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Massachusetts' major hospital and physician associations are taking a wait-and-see attitude on the state's new mandate on health care organizations to implement interoperable electronic health records systems by October 2015 as a condition of their state license. The law applies to the state's hospitals and community health centers.

The mandate is part of health care reform legislation enacted in August. The Massachusetts Hospital Association was neutral, says Dave Smith, senior director of health data analysis and research. "It was thought to be an inevitable part of a law that was going to pass," he adds.

The new law further mandates hospitals and community health centers to implement computerized physician order entry systems by October 2012, which is three years before the EHR mandate. Both types of adopted systems must be certified under criteria of the Certification Commission for Healthcare Information Technology or a successor organization.

Off the Hook

The original legislation mandated physician practices to also adopt EHRs. However, the Massachusetts Medical Society worked to strip that provision before it was passed. "For physicians and particularly small practices operating on thin margins, it is very expensive and essentially an unfunded mandate," says Stephen Shestakofsky, director of state legislation for the medical society.

The medical society argued that the state has a severe shortage of certain specialists and some of them would retire early because they wouldn't remain practicing long enough to recoup their investment. "Our position was to support EHRs as a goal and to encourage them, but not via a mandate," Shestakofsky says. Instead, language was added to establish an institute charged with full implementation of a statewide interoperable electronic health network by January 2015.

Work for Changes

Now that the legislation is law, the hospital association and medical society will work with regulators during the writing of implementation rules to clarify vague areas. They hope to obtain financial assistance for providers who will be adopting EHRs.

For instance, the law includes a $25 million appropriation to the new Massachusetts e-Health Institute that will work to establish the statewide health I.T. network.

The institute is the offshoot of the Massachusetts eHealth Collaborative, which led physician EHR adoption in three communities using $50 million in funding from Blue Cross Blue Shield of Massachusetts.

But it's not clear if some of the $25 million can be used to subsidize EHR adoption-or even if the appropriation will continue to be made in future years. "We just don't know and, of course, that's another concern," says Shestakofsky of the medical society. "Right now, we have a fairly severe budget deficit."

Changes in the Works

There will be opportunities in the rules process or future legislative sessions addressing the topic to amend the new law, says Smith of the hospital association. "Our main concern is some hospitals in financial distress will need a waiver," he notes. "Some hospitals will not be able to afford the capital and other resources without some type of subsidy."

Of Massachusetts' 70 acute care hospitals, only about 15% have fully implemented computerized physician order entry systems, Smith says. Another 15% are at an advanced stage of CPOE implementation. "There certainly will be a fair number of institutions that won't have the resources," he adds.

One major task for regulators will be to determine exactly what EHR and CPOE systems are, and what interoperability means, Smith believes. Many hospitals, for instance, have core clinical information systems, but the degree to which they are interoperable-or can be made so-is unknown.

The new law, Chapter 305 of the Acts of 2008, also mandates collection and reporting of quality and cost data by providers and insurers for dissemination to consumers via a state Web portal.

Pay Up

For all the mandates to be met, the hospital association contends that other industry stakeholders will have to step up and help.

"A lot of this new law is based on a leap of faith that these things will cut costs and improve patient safety," Smith contends.

"But these are unfunded mandates, and a lot of savings will be realized by other entities, including state government and insurers," he adds. "These entities should contribute to the costs of implementing these technologies."

Text of the law is available at www.mass.gov/legis/laws/seslaw08/sl080305.htm.

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