Should I buy my EMR now? The experts weigh in

Doctors have many questions about electronic medical records, especially now that the federal government is pushing for their use.

By Tyler Chin — Posted Oct. 11, 2004

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Until now, most physicians haven't seriously considered -- much less felt compelled to even think about -- buying an electronic medical records system.

But that started to change after the Health and Human Services Dept. in July released a strategic plan outlining a broad array of steps it plans to take to implement a national health information network and electronic records for every American within the next decade. Those include calling on the public and private sectors to offer financial incentives to encourage doctors in small- to medium-size practices to adopt an EMR.

Here are some common questions physicians have regarding EMRs and HHS' advocacy of them, followed by answers gleaned from physicians and technology experts.

So, should I buy an EMR now? There's no need to rush. The HHS plan doesn't mandate that physicians use EMRs. Also, the plan offers a broad vision of where HHS wants to move the industry, but no specifics on how.

"There are lots of details that have to be filled in to assure that the program will actually work and that clinicians will actually adopt technology," said Peter Basch, MD, co-chair of the Physicians' Electronic Health Record Coalition, which the AMA and 13 other medical societies founded in July to help doctors learn, choose and implement affordable EMRs.

In general, PEHRC supports the concept of using information technology as a tool to improve care and patient safety but hasn't yet taken a formal position on the HHS plan, said Dr. Basch, an internist at a four-doctor group owned by MedStar Health, a health system in the Washington, D.C., area.

"I'd not advocate that small- to medium-sized practices buy an EMR now unless they want to do it and like technology," said Peter Kongstvedt, MD, a vice president at Capgemini Health, a national health care consultancy.

At this time, EMRs makes more sense for larger practices because they can better afford and stand to reap greater economic benefits from using EMRs than smaller practices, he said. As a result, smaller practices "are probably better off waiting a few years" when EMRs sold by different vendors will be compatible with each other, less expensive and easier to use, Dr. Kongstvedt said.

Ultimately, whether you're ready to buy an EMR is a question only you can answer, based on the particular circumstances of your practice, said William F. Jessee, MD, president and CEO of the Medical Group Management Assn., in Englewood, Colo. Those circumstances include the size of your practice, what kind of technical and management support you have, and what other information technologies your office has.

"If I were a single physician practice with no previous information technology experience," Dr. Jessee said, "I probably wouldn't leap into an EMR as my first venture because it could be costly and much more difficult to successfully implement than taking some more incremental steps." Electronic billing, prescribing or document imaging are among the incremental steps Dr. Jessee described.

I don't want to buy an EMR. Can I count on this issue disappearing if President Bush isn't re-elected? No. Physician adoption of information technology is a bipartisan issue, and pressure to implement EMRs will continue to mount regardless of which party controls the White House, experts say.

If the government wants me to buy an EMR, will the Centers for Medicare & Medicaid Services pay for it? No. "Let me put it this way," Dr. Jessee said. "Based upon history, the current national deficit and upon the projections for what will happen under the sustainable growth formula for physician fees, I think that anyone who believes that CMS or anyone else is going to pay for the full cost of information technology in general, or EMR in particular, is smoking a funny weed."

So how is the government going to make it worth my while to buy an EMR? Groups such as PEHRC are asking HHS to find ways to help physicians recoup their investment in EMRs through some sort of incentive plan. But some wonder whether an incentive plan would involve reimbursing physicians without an EMR at a lower level than physicians with one.

Right now, there are no differences in what CMS pays, or what private plans pay, though some plans are starting up quality-based bonus initiatives in which EMR systems make it easier for a physician to compile the information insurers want to examine before handing over extra payment.

But experts say that the practice of giving a higher reimbursement to physicians with an EMR could become commonplace sometime in the next several years. "It will certainly be the case with Medicare and very likely the case with private payers that there will be a differential in reimbursement, depending on whether or not you're electronically enabled. But we're not there yet," Dr. Kongstvedt said.

Dr. Jessee said he hoped that organized medicine's effort to change the Medicare payment law would be successful so that CMS will offer doctors a net positive financial incentive to use technology in addition to higher payments for regular services.

But he also said: "I hate to be pessimistic about this -- but in 2006 the current projections are that the Medicare fee schedule will go down by an average of 5%. Assuming there's no change in the law between now and then -- which we all hope is not a correct assumption because the AMA, MGMA and everyone else is lobbying to get the law changed -- then CMS might say that for those physicians who implement an EMR, we're only going to cut your fees by 3%.

"It's a little bit like [asking] how would you like to rearrange your deck chair on the Titanic."

Would I be violating the Stark rule if I accepted hardware, software, technology support or subsidies from hospitals and insurers? The Stark II revision issued in March allows an exception for community-wide health information systems, said William H. Maruca, a partner with Fox Rothschild LLP, a law firm in Pittsburgh. Several hospital organizations around the country plan to build local health information networks to electronically exchange patient information with community physicians.

But doctors should not accept basic, all-purpose hardware such as computers or handheld devices that are easily used for purposes unrelated to community health information networks, Maruca said.

Also, while the Stark rule regulates financial relationships between physicians and hospitals, doctors should be wary about accepting subsidies from certain insurers. "If the payer is related in some fashion to a hospital network, health system or other provider of designated health services, the arrangement would need to be evaluated under the indirect relationship rules under Stark," Maruca said.

All things considered, I want to buy an EMR now. What should I get? If you take the plunge, make sure you ask vendors what they are doing regarding the more than 20 health information interoperability standards that HHS has endorsed since 2003. These standards are part of the agency's effort to ensure that different EMR products can "talk" to each other.

Avoid vendors whose compliance plan requires you to buy an entirely new product, Dr. Kongstvedt said. "If EMR systems don't conform to those standards -- and those are the standards that the industry is going to coalesce around -- doctors are going to be stuck with something that [won't deliver] the level of communication that they are going to ultimately want," he said.

The interoperability standards HHS has endorsed include Health Level Seven messaging standards; Laboratory Logical Observation Identifier Name Codes (LOINC) for the electronic exchange of clinical laboratory results, and Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT), a medical vocabulary owned by the College of American Pathologists.

Dr. Basch suggests that doctors wait until PEHRC releases its recommendations within the next 12 months before buying EMRs.

He also suggests that physicians keep on top of a recent industry initiative to develop a voluntary certification criteria for EMRs. He said that initiative would help physicians compare and evaluate systems. Three industry groups -- the Healthcare Information and Management Systems Society, the American Health Information Management Assn. and the National Alliance for Health Information Technology -- are leading that initiative.

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If they build it

In its strategic plan for building a national health network and electronic medical records for every American in 10 years, the Dept. of Health and Human Services lays out four goals and -- in broad terms -- possible strategies for achieving them:

Goal: Transform clinical practice by providing the information clinicians need when and where they need it.

Strategies: Offer incentives to encourage physician adoption of information technology. These could include awarding grants to regions, states or communities to create health information exchanges; paying for use of electronic medical records; and implementing pay-for-performance programs. Other strategies include working with the private sector to reduce implementation risks for physicians, encouraging the banking industry to offer low-interest loans, updating the Stark rule and promoting EMRs in rural and underserved areas.

Goal: Interconnect clinicians via interoperable technologies and networks so that patients' information is portable and will follow them from one point of care to another.

Strategies: Foster regional collaboration among those seeking to create community health information networks, develop a national health information network that will use common data and communication standards to ensure that doctors can easily share and access patient information regardless of what vendor's system they use and work to make federal health information systems interoperable and consistent with the national network.

Goal: Personalize care using technology to give patients more access and involvement in health care decisions.

Strategies: Encourage the use of personal health records, provide quality and other information to help patients choose doctors and health organizations, and promote telemedicine in rural and underserved areas.

Goal: Improve population health.

Strategies: Unify public health surveillance platforms into one interoperable platform, streamline quality and health status monitoring and accelerate research and dissemination of scientific data and discoveries.

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External links

"The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care," Dept. of Health and Human Service's framework for strategic action, July 21, in pdf (link)

Government Accountability Office report to Congress, "HHS's Efforts to Promote Health Information Technology and Legal Barriers to Its Adoption," Aug. 13, in pdf (link)

President Bush's consolidated health informatics initiative (link)

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