Stanley Feld M.D.,FACP,MACE
Physicians have been slow to adopt Electronic Medical Records (EMR) even though most physicians are computer savvy. There are reasons for physicians to be slow adoptors.
They are told that the EMR will increase their quality of care. However, quality of care has not been adequately defined by those who proclaim EMRs’ virtue. Physicians have negative experiences with information technology. The insurance industry and government have used IT against physicians to decrease the fees. Physicians know much of the data collected by the insurance industry and government has been formatted to answer the wrong questions. The potential of the EMR simply stimulates more mistrust and suspicion on the part of the physician against these entities.
Those knowledgeable about EMRs would say “Dr. Feld you have it completely backward.” Perhaps I do. I do not think so. I have expressed the perception of many physicians. Perception translates to the reality of resistance by physicians.
I understand the advantages of a functioning and effective EMR. If done correctly the physicians would flock to adopt the system. However, most demonstrations of EMRs are a disaster. The implementation of EMRs by most EMR companies has been worse. The purchase of an EMR to many physicians has simply been money down the drain. A few practices have been lucky and very successful.
The investment the physician must make is at minimum $50,000 per physician. In an environment of decreasing insurance and Medicare payments, $50,000 is a huge investment. In addition there is usually an annual maintenance fee as well as yearly service fee. Many software companies produce EMRs. Choosing the correct EMR seems impossible to most. Many physicians have been stung by the software company going out of business within two years, making their investment worthless.
In the January 2007 issue of Health Data Management there appeared a Newsline article “Hawaii Blues to Docs: We’ll Help with EMRs.
“A $50 million program from the Hawaii Medical Service Association, under which the Blues plan, would give providers substantial financial help to purchase electronic medical records systems, could wire up most physicians in the state.”
Why would the physicians want to be wired up? What does wired up mean?
“Honolulu-based HSMA also thinks the program will foster the longer-term goal of establishing regional health information organizations.”We’re making this investment to move the community along to wider adoption of I.T. so we can be ready for RHIO activity,” says Cliff Cisco, senior vice president. “There’s a lot of RHIO talk, but we’re a ways off from implementing a network. We want to prepare for that and give motivation.”
One should note that a RHIO is a network of information of all the patients’ charts in a regional and anyone can get patient information and physician care activity instantaneously with proper authorization. This would be great if we lived in an environment of total trust. It could work if everyone would keep this information private and would not use the data gathered against the patient or physician. Remember the social contract in medical care is between the patient and the physician.
“Under the three-year HMSA Initiative for Innovation and Quality the plan has committed $20 million toward the purchase of EMRs for physician practices. It will contribute up to half the cost of an EMR, capped at $20,000 per physician, for about 1,000 physicians.’
The physician would still have to pay $30,000 for something he does not want and he does not perceive will increase the quality of his care. It is viewed as a tool that will be used to punish him.
Cisco believes a “significant” amount of funds under the hospital program will go toward I.T., but the overall goal is to reduce practice variances and improve safety. Details of the program remain under development. “We’ve made the commitment and now are talking to hospitals,” he adds.”
Please notice the implication is the system is going to tell the physician what he should do to practice “good” medicine as defined by the insurance companies and hospital administrators. This seems like a way to generate more mistrust between physicians and the insurance industry.
“The program to help pay for EMRs is open to any physician who doesn’t have EMR software. But the focus will be on small and rural practices where adoption rates are low. HMSA hopes it will get most of these practices to take up its offer, Cisco says. “This is an effort to bring on slower adopters of the technology.”
My response is good luck!
The EMRs also will have to be certified by the Certification Commission for Healthcare Information Technology. HMSA is expected to have a list of acceptable EMRs available by the end of 2006.
If this program was perceived by the physicians as a good idea it would have to be a single uniform software program with measurable data points available to the physician for his proving an improvement in his quality of care to the patient. Multiple software vendors will increase the costs and decrease the mobility of the data collected. I will devote more time to describing the ideal EMR in the ideal MSA system. The system would greatly benefit the patient and the physician. The benefit to the facilitator stakeholders would be secondary and not punitive to the patient or the physician.
“Heavy penetration of EMRs in Hawaii could support more comprehensive pay-for-performance programs. HMSA for five years has had a pay-for-performance program that gives physicians and hospitals “modest” payments for meeting certain quality standards, Cisco says. The new initiative is much larger than existing P4P programs, he notes. “Our board thought we’d ramp this up a bit, put out this $50 million commitment and see what it achieved.”
Does anyone out there know the potential punishing effects to the healthcare system that pay for performance will inflict. In my view pay for performance is not well thought through presently. Many physicians are totally opposed to the notion because the decisions of performance are going to be made by the same insurance company administrators that used incorrect data to produce the failed punitive report card system.
This ambitious program is going in the opposite direction of the concept of the ideal Medical Saving Account. It is not empowering to the patient or physician. P4P in the present form does not provide incentive to the patients or the physicians to improve their performance. It is an administrative mechanism devised to dictate physician behavior, undo patient privacy and reduce payment.
It is sure to fail at best and generate more distrust and waste at worst. The healthcare system does not have three years to waste on this folly. The endeavor is bizarre to me. It is a waste of $50 million. I predict the $50 million loss will be passed on to the patients in the form of increased premiums
The $50 million could go a long way to create the ideal EMR in an ideal insurance system (MSA). Some smart entrepreneurial company will figure it out some day. I hope sooner rather than later.