An unsung victory in healthcare

By Ezekiel Emanuel
March 6, 2012

In 2008, 17 percent of office-based physicians and just 9 percent of hospitals had basic electronic health records (EHRs) and fewer than 10 percent used electronic prescriptions. This doesn’t mean most physicians were Luddites; rather, there were powerful disincentives to their adoption of health IT.

For example: Installing electronic health records required retraining physicians and staff, exacting months of significantly reduced productivity. Technology from different vendors typically did not communicate with each other, so the free flow of information — referral letters, hospital discharge summaries, lab results, X-rays and all the rest — that would make the investment worthwhile was not there. Then there was the network effect: Until a lot of doctors and hospitals were using electronic health records and a lot of vital information was available electronically — even if the various proprietary systems did communicate — it wasn’t worth it. And finally physicians feared that an expensive new EHR system would soon be obsolete, requiring another big capital investment.

On Feb. 17, 2009, President Obama signed the Recovery Act, which contained a number of healthcare provisions, including the Health Information Technology for Economic and Clinical Health Act (HITECH), which nullified these disincentives. HITECH did this by providing physicians payments of up to $44,000 from Medicare and $65,000 from Medicaid — and hospitals getting millions of dollars, with amounts varying based on how many Medicare and Medicaid patients they cared for — to help defray the cost of EHR adoption. Obviously, this is not free money. Physicians and hospitals receive the incentive payments if their EHRs are certified as capable of supporting “meaningful use.” This, in practical terms, means they can be used for e-prescribing, securely exchanging patients’ health information and electronically submitting data on the quality of care. The law also includes a penalty for physicians and hospitals that do not implement EHRs: Their Medicare payments will be reduced beginning in 2015. It also empowers the government to set technology standards regarding interoperability and the secure exchange of health information.

A lot of naysayers carped that this was not an economic stimulus that would help get the country out of a recession, so it didn’t belong in the Recovery Act. Others complained about the myriad requirements necessary for meaningful use. And not a few physicians were resentful, declaring that they would stop practicing rather than adopt EHRs.

It’s now been a year since the administration released the regulations specifying meaningful use and what it takes to be certified — the nuts and bolts of implementing the law. The results have been nothing short of spectacular.

As of December 2011, the use of EHR among office-based physicians has nearly doubled to 34 percent with e-prescribing exceeding 40 percent. Over 41,000 physicians have received more than $575 million in incentive payments. Going electronic will allow physicians to more closely track patients, especially the chronically ill,  enabling the seamless exchange of data across multiple physicians, hospitals and other providers. For instance, Delaware is completing a framework for the electronic exchange of patient information among all the state’s hospitals. And the more physicians and hospitals have electronic records, the more effective and useful the exchange of data will be, enhancing patient care, especially in emergencies.

The story is much the same among hospitals: 35 percent have adopted EHRs, and nearly 2,000 of the 4,700 hospitals have, collectively, received more than $2 billion in incentive payments. Every month has surpassed the previous month as measured by the number of physicians and hospitals that have signed up with the government for the EHR program, suggesting that these numbers will continue to rise.

Another great byproduct of the law is that the entire healthcare IT industry has been refocused away from developing new, improved ways for physicians and hospitals to code and bill the insurance industry and the government for payment. Instead, they now focus on making electronics work to improve care, enhance coordination among physicians and facilitate physician-patient communication.

What about jobs? Has this provision of the Recovery Act actually helped the recovery? According to the Department of Health and Human Services, over 50,000 high-paying health IT jobs were created between 2009 and 2011. Additionally, the Bureau of Labor Statistics estimates that the number of health IT jobs will increase by 20 percent from 2008 to 2018 — faster than any other occupation. And the number of vendors offering EHR’s that fulfill government requirements has tripled to 600.

By any measure this part of the Recovery Act has exceeded expectations. This is all good news for those of us who will be patients, because it is critical to controlling costs and improving quality. We can be sure that after 2015 the vast majority of physicians and hospitals will have EHRs and the lost record or misplaced X-ray will become a distant memory. More important, having almost everyone’s physician use an EHR in their care will enable hospitals and physicians to finally have reliable data to identify problems and improve care.

The quality of today’s EHRs does not mean their future will be disappointing. Given that the government will spend between $19 billion and $27 billion on health IT, that there are hundreds of billions of dollars in waste to be saved and that over 90 percent of physicians will have EHRs by the end of the decade, a slew of new companies offering great new applications we cannot even imagine today will be spawned, each trying to get a slice of that big pie.

Yet there are concerns. The program was built on the idea that you start with modest requirements to get physicians and hospitals on board and then escalate them to ensure a more robust system. People like me worry whether the escalation will really occur. As you might imagine, physicians and hospitals would like to have the incentive payments for meeting minimal requirements. Not surprisingly, when the draft regulations were written, many physicians and hospitals pushed to have them scaled back — and succeeded. The worry is that they will push back again. Instead, we need to ensure that by the third stage, 2015, all EHRs will have to have decision supports and integrated pathways for high-quality care to be certified. We also need to ensure the exchange of information so the discharge summary is sent the day the patient leaves any hospital to all of the patient’s doctors — primary-care as well as specialists. We need to have a system that allows all records to be securely sent electronically from one doctor to another for consultations. We also need to require that all EHRs have secure messaging between patients and physicians, so medicine can enter the 21st century of electronic communication.

But whatever my reservations, we have had great success in spreading electronic health records — and that is a sign that healthcare reform is changing American medicine. All of us patients will benefit.


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