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Physician EMR Adoption and Attitudes; and What Will Dr. Blumethal Do?

Posted Jun 03 2009 4:52pm
Several recent publications describe once again the large "practice variation" in EMR adoption at least as seen through the eyes of surveys. A brief overview of ARRA written by David Blumenthal provides some hints as to the direction of policy.

seeJha surveyed all acute care hospitals as part of an American Hospital Association annual survey. They received responses from approximately 3,000 (63%) of hospitals surveyed. The found very low rates of comprehensive use.

Carol Weimar of American College of Physician Executives has a piece that provides data on approximately 1000 respondents suggesting the "love/hate" relationship with the EMR. Quotations from the report include
  • “I feel like I hit a cliff head on and have been dragging myself to the top.” “But after 10 months, I can see the promised land.”
  • “It’s expensive, difficult and essential. We would never go back. The trick is using the technology to improve the process. We’re still and will always be working on that.”
  • “It was painful to implement, but I wouldn't go back to the way it was. Access to information is much faster and better, communication with patients has improved, but there has been some degradation of the office visit documentation.”
  • [Adopting electronic medical records has been “the worst aspect of my 25 years in medicine. It has ruined doctor productivity, produced lower quality care and encouraged notes that are false to the point of fraud.”
  • “The biggest issue is not necessarily the physician resistance—it is the administrative resistance to admitting that these are not just IT projects. They are clinical projects, just as any other process change in clinical care would be viewed.”
  • “There has been little attempt to train physicians so they can use the system well. The interface between the physician and software program is cumbersome. Rather than interface the main system with a documentation system that has a proven record in emergency departments, they are using a system that the docs don’t like. Pound foolish!”
  • “Don’t underestimate your partners’ anxiety in changing their comfortable ways of getting through the day. Promises of efficiency only come after hours of suffering. ‘It ain’t easy, but who said it should be simple?’”
In the same March 25 web publication issue, David Blumenthal, newly appointed National Coordinator, has a review of ARRA. Some comments in his piece (he also provided oversight for the Jha survey) are perhaps indicative of future trends.

First, he recognizes the "tight schedule" the requires the infrastructure to support HIT adoption to be in place "well before 2011 if physicians and hospitals are to be prepared to benefit from the most generous Medicare and Medicaid bonuses." He rightfully states that "it takes time to develop and implement innovative federal programs, and it will take even more time to create the local institutions needed to support HIT implementation." This writer is concerned that the tight timeline may actually lead to the implementation of products in some settings that either do not meet needs or, in simplifying the complex fragmented health care payment system, actually make substantive health care reform more difficult.

Second, Blumenthal focuses on the two critical terms that will define so much: "certified EHR" and "meaningful use." With respect to CCHIT, he states that "many certified EHRs are neither user-friendly nor designed to meet HITECH's ambitious goal of improving quality and efficiency in the health care system. Tightening the certification process is a critical early challenge for ONCHIT." He further states that effective use will require physicians to take "advantage of embedded clinical decision supports that help physicians take better care of their patients. By tying Medicare and Medicaid financial incentives to 'meaningful use,"'Congress has given the administration an important tool for motivating providers to take full advantage of EHRs, but if the requirements are set too high, many physicians and hospitals may rebel — petitioning Congress to change the law or just resigning themselves to forgoing incentives and accepting penalties.

Third, he realizes that the full potential of EHRs will be realized only through a dramatic change in "the health care system's overall payment incentives so that providers benefit from improving the quality and efficiency of the services they provide."

These are formidable challenges. At present the carriage seems before the horse. Incentives are provided to automate a health care system whose characteristics are not well defined. Given the tight frame, this suggests only incremental changes with an increased reliance on our current means of measuring quality and receiving compensation through administrative claims. The most likely outcome of this process will not be the "disruptive innovation" Clayton Christensen and others believe is necessary but rather a refinement of the status quo. But with the rise of alternative vehicles for care like on-site clinics, alternative care providers, inexpensive generic drugs, and self-pay programs, disruptive change may happen despite the federal government rather than because of it.

ONC and the federal government face a formidable challenge and the true nature of this challenge is recognized. But the focus of past work has been primarily focused on physicians and hospitals and the emphasis has been on CPOE and clinical decision support. Little mention is made of the pressing need to create an infrastructure of laboratory, pharmacy, and other information required to enable person-centered care. Indeed, many from Harvard have published or stated publicly a great skepticism about the health information field. A closer examination of what has - and has not - taken place in Massachussetts is in order.

The skills of the individuals involved (including publications that John Glaser may join ONC as a consultant for some period), give great reason for optimism, but the outcome is far from assured. This challange and time frame is critical. Without success, we have simply automated a health care delivery system that we know needs improvement.
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