Rise of the e-mandates: Soon, you may not have a choice

As the drumbeat for use of health information technology grows louder, physicians are feeling pressure to buy in -- no matter what they think about its value.

By Dave Hansen — Posted Dec. 17, 2007

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North Shore Cardiovascular Associates in Salem, Mass., recently spent $280,000 for an electronic medical records system, or $20,000 for each of its 14 physicians. It figured it had no choice but to spend the money.

That's because Partners HealthCare, its hospital partner, mandated that North Shore, and every other practice that refers patients, have an EMR. Otherwise, they no longer can practice at Partners facilities. The hospital system has offered to pay some costs, but not all of them.

"It is basically a loss," said Mario Motta, MD, a cardiologist with the North Shore practice. "I don't get to keep the medical record if I decide to move. The benefit primarily accrues to the system and insurers, who make out royally for this. They should be paying for the bulk of it."

Some Partners-affiliated doctors are choosing to retire or leave rather than buy a system. Dr. Motta understands how they feel. "If I was in my mid-60s, I would say 'no way.' "

But more physicians soon may well be in the position of being forced to adopt some form of information technology.

Frustration with the slow spread of medical technology is driving some payers, hospitals and legislators to consider mandates to require physicians to purchase it.

The argument for mandates is one of patient safety and health system efficiency. Technology adoption by physicians is necessary to reduce errors and costs, advocates say.

With surveys showing fewer than 10% of doctors using electronic prescribing and only 20% using electronic medical records -- and those numbers stagnating -- too much is at stake to wait for doctors to adopt technology, say those advocating mandates.

Health and Human Services Secretary Mike Leavitt nudged physicians to adopt e-prescribing in a Nov. 16 posting to his blog "Electronic prescribing will enhance the safety and convenience for patients," he wrote after attending a meeting of the American Health Information Community. "E-prescribing is not only more efficient and convenient for consumers, but widespread use would eliminate thousands of medication errors every year."

Leavitt concluded by writing, "Large health care providers, including Medicare and Medicaid, need to move toward making it a mandatory part of medical practice soon."

The American Medical Association is among those who see the benefits in technology and support its use. But the AMA and other physician organizations have set policy stating doctors must not be forced to use it.

Their argument against mandates is that the savings appear to benefit everyone but doctors, who are forced to shoulder the expense as well as the risk of a system not working as intended.

The AMA has urged Congress to consider direct assistance to physicians for purchasing HIT, such as low-interest loans, grants and tax credits.

"The decreasing revenue from public and private payers, high medical liability insurance premiums, and state and federal mandates make the cost associated with implementing HIT a significant impediment for physicians," said AMA Immediate Past President William G. Plested, MD, at a March 2007 House Small Business Committee hearing.

A good idea, but...

A 2007 national survey on e-prescribing by Ayres, McHenry & Associates found only 7% of physicians write prescriptions electronically even though 85% say e-prescribing is a "good idea" and 81% think it would reduce medication errors.

Of the 407 physicians surveyed, 63% said e-prescribing installation was not a priority in their practice. The most popular reason for not adopting e-prescribing was the expense and a lack of reimbursement for using it.

The survey defined e-prescribing as "having online access to a continually updated database with a patient's prescription history and formulary information, and transmitting the prescription electronically to a pharmacy" -- a feature not present in all systems.

Meanwhile, a February 2007 survey by the American Hospital Assn. discovered that only 16% of hospitals had most or all functions of an EMR in place by 2006 and estimated that only 20% of medical practices used EMRs.

Cost and a lack of financial benefit to practices is often cited as a reason not to adopt EMRs. So is the difficulty of changing practice patterns in a transfer from paper to electronic records.

And so is the real risk of buying a system -- and then junking it. A Medical Records Institute survey found that 18.8% of practices with an EMR had ripped it out and replaced it with another system, while another 8.2% completely abandoned EMRs and reverted to paper records. Meanwhile, one-third reported having physician partners who refused to use an EMR already installed.

Yet in the same survey, 90% believed EMRs would improve health care efficiency 10 years from now.

Dr. Motta is happy with his practice's system. "At the beginning, I had my doubts. But now I think it is an important advance for patient safety and care. I am a believer."

But, Dr. Motta said, that doesn't mean he supports Partners -- or anyone -- forcing him or another doctor to buy technology.

Dr. Motta said he and other doctors are feeling the pressure to buy, even if they aren't given a mandate. The Medical Records Institute survey found that 19.9% of private practice physicians adopting an EMR cited pressure from a payer group as a driving force. It was one of the least-cited reasons -- but it was up from 6.9% in 2006.

The time is coming

EMR use is "inevitable," Dr. Motta said. That's because of the amount of information available showing the effects of health information technology on patient safety and overall health costs.

A July 2007 study prepared for the Pharmaceutical Care Management Assn., which represents pharmacy benefit managers, found that mandating e-prescribing for participation in Medicare by 2010 would save $29 billion and avoid 1.6 million adverse drug events by 2017. Observers say PBMs also would save money through gains in efficiency.

By comparison, an incentives-only approach -- giving physicians an extra 1% of Medicare payments -- could avoid 300,000 adverse events and save $2 billion by 2017.

The study also found that fewer than 30,000 of more than 900,000 prescribers in the U.S. use full e-prescribing systems. Without a mandate and assuming current marketplace trends continue, it estimated that e-prescriptions would expand to 34% of all prescriptions by 2017.

Mandating e-prescribing as a condition of Medicare participation would increase the rate to 70%.

The PCMA launched a multimillion-dollar television and print campaign in November drumming up support for mandatory e-prescribing as a condition of participating in Medicare "before more people die."

Not a law (yet)

No federal legislation requiring e-prescribing has been introduced, but the concept is getting more support. Sen. John Kerry (D, Mass.) and former House Speaker Newt Gingrich (R, Ga.) called for Medicare to mandate e-prescribing as a condition of participation. They also called on the federal government to fine any physician who did not adopt e-prescribing within a few years.

"The deaths and inefficiencies of paper prescriptions can be nearly entirely eliminated if we use the same technology that we use in other aspects of our lives," Kerry and Gingrich wrote in a Nov. 16 Wall Street Journal op-ed piece. The federal government should offer bonus payments as an incentive but resort to a mandate if that fails to get a most physicians e-prescribing in a few years, they wrote.

But other mandates are being imposed or considered. Minnesota has passed legislation that would require filing of electronic claims by 2009 on the way to requiring doctors and hospitals to use EMRs by 2015. The Massachusetts Senate is looking at legislation that requires doctors and hospitals in that state to adopt EMRs.

Boston-based Partners HealthCare issued its mandate in March, when it announced that all physicians in its network must use EMRs.

Primary care physicians must comply by Jan. 1, 2008, and specialists by Jan. 1, 2009. Partners HealthCare President Tom Lee, MD, said primary care physicians gain the most from an EMR. Specialists will join as they realize they are cut off from their primary care referral base, Dr. Lee said.

The transition isn't easy, he said. The EMR makes physicians do extra work and will not give them a financial bonanza, he added, and some physicians might choose to retire early or quit. But "Partners feels pressure to improve performance. We can't do it by just sending out newsletters to people.

"It's a 'stay in business' decision," Dr. Lee said.

"You can't practice the medicine of a generation ago and expect to stay in business."

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Why physicians don't adopt e-prescribing

A July 2007 survey of 407 physicians by Ayres, McHenry & Associates found that 63% did not view implementing e-prescribing as a priority, although 85% thought e-prescribing was a good idea. The survey did not ask physicians who use e-prescribing what motivated their decision. But it did ask for the top reason why doctors weren't planning to e-prescribe:

Reason for not e-prescribing Respondents
Too expensive/no reimbursement 18%
Don't write many prescriptions 10%
Benefits not worth the cost 9%
Not enough time to learn 7%
Inefficiency/problems with e-prescribing 7%
Staff not trained 5%
Concerns about security/patient privacy 5%
Not available in my area 5%
Lack of technology/equipment 5%
Prefer paper method 5%
Satisfied with current method 5%
No single database/too many databases 4%
More important priorities 2%
Don't make the decisions 2%
Not familiar with e-prescribing 2%
Don't like computers 2%
Concerns about liability 1%
Inoperable with current system/software 1%
End of career/closing office 1%
Something else 4%
Don't know/no opinion 2%

Note: Total is greater than 100% because of rounding.

Source: Ayres, McHenry & Associates

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Ripping it out

One argument physicians make against technology mandates is the potentially high cost of installation. Another is the potentially even higher cost of ripping out a system that doesn't work. In the Medical Records Institute's annual survey on EMR use, 819 representatives of practices, hospitals and other health care entities detailed how often things went very wrong. Physicians and nurses represented 29% of those surveyed.

30% of respondents said they had clinicians who refused to use the EMR

  • 12% had this happen in the past
  • 18% are having this happen now

19% of respondents had to de-install (rip out) an electronic medical records system

  • 12% did so in the past
  • 7% are doing so now

8% of respondents, after de-installation, reverted to paper records

  • 6% did so in the past
  • 2% are doing so now

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