AHIC Electronic Health Records (EHR) Workgroup

Testimony Summary and Recommendation Discussion Items

Critical Component: Financial/ Business Case

Widespread physician adoption of EHRs has been limited. As few as 10% of practicing physicians actually use an EHR to document clinical notes, order tests and prescriptions, and record test results. The workgroup heard extensive testimony that the primary obstacle to widespread adoption of EHRs is financial. Fully function, certified EHRs are costly. Hardware is costly, as are implementations, updates, and maintenance. Lastly, there is significant revenue loss from decreased productivity during implementation and for months after. The financial/ business case issues presented to the workgroup by the eleven testifiers are:

• Business case alignment. What type of reimbursement can best support sustainable EHR adoption? Capitation? Increased rates of reimbursement for clinicians who use EHRs? Addition payment codes for first patient visits after EHR adoption?

• Realignment of incentives for adoption and rewarding use.

  • Payment for outcomes

  • Payment for use early on, building in weight for increased adoption over time.

• Loss of productivity adds to significant revenue loss at a time when significant investment must be made in EHR adoption. There are few or no supports to offset this particular negative balance.

• Decrease in administrative costs from adoption is dependent on the size of practice (larger practices have more opportunity for savings from greater economies of scale) and the degree of workflow and workforce chance that can be realized.

• Several studies demonstrate significant savings in claims costs, but these accrue to the entity that holds the financial risk for the care: to the clinician in a capitated environment, to the payer in a FFS environment.

Workgroup recommendation discussion:

• P4P has been suggested as an approach to realign the risk/reward to support a sustainable business case. Is this appropriate? Are there certain types of P4P or Pay for Use that encourages more adoption?

• Over the past year Stark and anti-kick back have been put forth. Is there a need for other regulations or protections to support the business case?

• There is a big adoption discrepancy between small and large practices. How can we better support the small practices to close the adoption gap?

• Is there significant non-monetary value in adoption of EHRs? What other ways can there be a ROI other than direct $.

  1. Patient/ Provider satisfaction

  2. Decreasing admin costs

  100. Time savings (refills)

  500. Data/ results management efficiencies

  5. Increase in appropriate charge capture if that had been problematic

• Other possible sources of making a better ROI? Perhaps low/no interest loans, start up grants, standard interfaces that decrease system costs, collaborative purchasing arrangements, increased charge capture if this had been problematic pre adoption of EHR, increased payments for physicians using EHRs via billing codes (new patients, certain types of care, transition to EHR from paper)

• Are reports and publications sufficiently compelling to make a business case for multi-stakeholder financial support of physician adoption?

Critical Component: Legal/ Regulatory

Perceived liability issues are also of significant concern to clinicians. The workgroup heard testimony from twelve presenters on the most salient legal and regulatory issues and how they may be addressed. These include:

• Access to and custodial control of large volumes of data is perceived to increase liability by providing unsolicited information that may require action.

• Who updates a “community” record

• Who “owns” the record(s)

• How does one handle patient added data

• Anticipating new types of errors as a result of electronically enabled information.

• Lack of clinical protocols for point-to-point data transmission that assures appropriate context, responsibility, and handoff, and follow-up.

• State based issues such as licensing, reporting requirements and record retention laws.

• Clarification of legal questions related to legislation such as “Stark”, fraud, and antitrust.

• Concern about legal consequences that stem from information transparency and broader information use (i.e. secondary uses of data.).

• Legal testimony identified ways to limit the perceived liability risks such as: improved user interfaces which structure the aggregated information in a hierarchical, easy to navigate fashion.

Workgroup recommendation discussion:

• Are there recommendations that could be made to the CCHIT to decrease liability?

• What can be done to promote malpractice insurers to provide incentives that could advance EHR adoption?

• Is there guidance that could be provided to hospitals and other entities addressing protections for HIT donations?

• What, if any, type of recommendation can be made about secondary uses of data?

Critical Component: Organizational

Once financial and technical barriers are solved and concerns about privacy, security, and liability are addressed, there are still a number of human factors that must be considered before widespread adoption and effective use of EHRs is the standard expectation. The workgroup heard about a number of these factors from twelve public testifiers, all of whom underlined the importance of understanding how disruptive EHR implementation can be to a physician’s practice. Also, underlined was the importance of workflow change, simply converting ink to electrons without taking advantage all of the opportunities an EHR affords will do little to improve patient care or efficiency. Among the topics discussed were:

• Cultural barriers

• Workforce education and training

• Need for well informed “champions”

• Efforts to link professional certification to HIT.

• Implementation assistance and workflow redesign is key to improvement (esp. small and safety net providers)

• Availability of resources such as DOQ-IT, DOQ-U, and the AHRQ resource center

• Lack of knowledge about EHR selection practices, which increases risk of the “right” purchase.

Workgroup recommendation discussion:

• Are on line consultant services sufficient to support adoption?

• Are there resources sufficient to support the adoption goals?

• Are there sufficient training programs available for all support staff?

• How can patients be more engaged in supporting HIT adoption among clinicians?

Critical Component: State of the Technology

Previous workgroup recommendations focused on critical components of interoperable information, leading to HITSP and CCHIT standards and criteria development. The workgroup heard testimony on other technological improvements that would enhance the value, and hence the adoption, of EHRs among clinicians. This testimony from the nineteen presenters primarily fell into the following 5 categories: interoperability, interconnectedness, clinical decision support, functionality, and usability. Key issues noted:

• Need standardized interfaces for such information as test results, e-prescribing, and administrative data.

• Currently, assessments of usability are limited and it is “buyer beware” in this arena.

• Software immaturity, lack of many EHRs with: embedded granular/actionable clinical decision support; robust tools for determining, aggregating, and reporting performance measures; forms/structure for following episodes of care over time; forms for care coordination; interoperability sufficient to share information with colleagues, patients, payers, and quality improvement organizations; dashboards for monitoring preventive/chronic care adherence.

• Discussion (recommendation made) regarding EHR data elements/functionality needed for clinicians to exchange information: Patient Identification; Medication List / Allergy; Laboratory Results; Problem List; Clinical / Encounter Notes; Anatomic Pathology Results; Vital Signs; Family History/ Health Factors; Radiology Reports: Not including images; & Immunizations.

Workgroup recommendation discussion: