The HITECH Age can be considered to have begun on February 17, 2009 when the HITECH Act was incorporated into the $787 billion American Recovery and Reinvestment Act of 2009. Depending upon your method of calculation, there is between $19.2 billion and $46 billion available to facilitate the ‘meaningful use’ of electronic health record technology within the next 5 years.
This has significantly changed the view that EHR technology is a luxury, and the new message is clear: EHRs and other health information technology will be all but an absolute necessity to practice medicine in the near future. However, the path to this transition is still unclear. There are major roadblocks. One obstacle is the Federal government’s yet to be defined conditions of ‘meaningful use,’ which will modify many definitions of EHR success and failure.
While a physician may qualify for $44,000 in recovery funds, he or she must demonstrate ‘meaningful use.’ The definition is late to arrive to the HITECH scene, and may affect those who fail or succeed by federal definition. Is it a failure if, after adopting an EHR that streamlines your workflow and allows you to run a more efficient office, you are still unable to obtain the expected $44,000 in Federal stimulus funds?
The question of how an EHR will be evaluated for success and failure will need to be answered by each individual within a practice. Unfortunately, a number of practices may fracture when measures of success and failure are answered differently by different participants. Therefore, defining EHR success and failure by each practice stakeholder is a pre-requisite to such determinations, and one could argue that this evaluation should serve as the foundation for EHR product decision making. This article will provide some guidance regarding how one can analyze this issue, provide specific examples, and offer advice on how to maximize the probability that you will be involved with EHRs in a successful manner.
First, let’s examine the conditions surrounding the ‘HITECH’ Age.
The HITECH Act Changes the EHR Environment
The Health Information Technology ( HIT ) provisions of the Recovery Act are found primarily in Title XIII, Division A, Health Information Technology, and in Title IV of Division B, Medicare and Medicaid Health Information Technology. Together, these titles are cited as the Health Information Technology for Economic and Clinical Health Act, or the HITECH Act.
The HITECH Act authorizes the Centers for Medicare & Medicaid Services (CMS) to provide up to $44,000 in reimbursement incentives for eligible professionals who are successful in becoming ‘meaningful users’ of certified electronic health record (EHR) technology. These incentive payments begin in 2011 and gradually decrease. Starting in 2015, participating providers are expected to have adopted and be actively utilizing a certified EHR in compliance with the meaningful use definition or they will be subject to financial penalties under Medicare. In addition, the Medicaid program will offer federal matching funds to States to support their administrative costs associated with these provisions. It is important to note that physicians may not receive an incentive under both Medicare and Medicaid in a given year. Eligible providers may include:
- A physician as defined in section 1861(r) of the Social Security Act:
- Doctor of medicine or osteopathy
- Doctor of dental surgery or medicine
- Doctor of podiatric medicine
- Doctor of optometry
- Certified nurse-midwives
- Nurse practitioners
- Physician assistants who are practicing in Federally Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs) led by a physician assistant.
To qualify for the federal assistance towards EHR adoption through the HITECH Act, qualified professionals must meet and report specific criteria for ‘meaningful use’. Unfortunately, the qualification criteria for incentives are still in development with CMS and the Office of the National Coordinator for HIT (ONC).
Physicians and practices are abuzz trying to decode the Federal government’s terms for funding. The lack of definitions for ‘meaningful use’ and ‘certified EHR technology’ are holding many back from EHR adoption, and with justifiable reason. The choice of software may very well determine success or failure if providers are seeking to participate in the incentive program.
The final conditions for meeting meaningful use are planned for release in early 2010; however, it is expected that meaningful use will define successful EHR users as those who can demonstrate improvements in specific quality and outcome measures. It is not enough to merely purchase EHR software; it must be used towards the exchange and use of health information to best inform clinical decisions at the point of care. The HIT Policy Committee has submitted recommendations to ONC that the following outcome measures be included:
- Improve safety, quality, efficiency, and reduce health disparities;
- Engage patients and families;
- Improve care coordination;
- Improve population and public health; and
- Ensure privacy protection of personal health and financial information (HIPAA and ‘Red Flag Rules’).
Within these broad outcome measures, there will be very specific goals and objectives that must be met and reported by 2011, 2013, and 2015 to receive funding. Choosing an EHR prior to the release of these conditions of ‘meaningful use’ may be risky; however many vendors are offering guarantees that future standards, whatever they may be, will be met. It is extremely important for physicians to negotiate well with an EHR vendor, and define very specific vendor responsibilities in the contract. This will help ensure that physicians who aim to receive federal incentives can measure, collect, and report ‘meaningful use’ outcomes after EHR adoption.
Additional Programs Under the HITECH Act
Aside from direct physician incentives, the federal government is allocating nearly $1.2 billion in grants to promote EHR adoption and interoperability. $564 million of these funds will go towards grants to assist the development of a Nationwide Health Information Network and other health information exchanges. An additional $700 million will fund the Health Information Technology Extension Program, which will establish resources to assist physicians throughout the EHR adoption process.
The Health Information Technology Extension Program will consist of two major entities: Extension Centers and a national Health Information Technology Research Center (HITRC). Of the total federal investment in this program, about $50 million is dedicated to establishing the national HITRC, and $640 million is devoted to the Regional Centers. The estimated range of award values for the initial two-year budget period is approximately $1 million to $30 million per Regional Center, with an estimated average of around $8.5 million.
While 60 –or more-Regional Extension Centers may arise nationwide, it is not clear exactly who they will help and to what extent. Over the four-year terms of agreement, it is expected that each Regional Center will provide individualized technical assistance to a minimum of 1,000 priority primary-care providers in the first two years, and over those same two years Regional Centers nationwide will support over 100,000 priority primary-care providers to achieve successful adoption and meaningful use of certified EHRs.
Since neither the terms ‘meaningful use’ nor ‘certified EHR’ have been defined, the scope and definition of a ‘certified EHR product’ will greatly affect who does and who does not qualify for Federal assistance under this program. What is this certification and what standards is the certification judged against? Physician standards? Federal standards? These standards may differ quite a bit, and this could be useful to think about as we begin delving into factors that lead to the success and failure of EHR implementations.
Defining of Success and Failure
Success From Any Vantage Point
‘Success’ can be defined in many ways, depending upon the vested interest of the one defining it. However, there are some parameters that most can agree would need to be included to deem an EHR implementation successful. These can include:
- Improved Patient Care
- Clinical Decision Support and Clinical Practice Guidelines
- Evidence Based Medicine
- Drug/Drug and Drug/Allergy Checking
- More timely availability of information
- Better Alerts systems
- Better Health Maintenance
- Lower Cost of Healthcare Nationally
- Better Health Maintenance
- Reduction in Duplication of Tests
- Better Coordination of Care
- Improved Office Efficiency
- Increased Revenue
- Lowered Costs
- Ability to see more patients in fewer hours
- Safety of Health Information
- Health Information Secured and Kept Private
- Information complies with HIPAA and ‘Red Flag Rules’
- Interoperability/Integration with Other Technologies
- Referrals/Communication with other providers/specialists and patients
- Reporting to state and federal authorities
- Voice recognition software integration
The priority of such parameters of success can be judged differently depending on the evaluation standards of stakeholders and involved parties, who can include:
- Governmental Agencies
- Insurance companies
- Society in general
In order to determine the success or failure of an EHR, one must identify from which vantage point the analysis is being undertaken. For the purposes of this paper, we will concentrate on the physician perspective; however, let’s first briefly touch upon how all entities listed above have important perspectives to consider.
Administrators are generally looking at the bottom line. They will be concerned with how much the EHR adoption process will cost, and if it yields a long-term ROI. Administrators may also consider quality measures as they must comply with federal government standards for reporting and ‘meaningful use’ if seeking funding assistance. Administrators may define success in numbers. The EHR system must be able to show that its benefits outweigh the costs involved, and will eventually turn a profit for the practice or hospital.
Less clear is the dichotomy between the perspectives of the physicians and their various staff members. Many staff members will determine the effectiveness of the new technology based upon their own personal interactions with it. If these interactions are positive, they may deem the EHR as a success, regardless of what it costs or time constraints it may be inflicting on physicians. If staff members’ job descriptions have been expanded without provisions in workflow, and/or modified to having more interaction with technology than with humans, they may consider the extraordinary increase in efficiency afforded by electronic data transfer to be a failure, as their job satisfaction will likely have declined. This can impact the success in the office itself, as job dissatisfaction, significant employee turnover, and other human resource problems may come to the foreground in your practice.
Other major benefactors include patients themselves. Through either a patient portal or a Personal Health Record ( PHR ), access to medical records over the Internet on a 24/7 basis can be considered a major benefit. And, in many instances there is either no additional cost or a merely trivial cost for this additional service. Who is paying for this service in time and money? Physicians. So, while patients may feel that an extraordinarily complex and expensive implementation was a success, just because they now have access to their medical records, this may not be the defining concept from the medical group’s perspective.
What does the community value? A reputation for accessible, quality, compassionate, and affordable healthcare. Communities will be less concerned about the health system’s or medical practice’s bottom line and financial viability. The EHR system could be driving the practice into the red, but defining success among the masses is mainly guided by the provision of medical care, not line items on a budget.
In regards to ARRA and the HITECH Act, the government is a major stakeholder in widespread EHR adoption. Physicians and hospitals that accept its financial assistance will have to abide by requirements and stipulations connected to these funds. The government will define a successful EHR by its ability to meet the ‘meaningful use’ definition, and comply with HIPAA regulations and the ‘Red Flag Rules.’ It is widely anticipated that meaningful use will be determined by a practice’s ability to report improvements in quality health care, interoperability of health information, and the provision of security measures to keep health and financial information safe.
One of the reasons for the lag in EHR adoption can be attributed to the reasonable belief that the predominant benefactors are third-party payers (including Medicare –the largest insurer) while the expenses and effort falls on the shoulders of the physicians and their staffs. This disconnect is most probably behind the federal governments $44,000 in incentive payments available through the stimulus funds of the HITECH Act. Is this amount of money sufficient to incentivize the majority of physicians to adopt EHRs according to the wishes of the Federal government? Time will only tell; however, the tens of billions of dollars being promised in healthcare savings further mitigates the amount of money being provided by the HITECH Act. If this savings does in fact materialize, then from the third-party payer standpoint, EHR adoption and the HITECH Act would appear successful. This is notwithstanding the financial issues being experienced by any individual medical group, or by the physician community at large for that matter.
Success from the Vantage Point of a Physician
Now let’s look at success from the physicians’ standpoint. EHR Scope, LLC has asked over 10,000 medical practices what it is that they are looking for by adopting an EHR. Not surprisingly, there are clearly defined patterns in their responses. First and foremost, physicians are looking at their own bottom lines and workflow in determining success or failure.
The single most frequently requested concept/feature is ‘Documenting a chart note quickly.’ Interestingly, not until you reach the 5th most frequently requested feature do you find a goal which could be considered in any way altruistic: “Improving Patient Care.”
The following bullet points show the top 5:
- Documenting a Chart Note Quickly
- Going Paperless
- Increasing Reimbursements
- Dealing with a Financially Stable Company
- Improving Patient Care.
What were some of the least frequently mentioned concepts/features?
- Assisting with HIPAA Compliance
- Providing Decision Support
- Providing Disease Management
- Having A Patient Portal
Is this list shocking? Maybe yes. Maybe no. In previous generations physicians were rather venerated, well-respected members of society and there was a bit of a mystique concerning the profession. For better or for worse, the practice of medicine in the early 21st Century has become a substantially more cold-calculating business venture. This may be due to substantial administrative, regulatory, and financial pressures that are placed upon physicians- including health insurance issues, malpractice issues, HIPAA, etc. Perhaps EHRs-if implemented successfully- could reduce some of these burdens upon physicians and bring the focus of medicine back to patient care.
This data does present an important issue: there is disconnect between what outcomes both the physicians and the Federal government want from EHR implementation. As vendors strive to develop products to meet the Federal government standards, many are neglecting to identify and cater to what physicians really want and need an EHR to do for their practices. And perhaps this is one major driving force for soaring implementation failure rates.
Failure, too, must be evaluated from the perspective of different stakeholders. Failure from the perspective of the Federal government may well be a mere lack of adoption. However, from the perspective of any individual medical group that does not adopt an EHR, particularly if there is not widespread adoption, this would not be considered a failure, but merely business as usual, without an EHR.
Focusing on the physician, failure will be determined based on the conditions surrounding EHR selection and adoption. As it stands now, physicians need only comply and report ‘meaningful use’ of EHRs if they are seeking federal dollars for assistance. Therefore, those who don’t choose to participate in the incentive program can define success and failure as they wish. This may not always remain the case, but for now, only the acceptance of Federal dollars can force physicians to comply with federal standards. Those seeking federal assistance will have to prioritize conditions for ‘success and failure’ as determined by the ‘meaningful use’ definition. The chart below is an example of how ‘failure’ can be viewed differently among the dichotomy of physicians who do and do not accept federal dollars; the Federal government who is looking at ‘failure’ from a very broad national perspective; and the patients, who have an entirely different view all together.
|Condition of ‘Failure’||Physician Not Seeking Fed. Assistance||Physician Seeking Fed. Assistance- qualifying for ‘meaningful use’ incentive||Federal Government (National EHR Adoption)||Patients|
|EHR Abandoned After Adoption||✓||✓||✓|
|Lack of Widespread Adoption||✓|
|Lack of Return on Investment (physician practice)||✓||✓|
|Lack of Return on Investment (national)||✓|
|EHR with lack of ‘usable’ features||✓||✓|
|Excessive Hours of Work by Physicians
|Excessive Staff Turnover
|Fractured Medical Practice||✓||✓|
|Security Breaches in Health/Financial Data||✓||✓||✓||✓|
|Inability to Integrate With Other Technologies (i.e. voice recognition, PM, E-prescribing, etc.)||✓|
|Difficulty Capturing and Exchanging Health Information With Government Authorities||✓||✓|
|Decrease in patient volume||✓||✓|
|Not Being Able to Demonstrate Meaningful Use||✓||✓|
This chart is by no means exhaustive, and is certainly subject to debate; however, its purpose is to demonstrate how federal standards of failure and an individual physician’s definition of failure can be in conflict. The federal government is more focused on health outcomes, quality of healthcare delivery, and the interoperability and privacy of health information. The individual physician, on the other hand, must highly concentrate on profitability, ROI, staff satisfaction, and workflow. The physician seeking government assistance may be stuck in conflict, as he/she may have to define ‘failure’ in large part by whether or not a check is received.
In sum, success or failure of an EHR will be determined by the EHR’s ability to meet the practice’s goals. Practice goals and their appropriate EHRs will differ greatly if a practice is motivated by federal standards for ‘meaningful use;’ or a practice is motivated more by making improvements in business processes, productivity and efficiency. Whatever the motivation, it must be matched with a supportive EHR. If most interested in meeting ‘meaningful use’ and qualifying for the federal incentive payments, a CCHIT or HHS certified product may be the product to meet a practice’s goals and needs. If, on the other hand, the practice’s goals are more aligned with getting an EHR to specifically increase efficiency and productivity, a narrative style EHR or non-certified product might be the right product to choose. Let’s look at some examples.
In one case example, an Orthopedic specialty practice decided to merge two different, 2-physician practices and adopt an Electronic Health Records system to meet two major goals:
- Go paperless; and
- Decrease transcription costs.
When deciding on an EHR system, this practice looked very carefully at two vendors, and chose the product that was less expensive. During the selection process there was little discussion among the four physicians in the practice, but it was assumed by all that the transition into a ‘paperless’ office would be simple and it would not disrupt their workflow and productivity.
The EHR system was implemented the ‘big bang’ style, and unfortunately, the EHR system (a traditional point-and-click), was problematic from the beginning. This system required many templates to be built for the physicians, and extra training was needed to understand the EHR’s imposed workflow and functionality. This training was offered by the vendor, but at a high cost. After two years of trying to make the EHR work in their office, the practice decided to de-install the EHR system and seek another due to:
- Decrease in productivity; and
- 2. Inability of the system to meet the needs of all physicians.
After reevaluating, the practice realized that the physicians needed an EHR that would increase productivity and maintain patient volume. Eliminating transcription costs completely was not as high of a priority the second time around; instead, efficiency, productivity, ease of documentation and ease of use were most important. To meet these needs, the practice chose a different EHR. This newer EHR had fewer features, but its design was implemented specifically for busy specialty physician offices.
This new EHR met the needs of the physicians, and worked to streamline workflow and increase productivity. Again, the implementation was the ‘big bang’ approach, but this time the practice experienced no decrease in productivity, found the system simple to use, and had no interruption in workflow. This practice deemed the implementation successful in its office, as it improved the practice’s ability to:
- Input and access information into the system/files
- Electronically prescribe and refer
- Analyze workflow and tailor the EHR to increase efficiency
- Maintain patient volume
- Eliminate paper charts
- Electronically obtain and file transcriptions
This office realized -the hard way -that it is essential to get all physicians at the discussion table during the EHR planning phase. Understanding the physician’s individual needs and expectations may have helped in developing a consensus between doctors that would help them choose the best EHR for their practice. Usability of this practice’s first EHR was a major challenge, and one that led to the de-installation of the program. For many offices, success of an EHR will depend on the ability of the EHR to merge with their current processes and make them more efficient. Unfortunately, many failures occur because the practice had to change too much to meet the needs of the software.
A 17 provider multi-specialty practice offers a patient-centered experience featuring a team of family physicians, physical therapists, pain management physicians, chiropractors and massage therapists. As the practice’s patient base grew, and it was increasingly burdened with the inefficiencies of managing paper charts, it decided to adopt an EHR and practice management (PM) solution.
This practice stands out because they initially had great physician buy-in and leadership with a physician champion. In addition, this practice completed several months of extensive research using product reviews from the internet and trade publications, as well as outreach to peers regarding their PM/EHR experiences. In this research, the search team focused on four main areas:
- Ease of documentation;
- Company financials; and
The practice selected a CCHIT® certified product. For implementation, the practice was concerned about meeting the varied needs of their providers in a multi-specialty environment. They were also apprehensive about overwhelming their staff with a new software system. However, they were successful because the vendor helped provide solutions, such as introducing the new software incrementally. The full implementation took about 1 year.
Once the system was in place, the practice saw major improvements in workflow. The number of patient visits per day increased by 40%; profitability increased by 100% by the second year of use. Patients also reported satisfaction with the digital transition, as patient wait times decreased by 50% and quality of care has improved. All in all, this EHR implementation was successful.
In this case example, it is evident that this practice took the time at the forefront to designate a physician champion to drive EHR project leadership. This leadership is vital to success. In addition, the practice had clearly defined goals, and did extensive research into EHR products and vendors that could help it meet such goals. This is an example of how extra time, research, and planning at the beginning of the EHR adoption process can build a strong foundation for success.
In one cardiovascular practice, the motivation to adopt an EHR was to streamline chart flow back and forth to outreach clinics. This practice was also looking into the future, feeling that an EHR was the technology that would be eventually adopted by all. To choose the EHR for this practice, leaders looked at numerous programs at length, and decided to go with a product and vendor that had an established business presence in the EHR industry.
This practice chose to implement the system with the ‘big bang’ approach. From the ‘get go,’ the program was found to have problems. The practice found it difficult to customize the product, as vendor’s tech support was unable to customize the program to meet the practice’s needs. For training, the Clinical Manager was sent to a one and a half day conference, and was then expected to program all of the practice’s preferences. A physician was also sent to the training and expected to develop all the point and click features for the practice. This practice found that this was a burden to the physicians and clinical support staff, as it hindered time for patient care. As the practice sought the help of the vendor, the vendor simply couldn’t provide solutions to meet the functionality and usability the practice needed in the EHR. Overall, this system was too cumbersome to set up and use. This particular EHR and vendor expected the client to conform to the EHR, which created problems.
The top four problems the practice identified in the EHR were the following:
- The EHR was based on codes for the assessment and plan. Unless a physician sat and typed in the review of systems s/he was unable to include his/her notes and connect it to the plan. It was too rigid of a system and was only based on the ICD9 codes. For example, if s/he ordered a stress test s/he would want to enter into his plan things like “if test is negative refer to GI or if the test is positive order cath possible.” This system would not allow the user to do that.
- The point and click system began stereotyping multiple patients’ plans of care, and contributed to patients’ records looking identical. This caused concerns in patient identification; many patient charts sounded alike.
- The vendor’s lack of tech support and unwillingness or inability to work with the practice’s needs caused problems. It wasn’t feasible for the practice to bend to fit the EHR product’s parameters.
- There wasn’t a good plan of action to scan records. Scanning of documents was very cumbersome. To find a document once scanned was also difficult for the end user.
As these problems continued to rise, physician productivity began to decrease, and the practice felt it was unable to provide individualized, patient-centered care. The practice spent much time re-evaluating its needs and goals, and decided to de-install the first EHR and look for another that could be customized and would optimize productivity for physicians and the entire staff. Scanning in documents was also a process that the practice wanted to streamline. The practice chose an EHR based upon the new criteria, and found that it met its needs. This practice deemed its second EHR successful over the first due to its usability, customizations, ability to enhance productivity, and generate cost savings.
This is an interesting case study, as this practice had team leadership for its EHR project, and spent many hours researching which EHR software to choose. It thought that by selecting a product and vendor that had a secure place in the EHR market, this practice, too, would be successful with the product. Unfortunately, this practice did not get the support that it needed from the vendor, and it sounds as if the vendor expected the practice to adapt to meet the EHR’s needs. This led the practice to abandon the first EHR and choose another that would be usable and customizable to meet the physicians’ and staff’s needs instead. Please note that support capabilities are not uniquely defined by the size of the vendor, but also by the size of their support team and its culture.
In conclusion, defining a ‘successful’ and ‘failed’ EHR implementation is a very subjective process. While this paper has offered perspectives of many parties, there are two major stakeholders who, regardless of success or failure, stand to be encumbered by exhaustive costs and workloads associated with implementing an EHR. The first is the physician and his/her practice, which must identify his/her main motive for EHR adoption. Understanding the practice’s goals and needs will help to select an EHR product aligned with success. On the contrary, choosing a product that does not meet the specific practice goals would be highly predictive of EHR failure. If the physician decides to become involved with the Federal government EHR incentive program, he/she may have to forgo some of his/her own practice goals to meet those standards set forth by the HITECH Act and the ‘meaningful use’ definition/conditions.
The second major stakeholder is the Federal government, which is contributing billions of dollars and writing policy to build a nationwide Health Information Technology Infrastructure. The government has a lot at stake, and while it is obviously not looking to squander money of such magnitude, it may do so unintentionally by setting up unrealistic ‘meaningful use’ standards that physicians simply cannot meet while running an efficient and profitable office. If physicians adopt EHRs to specifically meet the Federal standards and accept the incentive payments, but with time cannot meet the required outcome measures for reporting, or possibly even more importantly their payroll, they may be forced not only to uninstall their failed EHR that did not align with practice goals, but also pay penalties back to the Federal government for not meeting ‘meaningful use,’ interoperability, and security standards for reporting by 2015. In this case, both the Federal government and individual physicians fail. This is a scenario neither entity wants to envision for the future of EHRs and Health Information Technology. The main message: EHR adoption is a major movement; it’s shifting healthcare delivery standards ,and decisions surrounding it must be made with extreme caution.
While the HITECH Act may wave dollars in front of the eyes of physicians as a motivator to adopt an EHR, this money should not be the sole factor in EHR decision making. Each physician and each practice must weigh all options. As illustrated in some of the case studies, many offices have adopted EHRs, failed, and then succeeded on their second attempt at an EHR; others succeeded on their first attempt. Some practices have succeeded with a narrative based EHR; others with a point-and-click EHR, some ONC-ATCB certified, others not.
In conclusion, there isn’t a single EHR panacea; successful EHRs will be judged and determined by various parties, each with their own vested interest. It is up to an individual practice, its physicians, staff, and administrators to determine what party has the largest voice, and use that voice to find an EHR to meet the practice goals and motivations for a digitized record keeping system. Keeping practice goals at the forefront of EHR needs will help evaluate and measure different EHR vendors and products to increase the likelihood that involvement in EHR adoption is successful.