insurers or government agencies. And both Ashby and Simpson are unaware of any hospitals in their service areas rolling out I.T. donation or subsidy programs.
"Nobody was pushing us in that direction," Simpson says. "Nobody seems particularly interested. I thought attorneys would like it, but half of them can't handle electronic media and want the chart printed and mailed to them."
In Simpson's opinion, physicians themselves are the main driving force. Practices are becoming more sophisticated at I.T. planning and recognizing the importance of building I.T. and support infrastructures, he notes. During the last three years, Princeton Orthopaedic has hired an I.T. director and support staff, and Simpson regularly hears the same story when he talks with peers.
Further, physicians are becoming accustomed to using computers at the hospital and at home, he adds.
But in some parts of the nation, the aforementioned market forces are making an impact. There are signs that the federal government's revamping of rules to permit hospitals to donate I.T. systems and services to community physicians are starting to bear fruit, says Patrick Cline, president of NextGen Healthcare Information Systems Inc., a Horsham, Pa.-based physician software vendor.
"We have noticed an up-tick in the interest level of hospitals, and we do see them having related strategies in place or developing their strategies," he notes.
The Methodist Hospital System in Houston is developing a donation program. The Department of Health and Human Services' ruling in August 2006 to permit such programs provided an impetus for the project, says Matt Fink, vice president of information technology. "We had a strategy; the rules certainly made it easier."
Donation programs are most likely to evolve in competitive regions with four or five delivery systems, Cline says. "If one hospital can turn a large cardiac practice away from another hospital, it's worth millions of dollars to do it."
But he also sees some activity in non-competitive areas, in what he calls "Bozeman, Montana-types of places with a dominant hospital." For example, seven-hospital Munson Healthcare in Traverse City, Mich., has little competition in the hospital market, yet is rolling out an I.T. donation program (see story, page 32).
Other market forces, such as more affordable contract terms, and industry efforts to develop data standards and EHR certification programs, are starting to factor into decisions on whether to pull the trigger and adopt clinical systems.
Certification from the Certification Commission for Healthcare Information Technology was an important consideration when Advanced Pediatrics Associates in Aurora, Colo. chose its EHR vendor. "It's like a report card," says Mark Pearlman, M.D., a pediatrician and the practice's computer guru. "Do you really want someone with consistent D's, or A's and B's?'"
Even some physicians who adopted an EHR before CCHIT's program believe certification has value for other provider organizations now considering an EHR. "Having a certification program will give physicians confidence that someone has looked at the product and it's at least reasonable," says David Fairbrook, M.D., owner of The Clinic at Panorama City in Lacey, Wash.
The biggest change in the market may be a readiness among the physician community to implement clinical systems that wasn't present three years ago, says Chris Podges, corporate vice president of information systems and CIO at Munson Healthcare.
"People started to take notice as a handful of influential clinics took the jump," he notes. "There is a growing sense of inevitability, and the products have matured and gotten less expensive."
For Advanced Medicine & Laser Institute in Hudson, Ohio, the jump to an EHR occurred when solo practitioner Mahmud Kara, M.D., opened a second office in nearby Ravenna. "Sometimes, patients will see him in both offices and it's really hard to move charts back and forth," says Angela Ziccardi, office manager.
So Kara, an internist specializing in cosmetic and natural hormone replacement procedures, and his staff planned last month to go live with a combined practice management/electronic records system from Henry Schein Medical Systems, Melville, N.Y.
The practice considered an EHR several years ago when it just had the single office, but the cost was prohibitive, Ziccardi recalls. Now, prices and usability are better. She also expects good support because the software was bought from a local reseller.
What was missing in the decision to adopt clinical systems was any pressure from industry, government, insurers or patients. Kara, unaware of the CCHIT program, did not consider certification when selecting a vendor.
Nor was the practice aware of government initiatives at any level to encourage EHR adoption, Ziccardi says. While patients weren't asking why the clinic still used paper records, she believes other paper-based practices will start to feel that pressure as patients begin to ask such questions.
For the practice, the clinical benefits of having all patient data accessible at either office, and financial benefits from bringing billing in-house and spending less on transcription services, made the investment in clinical automation financially possible.
Still, the migration is a big task and at times has been a tedious one. The practice is scanning paper records into the clinical data repository, but in the weeks before go-live, Ziccardi hand-entered patient demographic data into the new system. "I wish there was a way old records could be merged into the EHR," she says.
Government Push
Business considerations also were the major force that compelled migration to electronic health records at The Clinic at Panorama City. But a bit of prodding from the Washington state government helped.
The practice has two physicians and one nurse practitioner serving 6,000 patients, 60% of them on Medicare.
Fairbrook, who will be 65 in October, has been laying the groundwork for a younger physician to take over the practice. "Trying to get someone to take a primary care practice with this many Medicare patients and paper records would be difficult," he notes.
Last year, Fairbrook's independent physician association was encouraging adoption of electronic prescription software and the state was mandating that prescriptions be printed or electronic. "The state's action certainly encouraged us to do something different," Fairbrook recalls.
He started with electronic prescribing in March 2006 and in July 2007 went live with practice management and electronic records software from Purkinje Inc., St. Louis. The practice also served as a beta site for the vendor's new outsourced billing and collections service, which gave it a sizable discount on the practice management and records software.
The Clinic at Panorama City spent $18,000 to upgrade its computer equipment and pays $340 a month for the software plus a certain percentage of the revenue that the vendor brings in from the billing service. For Fairbrook, the economics of migrating to electronic records have been reasonable. "I spend $500 a month to clean the building."
With the EHR, the clinic's transcription bills have gone from $4,000 a month to $200. With Purkinje handling the billing and collections, the practice's claims are paid in 10 to 14 days, twice as fast as before.
And Fairbrook believes he is a better physician. "EHR is all about the clinical decision support that should come with it," he contends. "We need to practice evidence-based medicine and have the evidence at our fingertips."
Further, he's more confident in his quality of care: Electronic prescriptions are checked for appropriateness, he has access to treatment guidelines to double-check decisions and he knows when patients are due for preventive services.
Fairbrook believes another state initiative will unintentionally move other physicians to automate.
The state has created a chronic disease electronic management system to analyze self-reported data to help physicians better monitor chronically ill patients. Without an EHR, collecting and reporting that data can be exceedingly difficult; with an EHR it can be automated. "This will move doctors to say, 'Why do I have to do this on paper, why not get an EHR and do it myself?'" Fairbrook says.
For Fairbrook, the benefits of EHRs are clear, yet he never received outside pressure to adopt the technology.
However, he believes insurers will start to care about physicians moving away from paper records as pay-for-performance programs are rolled out. Payers, he notes, will want documentation on how their members are treated, such as proof that mammograms are being scheduled and performed according to best practices.
Fairbrook has been encouraging a local hospital to consider an I.T. donation program and call his EHR vendor. Hospital executives have been to the clinic to see the system, and he's hopeful that some sort of program could be forthcoming.
The Methodist Hospital System in Houston for several years has looked at ways to integrate inpatient and ambulatory data. That goal is a major reason for its planned I.T. donation program.
Opposition Pressure
But Methodist also has competitive reasons-several rivals in its market are offering or are developing donation programs, notes Matt Fink, the vice president of information technology. Once the Department of Health and Human Services and the Internal Revenue Service issued rulings that permit donations, Methodist started moving.
But rolling out donation programs would be easier if the feds were more clear on exactly what is permissible and what is not, Fink contends.
For its owned ambulatory sites Methodist Hospital System will implement practice management software from Cambridge, Mass.-based athenahealth Inc. integrated with the ambulatory EHR of Eclipsys Corp., Boca Raton, Fla.
The delivery system will subsidize the purchase of the technology-which will integrate with Methodist's inpatient EHR from Eclipsys-by independent community physicians.
The donation program will start in 2008 and roll out over several years, Fink says. For now, Methodist has work groups studying the pricing and legality of its proposed program. He would like the federal government to come up with a clearer definition of what I.T. and services can be donated.
For instance, if practice management and electronic records are in an integrated package, is the practice management component eligible for subsidized pricing? "It can be challenging to determine what pieces can be donated and which cannot," Fink says.
Consultant Jim Gaddis of HIMformatics LLC in Atlanta believes 10% to 15% of hospitals are considering donation programs. A half-dozen of his hospital clients-in competitive markets-are in the early stages of looking at the issue.
"They don't yet know how much it will cost and what the benefits are," he says. "They know it will tie them closer to doctors but are not sure if those benefits are enough."
While the HHS and IRS rules certainly have helped push donation programs, the government needs to be more specific in many areas, Gaddis says. "There is no guidance on structuring subsidies except to not do it based on referral patterns," he notes.
More guidance would speed donation programs, he believes. Hospitals are struggling with such issues as whether they can give a bigger subsidy to early adopters or physicians serving certain populations, and how software-hosting arrangements affect the fee structure.
For instance, he asks, if a hospital's hardware used to host its inpatient EHR also will host the ambulatory EHR, how does that affect its fee structure as the hospital determines fair value of an infrastructure already in place?
Leave Me Out
Not every physician practice is enamored with the idea of a local hospital donating information systems.
Pearlman, the pediatrician at Advanced Pediatrics Associates, doesn't trust a hospital to adequately maintain and support an ambulatory EHR. His fear is that with the hospital information technology department having so many priorities, the ambulatory EHR would be low on the totem pole.
"If you need something fixed, you're not going to be at the head of the line," Pearlman believes. "Truly, you'll probably get what you pay for."
Advanced Pediatrics Associates expected on Sept. 18 to go live on its TouchWorks EHR from Chicago-based Allscripts LLC, sold and serviced by MED3000 Group Inc. of Pittsburgh.
The 10-physician practice, with 12 mid-level practitioners and three sites, is growing and getting too big for paper charts, Pearlman says. A patient may be seen at one office but the charts often are at another. "With three offices, it's becoming more and more onerous to see patients without charts," he contends. "We sometimes work with one sheet of paper that's blank and that's no help when a patient has a question. We're looking at opening a fourth office and no way would do that without an EHR."
While implementing EHRs is a big step for a practice, it's no longer a flying leap: Templates in today's ambulatory EHRs are easier to customize than two or three years ago, enabling physicians with moderate computer skills to set up templates, Pearlman notes. "None of the stuff we're doing is rocket science." He's also getting help from the vendors when needed.
Another change in the past few years is the attitude of physicians toward EHRs, Pearlman says. Two or three years ago, some of his partners would have refused to automate, but now they grudgingly accept it. "For people practicing 30 years, it's a major change."
Still, group practices will have to roll up their sleeves to install an EHR, Pearlman cautions. "No matter how much time others tell you it will take to select, build, train and bring up, it will take more," he adds. "It will take 50% more time in hours working in the background to make the EHR work the way you want. It's worth taking the time because the end product will be much better."
Sidebar
EHRs become affordable for solo doc
When Robert Ashby, M.D., looked at electronic health records systems he saw "a lot of the systems for $50,000 designed for large practices with features I didn't need," recalls the Scottsdale, Ariz.-based solo practitioner with one medical assistant.
This year, he settled on the SpringCharts EHR from Houston-based Spring Medical Systems Inc. because it combined low cost with the necessary functionality.
Ashby paid $5,500 for the software, $2,000 for a server, and $3,000 to replace two computers with Macs from Apple Inc., Cupertino, Calif. The Macs were bought because they are more user-friendly than PCs, Ashby says, plus he felt comfortable using them to set up and maintain the network himself.
He also paid $3,200 for training and has an annual maintenance fee of about $500. A document scanner was purchased for $500 to digitize remaining paper documents, which it does at 36 pages a minute.
Instead of creating a library of templates for different diagnoses he treats, Ashby, a specialist in addiction and pain management, waits until he treats a patient with a certain condition before he creates a template. "It's sort of time-consuming the first time, but very quick afterward," he says.
Earlier this year, Ashby seriously considered two EHR products. He picked SpringCharts because the vendor had a downloadable program "and I played with it quite a bit and liked it."
Ashby's message to small practices is that EHRs are doable, improve care and should increase revenue through more complete coding and documentation. "It can be done and I think in the long run it will help my bottom line by greatly increasing efficiency."
Sidebar
Munson explains its donation programMunson Healthcare for seven years has been building an electronic health records infrastructure in its seven hospitals serving northern Michigan. The work is part of a vision of integrating community health data to enable clinician access to acute care and ambulatory patient data throughout the delivery system.
A new part of that strategy started rolling out in June when the Traverse City-based delivery system launched an EHR donation program for community physicians.
Planning started in earnest after the Department of Health and Human Services published rules last August to permit I.T. donations. In June, the Internal Revenue Service ruled that donations would not jeopardize hospitals' tax-exempt status, and the program was deployed.
"We knew the legal environment was changing," says Chris Podges, corporate vice president of information technology and CIO. "We moved along with the strategy but waited for the rulings before launching."
Flagship 391-bed Munson Medical Center is heading up the donation program. The degree to which six affiliated community hospitals will participate isn't yet determined.
About 350 physicians in more than 50 practices have privileges at Munson Medical. After two months, five practices had joined and three others were finalizing their contracts, Podges says. "The investment level of the clinic is such that this is not a free lunch," he adds. "They have to be committed, so we didn't expect a line out the door."
Under the donation program, Munson Medical is subsidizing 40% of the software license fee for practices with five or more physicians. For smaller practices, it is subsidizing 40% of the license and implementation costs. Munson will remotely host the software and the practices will pay for office-based hardware.
Further, Munson subsidizes 85% of annual hosting fees, for which it determined a fair market value of $2,500 per physician per year. That means the practices annually will pay about $375 per physician.
Munson Healthcare is subsidizing EHRs from NextGen Healthcare Information Systems, Misys Healthcare Systems and the A4 Health unit of Allscripts LLC.
The delivery system would have preferred to pick a single vendor, but all three have significant market share in its service area, Podges says. "The community was never going to settle on one vendor, but I didn't want to integrate with too many EHRs," he notes.
Uncertainty Remains
While the IRS gave the green light to I.T. donations, it has yet to determine if the donations can be considered taxable income, Podges says. This means physicians could be compelled to pay taxes on the full value of the I.T. being subsidized.
Munson Health executives believe the IRS eventually will issue a favorable decision. But for now, the I.T. donation contracts include language that alerts physicians to the possibility that they may be liable for taxes.
So far, no one has balked at that caveat, Podges says. "The subsidy is compelling enough for those who are ready to invest and make the leap."
Munson Healthcare faces little competition in its service area, so gaining an advantage over other hospitals wasn't a motivator for the I.T. donation program. Its vision of integrated community health data was the reason, Podges notes. "We're never going to reach our vision if we ignore the data in clinics."
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