EMRs missing the mark on care coordination efforts

The government's expectation that electronic medical records will dramatically improve care coordination across multiple care settings might come up short if changes are not made to both policy and EMR systems themselves, according to a recent study.

The Center for Studying Health System Change found that EMRs are helping coordinate care within a practice but are less helpful with exchanging data between care settings.

Researchers from HSC conducted phone interviews with doctors or staff from 26 practices that had commercial ambulatory care EMRs for two years. They also spoke to CMOs at four EMR vendors and to four national thought leaders. The study, "Are Electronic Medical Records Helpful for Care Coordination? Experiences of Physician Practices," was published online in the Journal of General Internal Medicine in December 2009. A summary is available; access to the full study needs a subscription.

David Blumenthal, MD, national coordinator for health IT, said the study "looks at the state of affairs before the HITECH legislation. It emphasized how valuable it would be to have financial incentives to encourage use of records for care improvement purposes and it pointed out there was no interoperability, which was a limiting factor." It also says not all the records are useable, he added.

Financial incentives are available through HITECH, the Health Information Technology for Economic and Clinical Health Act (part of the federal stimulus package) that gives credit of up to $44,000 per physician for purchase and meaningful use of EMRs.

Dr. Blumenthal said the study reinforced that Congress, as well as his office, are on the right track.

The study also showed support for EMR use. "There were some nice quotes in this article along the lines of never going back, about physicians that are having access to information at their fingertips and being able to meet patient expectations consistently ... that took a really different tone from the headline of this study," said Melinda Buntin, PhD, an economist and director of the Office of Economic Analysis and Modeling in Dr. Blumenthal's office.

Ann O'Malley, MD, MPH, senior researcher at HSC and primary author of the study, agrees that even in their current state, EMRs have been beneficial. "By and large, clinicians that do adopt EMRs find them quite helpful for care delivery within the office and overall are pretty positive and say they do not want to go back to the paper days," she said. "But they should not be under any illusions that it's magically going to help them coordinate care with other providers outside of the office."

Researchers have long said that interoperability is key to a large-scale return on technology investment. But it's not simply a matter of more people adopting the technology.

"Even if everyone had an EMR in place right now, the EMRs can't talk to one another," Dr. O'Malley said. Despite the government's efforts to design standards promoting interoperability, the systems aren't there yet.

And, even with the standards and incentives to promote EMR adoption, physicians still won't be paid to talk to one another, she said, and that is preventing many practices from making the necessary work flow changes.

Steven E. Waldren, MD, director of the American Academy of Family Physicians' Center for Health IT, said the only real incentives that exist today promote using systems for billing. There are no incentives to adopt technology that helps promote clinical quality and efficiencies.

"It is a chicken-and-egg issue, in that do you have to have the technology to capture, analyze and report quality and efficiency such that it can be paid for? Or do you pay for quality and efficiency such that practices and hospitals are incentivized to put in the technologies to get to those?" Dr. Waldren asked. "That is something we have struggled with as an industry."

Without incentives, physicians don't have a reason to lobby vendors to develop systems that will allow meaningful communication between health care facilities, Dr. O'Malley said. And vendors aren't going to develop products that have no market.

The government is attempting to encourage interoperability, as well as coordination of care. Grant programs have been created to promote the patient-centered medical home concept, which relies heavily on technology that allows practices to coordinate care among many caregivers.

But for now, EMR support for medical home activities is "suboptimal," study participants said.

"We're within a paradigm shift," Dr. Waldren said. Eventually, the health care system will require technology that allows communication and coordination of care. In the meantime, physicians need to "play the documentation game" to get paid and need a system to help make documentation more efficient.

Physicians considering investing in technology need to adopt a system that not only will help them be successful in a quality-based payment world but also will support documentation-based billing, Dr. Waldron said. Those systems exist but require effort to get up and running.

Whether Congress will tackle payment reform remains to be seen. Dr. Blumenthal said he feels the government needs to "pay for what's right and care coordination is one of those things that's right to do." But in the end, he said, "professionalism will drive physicians to accept and cherish electronic health records."