While the ongoing transition to electronic health records promises to bring revolutionary advances in care in Kentucky and elsewhere, to say it has been neither easy nor cheap is a massive understatement. Dr. David Bensema, chief medical information officer at Baptist Health, and Cheryl Brown and Dr. David Danhauer, information technology leaders at Owensboro Health, readily attest to both of the latter points.
Implementing electronic health record technology has been frustrating and expensive. Thankfully, four years ago Kentucky became the first state to issue payments through its incentive program for meeting federal Modifications to Meaningful Use (MU) in The Health Information Technology for Economic and Clinical Health Act that created the HITECH incentive program and also secured funding for the Kentucky Health Information Exchange.
President Bush in 2004 set the goal of electronic health record (EHR) implementation by 2014, and the American Recovery and Reinvestment Act of 2009 provided financial help and incentives.
Commonwealth healthcare IT personnel do praise the state’s foresight in establishing the Kentucky Health Information Exchange (KHIE), a central resource to help hospitals and physicians implement electronic health records technology. However, at a point at least two years from finishing, those same IT professionals and many physicians express great dissatisfaction with current EHR systems and the priorities the federal Center for Medicaid and Medicare Services (CMS) is dictating to developers.
CMS defines the MU standards providers must demonstrate in stages to earn incentives and avoid penalties.
“Meaningful use,” as defined by HealthIT.gov, consists of using digital medical and health records to:
• Improve quality, safety, efficiency and reduce health disparities.
• Engage patients and family.
• Improve care coordination, and population and public health.
• Maintain patient information privacy and security.
It is difficult, meanwhile, to pin down the exact cost of implementing electronic health records into provider operations. Bensema and Danhauer each estimate their respective healthcare systems to date have invested well over $100 million on software and third-party packages. Costs soar into the hundreds of millions when factoring in the time to orient physicians and allied personnel to the program interfaces, reporting mechanisms and added procedures to follow, Bensema said.
Federal and state MU program incentive payments have been valuable to the participating providers.
As of Oct. 1, the Kentucky program has made 4,860 payments totaling $200.2 million to providers, according to KHIE, and federal MU incentive programs at the Center for Medicare and Medicaid Services have injected another $337.6 million into Kentucky.
Nationally, CMS has invested over $30 billion in incentive payments, said Steven Stack, medical director of the Saint Joseph East emergency department in Lexington and current president of the American Medical Association.
“That sounds like a lot of money, but put it in context,” Stack said. “Over that same time period, the U.S. health system is estimated to have spent close to $9 trillion.”
On the Kentucky front, Bensema said, the roughly $537 million that state and federal MU programs have paid doesn’t come close to the expenses hospitals and medical practices have incurred trying to implement EHR to proscribed federal standards.
“The most transformational thing in decades”
Are EHR systems worth all the cost, fuss and frustration?
Despite the controversy and all the criticism providers express over EHR and the MU program, the answer to that fundamental question appears to be: “Yes, absolutely.”
“EHR is the most transformational thing to happen in medicine in decades,” in Danhauer’s view. “It has caused more change in healthcare than anything capturing news headlines.”
Once the dust settles over this period of fundamental change, Danhauer predicts most providers will wonder how previous generations functioned without the shared information that EHR enables.
Despite the criticisms of EHR systems in general, “the medical staff makes certain our office hears about it,” Brown said, when Owensboro’s system goes down or is temporarily off-line.
Stack’s response is even more succinct: “The majority of physicians do not want to go back to paper records.”
No one argues that the information that MU programs want captured is not valuable, Bensema said. Providers agree that EHR is an enormous benefit and will eventually realize its potential as an indispensable tool in patient care.
There is argument, however, that CMS is trying to accomplish trying too much at once in its Stage 2 Meaningful Use objectives.
Despite complaints about Meaningful Use and EHR technology, Kentucky hospital systems are moving forward with ambitious plans to introduce full electronic connectivity and shared data under one system. Bensema outlined the structured plan Baptist Health’s IT team will implement through 2016 to connect the commonwealth healthcare giant’s hospitals and affiliated physician practices under a single integrated EHR system.
“Baptist Health will be a fully unified electronic system by 2017,” he said, with a period of system refinement to follow.
The resulting ability to organize and share patient history, imaging and medication information among hospital services, primary care providers and specialists, Danhauer said, will have an enormous impact on raising patient care quality in Kentucky by reducing medication errors and unnecessary duplication of services.
The data that EHR systems collect will enable public health entities to better track trends in diagnoses and disease, Brown added. When it successfully attested to Stage 2 MU in 2014 and 2015, she said, one of Owensboro Health’s accomplishments was transmitting public health data to two organizations.
However, many physicians are dissatisfied presently with the way EHR implementation is being handled. And Stack said the cost of complying with MU standards currently outweighs the current value of EHR systems.
Bogged down by too much at once
Meaningful Use objectives, dictated from the CMS and tied to a system of financial rewards and penalties, have come under criticism from the American Medical Association and other national and state medical societies.
Stack has presided over a series of AMA-sponsored Internet town hall meetings titled “Break the Red Tape” (bit.ly/1kbBVV9), which have given voice to its membership’s concerns over the current state of EHR technology and the rate at which CMS is expecting MU standards to be accomplished.
“Doctors want EHR systems,” Stack said. “But they want systems that support the way they conduct patient care.”
Physicians and healthcare providers, as a general rule, are voracious adopters of new technology, he said.
“They snatch up the latest smart phones, tablets, minimally invasive scopes and surgical tools, and any other technology on the cutting edge of care delivery,” Stack said. “So it is unusual to see this group be so critical of new technology that has so much potential to benefit the industry.”
Problems are wide-ranging, but it all boils down to one basic issue. The current generation of certified EHR technology is not delivering on its promise. Instead of improving patient encounters, the tech is slowing physicians down, Stack said.
“Instead of defining a very small number of high-use instances where data must be transmissable – lab results, imaging, prescriptions – EHRs are concentrating on the minutia and trying to standardize care across specialties, regardless of whether the information is applicable or not,” he said.
Following a patient encounter, MU objectives dictate that physicians key in text, navigate complex on-screen menus and wade through complicated dashboards. All that data entry interferes with direct patient care, which is what the doctor cares most about, he said.
“Current EHR mandates focus the energies of providers in the wrong direction,” Stack said. “It has reduced highly skilled professionals into deskbound clerks and typists.”
EHR systems need to evolve, Danhauer said, so that documentation takes about the same amount of time as it does to record orders on paper, but seamlessly with fewer flaws and more clarity.
Why isn’t EHR as smart as my phone?
According to current complaints, he said, most EHR systems are “inelegant, user-hostile and still lack interoperability with other EHR systems, which must be a priority.”
“It’s the exact opposite of the experience providers have with smart phones. For example: These devices are designed to be intuitive, easily understood by users and require little prior exposure to quickly know how to use them,” Stack said. “EHRs, on the other hand, take individuals with extensive educational backgrounds and hands-on experience with advanced technology, and paralyzes them with programs rife with a lack of intuitive functionality and interoperability.”
One of the fundamental problems is that the MU program, though well-intentioned to spur adoption of EHR, has created a “false marketplace” that serves the demands of Meaningful Use rather than physician needs.
“Any physician accepting Medicare and Medicaid payments is required to purchase EHR under threat of penalty,” Stack said. “But the programs themselves aren’t designed to accommodate the needs of the user, the physicians and allied health personnel, but rather the data-gathering interests of the CMS.”
Meaningful Use dictates a “one-size-fits-all” approach to patient care, he continued. It’s important that EHR systems reflect how providers interact with patients.
Physicians have expressed their frustrations by dropping out of the MU program during implementation of Stage 2, Stack said. Doctors have been willing to shoulder the penalty of not attesting to Stage 2 objectives because it’s more affordable than trying to keep up.
Dropping out of the program is not a viable long-term solution, Bensema said. Eventually the penalties catch up with those who start late. The AMA’s general argument is not against the ultimate goals of Meaningful Use but that the program is trying to accomplish too much at one time.
“No one is arguing that MU objectives aren’t worth achieving,” Stack said. “But after creating MU Stage 1 out of whole cloth, Stage 2 was initiated before there was any critical evaluation of how Stage 1 was working. And CMS has chosen to continue down this pathway without any attempt at course corrections based on feedback from EHR’s primary users.”
One of the goals of “Break the Red Tape” is to gather that feedback from physicians regarding the current state of EHR technology.
Already facing doctor shortages in some rural communities, Kentucky is in danger of losing a whole generation of physicians if MU is not modified and its timeframes relaxed, Danhauer said. Provider shortages are already bad enough in the commonwealth, he said, without disenfranchising experienced physicians in their 50s and 60s by trying to force them to change their entire way of working on a dime.
KHIE is a valuable resource
While concerns about EHR are shared nationally, Danhauer said the General Assembly demonstrated great wisdom in establishing a state sponsored health information exchange program. In fact, Danhauer and Brown credit much of Owensboro Health’s success in attesting to MU Stage 1 and Stage 2 to invaluable assistance from KHIE.
As an early adopter of EHR technology, Brown said, the Western Kentucky health system would not have been successful without KHIE.
“They were our gateway for critical information on systems, interoperability and organizing our system so that we would meet MU objectives,” Brown said. Having a central authority in Kentucky for health information systems clearly has made the transition to EHR a lot easier than it would have been had Owensboro tried to go it alone.
“Our partnership with KHIE has been nothing less than phenomenal,” Brown said.
In October, CMS announced it is modifying MU Stage 2 attestation requirements for 2016 and extending MU Stage 3 deadline for providers until 2018. The AMA was still assessing the details of the 70-page release and deferred comment.
At Owensboro Health, Brown welcomed the modifications, saying the new requirements are easier to attain. Modifications relax standards involving third parties such as requiring patients to use Owensboro Health patient portal to ask for information.
“We have no ability to force patients to use that portal,” Brown said. “So meeting the Stage 2 requirement that a percentage of our patients use that portal was a standard over which we had no control.”
ROI can’t be measured … yet
It is difficult to appreciate the potential returns on investment at this stage because they are still years off, Bensema said.
Baptist Health assembled a value realization task force to compare the system’s current rate of expenditure against the revenues it could gain by recouping lost charges, improving workflows as the technology refines itself, improving patient outcomes through shared information, and other factors. The task force made a conservative projection that Baptist Health could save a minimum of $18 million annually after EHR is implemented and refined.
“That figure was on the low end of the scale. I believe it’s likely to be much more,” Bensema said.
Despite today’s challenges, Danhauer said, a subset of Owensboro Health’s patient population is very engaged in that system’s progress to full EHR implementation.
“There is a generation of people who are accustomed to conducting business and managing finances electronically,” he said. “They want their health information, lab results and X-rays in front of them with their doctor or surgeon answering their questions.”
In the long run, he predicted that it will be the patients, not CMS, who will drive healthcare’s embrace of EHR.
“We’re already seeing it happen,” Danhauer said.