This article is the last in a six-part series examining what industry pioneers have accomplished with electronic health records. In this installment, Editorial Director Gary Baldwin reconnected with sources from the series and with other experts to raise one final question: What does the future hold for clinical I.T.? Much of the discussion centered on the impact of the federal government's $49 billion program of incentives, grants and supporting projects aimed at promoting EHRs. While all were optimistic, each raised serious concerns that, if left unaddressed, could derail the nation's march to the EHR.

The Physician Champion

Larry Garber, M.D., Medical director, informatics
Organization: Fallon Clinic, Worcester, Mass.
EHR Achievement: Paperless medical group

Fallon Clinic has attained a degree of electronic clinical documentation that remains a pipe dream for the vast majority of the nation's group practices. With the exception of consent forms, no paper documents are in use at the 250-physician, multi-specialty group practice. Physicians have access to a bevy of data, including 15 years of test and treatment results; current medications and allergies; and inpatient and emergency department documentation from several local hospitals. Fallon also is connected to its major health plan, which feeds claims data into the group's EHR. Patients, too, are in the electronic loop, having the ability to send physicians secure messages and retrieve a personal health record based on the official chart. "We're living in the future and waiting for the rest of the country to catch up with us," Garber says. "They will."

The source of Garber's optimism is the massive I.T. stimulus program, a $49 billion package of incentives, grants, training centers and other initiatives aimed at spurring the industry into connectivity. "The stimulus legislation is a great enabler for the country to be successful," Garber says. Under the program, physician groups and hospitals would qualify for bonus payments - of up to $44,000 per physician from Medicare or up to $63,000 from Medicaid - for using certified systems in a meaningful way. While the terms of the program have yet to be spelled out, the money represents a financial incentive to adopt that heretofore has been lacking for group practices. And make no mistake, the technology requires capital. Fallon spent nearly $24 million on its EHR in its first three years

The barrier to physician adoption is not just financial, however, Garber adds. There are also workflow issues and training needs. "We could implement because it was practical for us, given our size," Garber notes. "We can have a help desk, eight trainers, a large team of analysts, techs and database specialists. But we have 330 providers (Fallon also encompasses 80 mid-level providers in addition to its physicians)." That's not feasible for the smaller group practices that comprise the vast majority of the industry, he says. "A small group cannot hire one-tenth of a trainer."

The federal stimulus program understands that dilemma, Garber says. The program includes regional extension centers, which would function as training and resource centers for practices, particularly small and rural ones. "The government was smart to shift money to the extension centers and put less emphasis on loans. That made it harder for docs to just jump out on their own." The downside to premature physician adoption, Garber contends, is that many practices might make unwise decisions about their systems, such as picking the wrong underlying data sets to support electronic orders. "The extension centers will pull together communities," he predicts. "When you have 100 physicians going live at the same time, you can pull together a team to help them."

The Pragmatist

Phyllis Schuck, CIO
Organization: Pinehurst (N.C.) Surgical
EHR Achievement: Paperless medical group

The industry is on the cusp of a major sea change, Schuck says. Group practices are about to lose much of the autonomy they have enjoyed, because the government, and other payers, will no longer tolerate inefficient business practices. A reimbursement overhaul is inevitable, she predicts, given rapidly rising costs. "The talk about EHR is just laying the groundwork for changes in how health care is paid for. The industry will force physician groups to adopt," she says. "And some providers will retire, rather than change."

The change, however, is overdue. "Hospitals and physician offices do not coordinate care very well," she says. "The rules make it difficult to share information. But once we get health information exchanges in place, there will be great strides in the EHR."

State data exchanges will likely play a major role in the distribution of federal incentive money. Schuck envisions the model working because "every state has a financial obligation to Medicaid. It is in their own best interest to develop a method that allows a common database to keep tabs on what goes on with Medicaid patients."

As far as the federal incentives for physicians to adopt EHRs, Schuck is ambivalent. Despite its own electronic records success, Pinehurst Surgical has had limited success embracing any of the government's other I.T. incentive programs, such as the Physician Quality Reporting Initiative, which rewards group practices for hitting certain care milestones for chronic conditions. "Our physicians have tried and found it is not practical," she says.

CMS wants to know if physicians are following the right diagnostic steps and uses a checklist. It is very time-consuming."

What shapes the reporting of data to attest EHR meaningful use will take is anyone's guess. Schuck only hopes the requirements are not overly complicated. "The way I see it, we already have meaningful use."

The Consumer Advocate

Ed Babakanian, CIO
Organization: UC San Diego Medical Centers
EHR Achievement: HIMSS Analytics Stage 6

When Babakanian peers into his crystal ball, he sees the face of consumerism. Consumers would never do business with a bank that did not enable electronic transactions, and in time, they will carry that expectation to the health care industry. "People don't want to call us and wait an hour on the phone," he says. "They want to send us a secure message, like they do in making airline reservations." To that end, UC San Diego is building a consumer-oriented patient portal, called MyChart. It's linked to the academic medical center's EHR.

The patient portal is just the icing on the cake, as UC San Diego has been building its EHR for several years. It recently ascended to stage 6 on a seven-rung scale devised by Chicago-based HIMSS Analytics, an accomplishment made by less than 1% of U.S. hospitals. The technology has resulted in measurable quality improvements, the CIO says, including faster delivery of medications. A "closed loop" system automates the process from the initial order. "We have eliminated paper errors," Babakanian says.

He's optimistic that the rest of the industry will follow the lead, describing what he calls a "perfect storm" of incentives. The rising tide of consumerism is only part of the picture. At the same time, the federal stimulus package stands to provide millions of dollars in incentive money to large hospitals with closely aligned group practices. There's also the looming stick of reduced Medicare and Medicaid payments in 2015.

Yet, Babakanian worries that the incentive money might be a little too powerful. If hospitals embrace I.T. just to get the payment, and not improve operations and quality, things could backfire. "My concern is that we will waste a lot of money trying to do something good," he says.

In his view, consumers - if not payers - will be a major force in keeping hospitals honest. Hospitals that cannot deliver, or measure, quality performance, will "go out of business," he predicts.

"The government and payers will naturally select providers that can demonstrate what they produce. Consumers will expect a scorecard."

The Fiscalist

Mitch Morris, M.D., National leader, health I.T.
Organization: Deloitte Consulting, Costa Mesa, CA

For Morris the federal stimulus program is a major boost for the industry - with a few "ifs," and big ones at that. "CIOs are seeing their funding increased as a means of getting to the incentive payments," says Morris, who has advised such large health systems as Catholic Health Initiatives on their adoption strategies. He credits the Obama Administration for elevating the debate. "It started during the Bush Administration, but Obama has taken it to another level by putting dollars behind it. He made the Office of the National Coordinator a significant agency."

According to Morris, most hospitals are well-positioned to take advantage of EHR incentive dollars, regardless of how meaningful use is defined. "In the most typical scenario, the hospital has picked a core vendor, installed some ancillaries, but has not yet done CPOE or built a data warehouse. Getting to the finish line is a cultural shift."

Among physician practices, the most under-automated sector of the industry, Morris says that EHR systems are now on the radar, "even in solo practices." Furthermore, hospitals realize that they need to create an ambulatory strategy and figure out a how to support EHR adoption by area physicians.

The challenge for all sectors, however, remains the economy. Decreased cash flow and decreased philanthropy create a double whammy for not-for-profit hospitals, Morris observes. "If you let your cash on hand go lower, your variable interest rate will go up. So CFOs are saying they cannot spend any money because their interest rates will go up. They will be in the red. Finding the financial resources [to fund adoption] really concerns me."

Of particular concern, Morris adds, are rural and critical access hospitals. They will be hard-pressed to attain meaningful use and qualify for incentives. "Does the federal government want to penalize critical access hospitals if they cannot comply?"

The Realist

Chuck Christian, CIO
Organization: Good Samaritan Hospital, Vincennes, Ind.
EHR Achievement: Bar coded medication administration

If nothing else, Good Samaritan Hospital testifies to the need for patience - at least when it comes to EHRs. Nearly a decade ago, Christian laid out a vision of how the technology could boost quality. "We were also hedging our bets that the EHR would be a requirement."

The foresight proved to be 20-20. Good Samaritan is poised to jump to Stage 6 on the HIMSS Analytics scale, lacking only computerized physician order entry to make the leap from its current stage 3, according to Christian's analysis. Good Samaritan has a physician portal, automated labs and a radiology system integrated with its PACS. And it has tackled some difficult chores, such as automating medication reconciliation.

The hospital stands to benefit from the federal stimulus package, which would reward its use of the technology. For Christian, the stimulus is a bit of a mixed blessing. "The good news is that there is a light at the end of the tunnel," he says. "The bad news is that there is a train attached to it, and oh by the way, the engineers will turn the light out and you won't know when it is going to run over you."

Christian's colorful metaphor may not be entirely accurate, but it comes close enough. For CIOs like him, there is a tremendous amount of uncertainty around the stimulus program, and furthermore, there are penalties which would kick in eventually for non-compliance. "I just don't know if we will hit the magical marks set by the government in 2015 (the year the penalties begin)," he says. "The government is betting the industry won't, because the cost savings includes billions in penalties to offset some of the investment."

The presence of an operating data exchange in each state will greatly impact how successfully small practices can adopt EHRs, he says. That's assuming that participating in a data exchange will be a component of meaningful use. Beyond that, some observers predict that the data exchanges will verify adoption. "Will they penalize physicians who don't have access to an operating data exchange?" Christian asks.

The Questioner

Dan Rode, Vice president of policy and government relations
Organization: American Health Information Management Association, Chicago

Rode's long-term view is optimistic, with the prospects for national adoption of clinical I.T. "bright and sunny." Short term is another story. "My forecast is partly cloudy; there are so many unknowns we are presented with now."

His long-range optimism is engendered by the federal I.T. stimulus package, which he describes as overdue recognition of many of the issues proponents have been championing for years. "We have begun talks about data standards, the integration of terminologies and how the accumulation of data can help population health. And we're taking steps in privacy and security to build more trust."

The stimulus program, Rode says, accelerated the debate and pushed the EHR into prominence. Despite that, the sheer magnitude of effort - coupled with an "aggressive adoption schedule" inserted by Congress into the enabling legislation - raise questions. "We've got a lot on our plates and we've been behind in a number of projects, such as converting to HIPAA 5010 and ICD-10," Rode says. "We have demand for health information exchange, but we have a lot of players we have not ferreted out."

Beyond that, the stimulus package includes a variety of adoption deadlines that "the government is desperately trying to meet," Rode says. "The question is are the deadlines feasible?" For example, building up regional extension centers - state and regional support groups to help propel physician adoption - is itself a difficult task. "Can the federal government guarantee that every regional center will be in place in time for medical groups by 2011 (the year certain incentives begin)? The ability to be more elastic with scheduling might make more sense."

The other looming storm cloud on the horizon is federal health reform. For example, if proposed cuts in physician payment go through, physicians face draconian reductions in income. "If the physician payment process is not corrected, and physicians take a 20% hit in income next year, will they go after incentive money that is effectively a Medicare add-on or will they drop Medicare patients?"

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