American Health Information Community

Electronic Health Records Workgroup

Summary of the 16th Web Conference of This Workgroup

Tuesday, May 22, 2007

PURPOSE OF MEETING

The purpose of the 16th Web conference of the Electronic Health Records Workgroup (EHR WG), chaired by Jonathan Perlin, was (1) to begin hearing testimony related to the EHR WG’s development of recommendations to encourage the widespread adoption and use of certified electronic health records (EHRs) in hospital inpatient settings and (2) to modify three of the EHR WG’s recommendations regarding the adoption and use of EHRs by physician practices to reflect guidance received at the April 24, 2007, meeting of the American Health Information Community (AHIC).

INTRODUCTORY REMARKS

Dr. Perlin began the meeting shortly after 1 p.m. The minutes of the April 18, 2007, EHR WG meeting were approved. Dr. Karen Bell reported that the Internal Revenue Service had issued a long-awaited memo on May 11, 2007, providing guidance that nonprofit hospitals are not to be held liable if they provide financial assistance for EHR software and technical support to medical staff physicians under Federal EHR regulations issued August 8, 2006 (42 CFR 411.357; 42 CFR 1001.952).

KEY TOPICS

1. Presentation: “Hospital Use of Information Technology 2007” Kristin Welsh, American Hospital Association (AHA)

Ms. Welsh reported on a recent AHA survey of hospitals’ use of health information technology (HIT). The survey covered topics such as information technologies used by hospitals, the functions of hospitals’ EHRs, information exchange, and barriers to greater adoption of information technology. Of the survey respondents, more than two-thirds those hospitals have fully or partially implemented EHRs. Hospitals without EHRs tend to be the smaller, rural, nonteaching, and nonsystem hospitals with more limited resources than hospitals that have implemented EHRs.

Ms. Welsh’s presentation, “Continued Progress: Hospital Use of Information Technology 2007,” is available online at http://www.hhs.gov/healthit/ahic/healthrecords/ehr_archive.html.

2. Workgroup Planning: EHR Membership Discussion

EHR WG members have been asked to indicate whether they want to continue their participation as the Workgroup moves on to the next phase of its work, which is to make recommendations to encourage the widespread adoption of certified EHRs in hospital inpatient settings. Two members have said that they will not continue, and the EHR WG can probably accommodate as many as five new members. Dr. Bell asked for suggestions about which sectors new members should represent. EHR WG members suggested (1) hospital pharmacy departments/services; (2) the vendor community represented by the Healthcare Information and Management Systems Society; (3) physician groups whose main focus is within the hospital (e.g., hospitalists, radiologists, emergency room physicians); (4) hospital nurses, including nurse informaticists; and (5) critical access hospitals. Office of the National Coordinator (ONC) staff will receive nominations and recruit new members for the EHR WG’s July 20th, 2007, meeting.

Staff Action Item #1: Receive workgroup member recommendations and recruit new members by the meeting on July 20, 2007.

3. Presentation: “Incentives for ICT Adoption: An Example from California,” Kristiana Raube, Ph.D., Berkeley

Dr. Raube gave a presentation on the Integrated Health Care Association’s pay-for-performance (P4P) program in California. This program, which involves seven major commercial HMOs and point-of-service plans in California, began making payouts in 2004 to improve the quality of clinical care and patient experience. The program’s experience suggests that it is possible to use financial rewards to create incentives for the adoption and use of HIT in physicians’ offices. It also suggests that better HIT may be related to improved clinical care.

Dr. Raube’s presentation, “Incentives for ICT Adoption: An Example from California,” is available online at http://www.hhs.gov/healthit/ahic/healthrecords/ehr_archive.html.

4. Amending Three of the EHR WG’s April 24 Recommendations to AHIC Pertaining to the Adoption and Use of Certified EHRs by Physicians

The EHR WG was charged at the April 24, 2007, AHIC meeting with amending the language of Recommendations 1.0, 1.1, and 4.0 to encourage the widespread adoption and use of certified EHRs in physician office settings to clarify the recommendations’ scope and meaning.

Recommendations 1.0 and 1.1: Business Case Alignment for Physicians. Recommendations 1.0 and 1.1 pertained to using Federal contracts to foster the use of P4P incentives for the adoption and use of certified HIT by physicians. The EHR WG was asked at the AHIC meeting (1) to clarify the entities to which the recommendations should apply; (2) to reconsider whether MedPAC is the appropriate entity to look to for measures, as suggested in Recommendation 1.1; (3) to consider whether the term “pay for use” is more appropriate than “pay for performance”; (4) to clarify what should be measured and what measures should be used; and (5) to clarify the scope of what is to be addressed in Federal contracts with health plans and insurers. AHIC is ready to approve the recommendations once these issues are addressed.

Chip Kahn observed that Recommendation 1.0 is actually suggesting pay for use of EHRs, not P4P. He added that in the context of Medicare, pay for use is not really an incentive for the use of HIT but a penalty if one does not use it. He understands that Recommendation 1.0 is about Federal Government contracts with health plans, not Medicare, but he is concerned that it could set a precedent for Medicare. If the recommendation was worded in a very limited way to specify effective utilization of certified EHRs for physicians as part of existing health plan incentive programs, he would find it more acceptable. Mr. Kahn also suggested that the recommendation should specify the use of HIT that meets very specific standards, for example, those of the Healthcare Information Technology Standards Panel (HITSP) or the Certification Commission for Healthcare Information Technology (CCHIT). He added that if there is going to be a measurable metric, the metric should be endorsed by a single body such as the National Quality Forum.

Dr. Bell explained that Recommendation 1.0 was intended to cover all Federal contracts. She said the Office of Personnel Management (OPM) is comfortable with a recommendation (not a requirement) that OPM, in its contracts with health plans, pay for the adoption or use of certified HIT, so long as the recommendation does not apply only to OPM contracts. Dr. Bell also noted that MedPAC supplies examples of measures; it does not create them.

Staff Action Item #2: Revise the EHR WG’s Recommendations 1.0 and 1.1 pertaining to the business case alignment for the adoption of EHRs by physicians and circulate the new versions to EHR WG members for review and approval, so that final recommendations can be sent back to AHIC by June 12, 2007.

Recommendation 4.0: Overarching Recommendation. Recommendation 4.0 pertained to differential reimbursement to physicians for use or nonuse of EHRs. The EHR WG was asked by AHIC at the April 24, 2007, meeting (1) to clarify what the legal authority is for the Centers for Medicare & Medicaid Services (CMS) to provide differential payment to physicians, (2) to recommend to AHIC what type of metrics should be used to assess the use of certified HIT by physicians, and (3) to obtain public input on the revised recommendation.

Mr. Kahn stated that the legal authority for differential reimbursement to physicians might require that Congress enact legislation, although CMS has fairly broad authorities under Medicare conditions of participation, so some vehicles beside payment might be worth investigating. Dr. Perlin asked ONC to explore and provide counsel on the legal authority for the recommendation.

Staff Action Item #3: ONC will provide a forum to explore the legal authority for CMS to encourage the use of HIT by hospitals and physicians through differential reimbursement or other means such as Medicare conditions of participation.

Mr. Kahn recommended that the EHR WG obtain public testimony from both hospitals and physicians instead of taking a silo approach. On the hospital side, he recommended hearing from various types of hospitals, not just major hospital systems but small hospitals and rural hospitals.

Staff Action Item #4: Develop ideas about the format for public input related to hospitals and physicians for the EHR WG’s new recommendation that replaces Recommendation 4.0.

In the next few months, the EHR WG will be developing recommendations about how to advance the adoption and use of EHRs in hospital inpatient settings. At Dr. Bell’s suggestion, EHR WG members decided to table Recommendation 4.0 and work through the issues of authority, metric use, and public input with the goal of revising the recommendation to make it primarily a recommendation to advance hospitals’ adoption and use of EHRs, but also articulating how such a recommendation might help with the adoption and use of EHRs by physicians.

5. Workgroup Planning: Structure for Inpatient Focus in Advancing the EHR WG’s Broad Charge

EHR WG members agreed that the same general framework used to structure the EHR WG’s work on developing recommendations to encourage the adoption and use of EHRs by physicians should be used for its work on recommendations to advancing the adoption and use of EHRs in hospital inpatient settings. The EHR WG’s meeting on July 10, 2007, will focus on the business case and financial issues related to the adoption and use of EHRs in hospital inpatient settings.

Staff Action Item #5: Arrange for presentations at the EHR WG’s July 10, 2007, meeting on key financial issues related to hospitals’ adoption and use of EHRs.

6. Public Comment

Angela Jeansonne, from the American Osteopathic Association, expressed concerns about differential reimbursement to physicians for the use of HIT, especially penalties for failing to use HIT. She also emphasized the importance of considering things in terms of small and rural practices. Finally, she noted that representatives of physician specialty organizations, including emergency medicine and radiologists, would be glad to provide input to the EHR WG.

SUMMARY OF ACTION ITEMS

Staff Action Item #1: Provide a list of recommended candidates for EHR WG membership at the EHR WG’s meeting on July 10, 2007.

Status #1: New workgroup membership recruitment completed.

Staff Action Item #2: Revise the EHR WG’s Recommendations 1.0 and 1.1 pertaining to the business case alignment for the adoption of EHRs by physicians and circulate the new versions to EHR WG members for review and approval, so that final recommendations can be sent back to AHIC by June 12, 2007.

Status #2: Revision completed and revised recommendations accepted by AHIC.

Staff Action Item #3: Obtain advice for the EHR WG from the legal counsel of ONC or CMS on the legal authority for CMS to encourage the use of HIT by hospitals and physicians through differential reimbursement or other means such as Medicare conditions of participation.

Status #3: Outstanding. Inquiry to CMS pending. Topic to be discussed during Aug EHR WG meeting/Town Hall.

Staff Action Item #4: Develop ideas about the format for public input related to hospitals and physicians for the EHR WG’s new recommendation that replaces Recommendation 4.0.

Status #4: Topic to be discussed during Aug EHR WG meeting/Town Hall.

Staff Action Item #5: Arrange for presentations at the EHR WG’s July 20, 2007, meeting on key financial issues related to hospitals’ adoption and use of EHRs.

Status #5: Presentations planned from three hospital systems.

MEETING MATERIALS

• Agenda & April 2007 meeting minutes for approval

• AHIC 4/24 Final Recommendation Letter & AHIC transcript of recommendation discussion

• IRS memo: “Hospitals Providing Financial Assistance to Staff Physicians Involving Electronic Health Records”

• Presentations

  • Kristen Welsh, “Continued Progress: Hospital Use of Information Technology 2007”

• Kristiana Raube, PhD, and Cheryl L. Damberg, PhD, “Incentives for ICT Adoption: An Example from California”

Electronic Health Records Workgroup

Members and Designees Participating in the Web Conference

Tuesday, May 22, 2007