The Future of Digital Health

Gary Baldwin
Health Data Management Magazine, December 1, 2009

This article is the last in a six-part series examining what industry pioneers have accomplished with electronic health records. In this installment, Editorial Director Gary Baldwin reconnected with sources from the series and with other experts to raise one final question: What does the future hold for clinical I.T.? Much of the discussion centered on the impact of the federal government's $49 billion program of incentives, grants and supporting projects aimed at promoting EHRs. While all were optimistic, each raised serious concerns that, if left unaddressed, could derail the nation's march to the EHR.

THE PHYSICIAN CHAMPION

Larry Garber, M.D., Medical director, informatics

Organization: Fallon Clinic, Worcester, Mass.

EHR Achievement: Paperless medical group

Fallon Clinic has attained a degree of electronic clinical documentation that remains a pipe dream for the vast majority of the nation's group practices. With the exception of consent forms, no paper documents are in use at the 250-physician, multi-specialty group practice. Physicians have access to a bevy of data, including 15 years of test and treatment results; current medications and allergies; and inpatient and emergency department documentation from several local hospitals. Fallon also is connected to its major health plan, which feeds claims data into the group's EHR. Patients, too, are in the electronic loop, having the ability to send physicians secure messages and retrieve a personal health record based on the official chart. "We're living in the future and waiting for the rest of the country to catch up with us," Garber says. "They will."

The source of Garber's optimism is the massive I.T. stimulus program, a $49 billion package of incentives, grants, training centers and other initiatives aimed at spurring the industry into connectivity. "The stimulus legislation is a great enabler for the country to be successful," Garber says. Under the program, physician groups and hospitals would qualify for bonus payments - of up to $44,000 per physician from Medicare or up to $63,000 from Medicaid - for using certified systems in a meaningful way. While the terms of the program have yet to be spelled out, the money represents a financial incentive to adopt that heretofore has been lacking for group practices. And make no mistake, the technology requires capital. Fallon spent nearly $24 million on its EHR in its first three years

The barrier to physician adoption is not just financial, however, Garber adds. There are also workflow issues and training needs. "We could implement because it was practical for us, given our size," Garber notes. "We can have a help desk, eight trainers, a large team of analysts, techs and database specialists. But we have 330 providers (Fallon also encompasses 80 mid-level providers in addition to its physicians)." That's not feasible for the smaller group practices that comprise the vast majority of the industry, he says. "A small group cannot hire one-tenth of a trainer."

The federal stimulus program understands that dilemma, Garber says. The program includes regional extension centers, which would function as training and resource centers for practices, particularly small and rural ones. "The government was smart to shift money to the extension centers and put less emphasis on loans. That made it harder for docs to just jump out on their own." The downside to premature physician adoption, Garber contends, is that many practices might make unwise decisions about their systems, such as picking the wrong underlying data sets to support electronic orders. "The extension centers will pull together communities," he predicts. "When you have 100 physicians going live at the same time, you can pull together a team to help them."

THE PRAGMATIST

Phyllis Schuck, CIO

Organization: Pinehurst (N.C.) Surgical

EHR Achievement: Paperless medical group

The industry is on the cusp of a major sea change, Schuck says. Group practices are about to lose much of the autonomy they have enjoyed, because the government, and other payers, will no longer tolerate inefficient business practices. A reimbursement overhaul is inevitable, she predicts, given rapidly rising costs. "The talk about EHR is just laying the groundwork for changes in how health care is paid for. The industry will force physician groups to adopt," she says. "And some providers will retire, rather than change."

The change, however, is overdue. "Hospitals and physician offices do not coordinate care very well," she says. "The rules make it difficult to share information. But once we get health information exchanges in place, there will be great strides in the EHR."

State data exchanges will likely play a major role in the distribution of federal incentive money. Schuck envisions the model working because "every state has a financial obligation to Medicaid. It is in their own best interest to develop a method that allows a common database to keep tabs on what goes on with Medicaid patients."

As far as the federal incentives for physicians to adopt EHRs, Schuck is ambivalent. Despite its own electronic records success, Pinehurst Surgical has had limited success embracing any of the government's other I.T. incentive programs, such as the Physician Quality Reporting Initiative, which rewards group practices for hitting certain care milestones for chronic conditions. "Our physicians have tried and found it is not practical," she says.

CMS wants to know if physicians are following the right diagnostic steps and uses a checklist. It is very time-consuming."

What shapes the reporting of data to attest EHR meaningful use will take is anyone's guess. Schuck only hopes the requirements are not overly complicated. "The way I see it, we already have meaningful use."

THE CONSUMER ADVOCATE

Ed Babakanian, CIO

Organization: UC San Diego Medical Centers

EHR Achievement: HIMSS Analytics Stage 6

When Babakanian peers into his crystal ball, he sees the face of consumerism. Consumers would never do business with a bank that did not enable electronic transactions, and in time, they will carry that expectation to the health care industry. "People don't want to call us and wait an hour on the phone," he says. "They want to send us a secure message, like they do in making airline reservations." To that end, UC San Diego is building a consumer-oriented patient portal, called MyChart. It's linked to the academic medical center's EHR.

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