Often, the question is asked about where EHR adoption and use will go from here. The question is especially salient for small and rural hospitals, and eligible professionals in those areas. Now that the EHR meaningful use carrot from CMS has or is expiring, what does this new reality say about the future?

My first suggestion is to remember the penalties on Medicare reimbursement for not having EHRs in place. Many have run the numbers and concluded that continued implementation, advancement and utilizations of EHRs will cost more than the penalties, and therefore retreating from the process is a wise business decision.

While numbers normally tell the story behind business decisions such as this, we must remember that what CMS giveth, CMS can taketh away. There are no guarantees that the penalties will not be increased over time. It is certain Medicare will become a larger portion of the population, and the Patient Protection and Affordable Care Act represents a whole new arena for potential impacts—penalties if you will—if there is a lack of EHR adoption and utilization.

In my view, MU Stage 3 can be summarized as interoperability, pure and simple. It is coming and is undeniable, so continued use of EHR technologies will be mandated as we move ahead.

Many providers have focused on the increased operational costs of EHR implementations in the form of ongoing support and maintenance costs from the vendors, and have added in the internal costs of continued implementations, training and documentation development. However, few have realized, or better yet been able to measure, the positive impacts of EHRs on operating costs.

Add to the equation the positive impact on patient outcomes and satisfaction—the quality side of the equation. Whether you argue that quality factors haven’t yet been fully realized, or that they should not be included in value discussions, the conversation becomes muddied at best.

I do not see a way that makes sense for the industry to retreat from the journey we are on. What started with ARRA and HITECH in 2009 will not suddenly disappear now that the incentives are drying up. Further, I do not see another round of incentives to rescue the providers from EHR cost burdens. So, with that said, what comes next?

I believe the answer will come in economies of scale, on a variety of fronts. There will be economies of scale on the vendor side, via mergers and acquisitions, as well as economies of scale on the provider side, as practices are acquired by hospitals or are merged together to form far larger practices, not to mention mergers among hospitals and systems themselves. These activities are happening now, and I see no real downside to them, as long as participants do them with the patient in mind.

That does not mean that things will go indefinitely as they are now. The days of the small hospital, by whatever definitions you apply to small (critical access facilities, community hospitals, those with small bed counts or independent facilities) are quite frankly numbered. The same applies to physician practices. Economies of scale are necessary for both to cover the cost burdens of today, and are a positive result for patients.

Some will argue that this paints a bleak picture for small and rural facilities and practices. Rather, it presents an opportunity. It is not about what they do to achieve these economies, be that merger or practice consolidation or acquisition, but how they do it, with the best interests of their patient populations and communities in mind.

There are good consolidations to achieve these economies, and there also are bad ones. The challenge for leadership today is to achieve the economies in ways that better serve the patients and communities, produce better outcomes and reduce costs. After all, better outcomes and reduced costs are why we all began this HITECH journey years ago. It is also why we must continue that journey.

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