Implementing Electronic Health Records in Doctors' Offices
For e-health records to work, physicians need to be brought online.
It’s the unlikeliest of portals into the future of health-care delivery in the U.S.: a small, low-slung, brick building in the middle of Queens, N.Y., with a blue banner strung across the facade heralding street-front primary care.
But inside, Dr. Michele C. Reed, medical director of the five-person practice, has done something that she thinks is absolutely necessary for anyone who wants to practice medicine in the modern world: Her office has gone paperless.
No more chasing files. No more lost charts. No more bringing home folders full of lab reports and examination notes. No more dank basements full of filing cabinets crammed with paper. She is well on her way toward creating a seamless system of health care whereby everything from scheduling, to referrals, to prescriptions, to getting lab results, to interactions with insurance providers takes place by wire, air and microchip.
From Oregon to Georgia to New York, medical facilities, giant health-care networks and physicians’ offices—including small, independent primary-care practices like Reed’s that serve large populations of Medicare and Medicaid patients—are part of an ambitious drive toward full adoption of electronic health records (EHRs). It is part of an all-out effort to both streamline interactions between all players on the health-care front, from pharmacies and labs to ambulance crews and insurance companies, and improve health outcomes while lowering costs.
Done correctly, EHRs allow a health-care provider to deliver medicine faster, more cheaply and better. That’s the position Dr. Thomas Farley, New York City health commissioner, takes. And it is why New York City is one of the places that is most actively and aggressively pushing EHRs by offering physicians like Reed a wide range of support, including help in choosing, installing and operating EHR systems.
Meanwhile, the federal government is investing $20 billion to $30 billion in stimulus money on promoting EHRs through a system of 62 regional extension centers. The centers are hosted by a variety of entities, from government agencies to not-for-profit health-care consortia. The extensions have been given the formidable job of both selling and supporting the switch to EHRs across the country. In Georgia, for example, the project is being coordinated by the Georgia Health Information Technology Regional Extension Center, which is working through the Morehouse School of Medicine’s National Center for Primary Care (NCPC) to help around 2,000 primary-care providers in smaller practices switch to EHR systems.
Among the foot soldiers in the NCPC push is the Georgia Institute of Technology, which is getting nearly $3 million of the school’s $19.5 million federal grant to put boots on the ground to convert primary-care physicians. Georgia Tech is helping educate providers by fielding two sets of outreach teams. The first team works on educating providers about the potential benefits of EHRs and the potential penalties for failure to adopt. (Starting in 2016, Medicaid and Medicare providers who aren’t using EHRs will risk seeing their reimbursements shrink.) The second team provides hands-on advice about technology systems and actual implementation.
Using computers to keep track of patients isn’t, of course, anything new. Since computers arrived on the scene, they’ve been finding their way into the basements and back rooms of health-care providers, particularly large institutions, such as hospitals. These days, those large facilities are using IT to do more and more. Patients who check into most large hospitals today don’t just get a name tag, they get a bar code too. That bar code is used to manage and record everything from medical tests and results, to drug dosages and billing.
But uptake has been the weakest exactly where many public health-care experts believe it is needed most: on the front line of medical care, among the thousands of doctors who see the poorest and the sickest patients in the nation. These are the patients who, not incidentally, represent a significant portion of public health-care expense. Estimates are that 20 percent of those on Medicaid and Medicare represent 50 percent of the cost. So there is a well reasoned logic behind efforts to help physicians serving those populations improve how they manage client health.
That was in significant part why the federal government created the Office of the National Coordinator for Health Information Technology (ONC). The ONC was established by executive order in 2004 to create policies and standards for a National Health Information Network. Cost containment was clearly a major reason for that. Part of ONC’s mission is to cut $10 billion a year from the federal government’s health-care bill by improving how health care is delivered, which means not only reducing duplication and medical mistakes, but also improving care, particularly for those with long-term chronic health-care issues like high blood pressure, asthma, heart disease and diabetes.
But getting physicians to sign on for EHRs hasn’t been easy, and there are some obvious reasons why. “It’s an old problem,” says Dr. Mark Braunstein, associate director of the Health Systems Institute, a program operated jointly by Georgia Tech and Emory University, and a longtime advocate for EHRs. “If you look at studies as to why doctors don’t implement these systems, the reasons are actually very sensible: cost, confusion over which system to choose, how to install it and how to convert a whole practice. Doctors will also say, ‘I’m a doctor, I don’t want to run a computer company.’”
Health experts in the field note that local government officials are key players when it comes to making the kinds of connections that can help a community with EHR uptake. “County officials,” says Steve Rushing with Georgia Tech, “can be incredibly helpful and supportive bringing the right players to the table.” Such assistance can be more than just a courtesy to those charged with disseminating EHR information. “Local officials in Georgia are increasingly aware,” Rushing says, “that this is extremely important from an economic development standpoint.”
It was government’s role in improving public health that was foremost on New York City’s mind when, eight years ago, officials started their drive toward citywide EHR adoption. “We knew about advancements in EHRs, and there was a lot of best practice about how to use the data,” says Linda Gibbs, New York City deputy mayor for health and human services. “The piece that was really missing was connecting these hundreds and hundreds of small local community clinics to improve preventive primary-care practices among those who serve the poorest communities in the city.”
New York City now offers multiple types of support for primary-care providers willing to switch to EHRs. These include subsidies and intense, hands-on technical support in everything from choosing systems to implementation. The city will also work with providers to help them safeguard patient data.
Health Commissioner Farley estimates there are some 32,000 practicing physicians in New York City, about 9,000 of whom are, like Michele Reed, part of a small army of front-line doctors delivering primary care to millions of New Yorkers. Get them connected and tuned in -- 2,500 of them already are -- and there is the potential for exponential improvements in disease management and prevention.
For example, a study of 6,000 patients in 50 practices in the city indicated a 7 percent improvement in managing high blood pressure among participating clients. Seven percent, Farley admits, may not seem like a lot, “but multiplied across a population of millions, it can have a big health effect.”
There have been numerous national studies on the health impacts of EHRs. Although it’s arguably too early to do any sort of definitive study, most indicate the sorts of modest, but important, improvements seen in New York City.
But there are other reasons why government has a direct interest in making EHRs standard practice nationally. One big one is that more states are looking to implement what are known as “global payments” -- a flat, per-client fee for all patients in a network. Well coordinated care is absolutely central to such a system. “You’re going to have to figure out the best way to spend that payment, which means you have to have a very close relationship between all players,” says Dr. Dick Gibson, president of the Oregon Health Network, which is involved in that state’s push to get smaller primary-care providers converted to EHRs. By that, Gibson means that doctors and hospitals, laboratories and pharmacies have to closely coordinate decisions about care and treatment for each patient.
At the same time, the Affordable Care Act -- President Obama’s seminal push on health reform in the U.S. -- will be easier and more cost-effective to implement if electronic records are in place. This is particularly true of one of the first measures states will be dealing with under the new law: setting up health insurance exchanges. The ability to quickly and accurately exchange patient health data will be critical.
Convincing doctors of the importance of EHRs will remain a significant hurdle, however. Many doctors in far-flung, rural parts of the country lack the IT infrastructure needed to take full advantage of EHRs, and many doctors just don’t want to bother. They may have heard from peers how difficult it is. “Never ask a doctor who is three or six months into the conversion process how it’s going,” Gibson warns. “They’ll be grumpy.”
But doctors like Michele Reed needed no convincing. Reed has made the switch and is now looking for ways to continue building connectivity to virtually every player in the health-care arena—she’s even talking about switching over from her in-house server to the cloud. Meanwhile, she has not only grown her practice, thanks to EHRs, she says, but she believes the system is helping her keep people from getting sick in the first place. Asked about the future of doctors who don’t want to switch over, and Reed answers without hesitation: “They won’t be practicing medicine.”