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Ambulatory Electronic Health Records 2010. Sizzle or Fizzle? Bob Hoyt MD FACP February 5 2010. Learning Objectives After presentation participants should be able to: . Enumerate why the federal government is interested in EHRs

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ambulatory electronic health records 2010

Ambulatory Electronic Health Records 2010

Sizzle or Fizzle?

Bob Hoyt MD FACP

February 5 2010

learning objectives after presentation participants should be able to
Learning ObjectivesAfter presentation participants should be able to:
  • Enumerate why the federal government is interested in EHRs
  • Compare and contrast the benefits and obstacles related to ambulatory EHRs
  • List Medicare and Medicaid eligibility criteria and reimbursement plans
  • Discuss the meaning of meaningful use
  • Provide examples of commonly purchased EHRs
  • I have no conflicts of interest to report
  • I will be discussing outpatient and not inpatient electronic health records
  • My comments will be general and might not apply to every medical office scenario
EHRs will not solve everything“Technology is not the destination, it is the transportation” Dr. Safron AMIA
why is the government promoting ehrs
Why is the government promoting EHRs?
  • EHR adoption rates are low
  • According to the Institute of Medicine (IOM):
    • Paper charts are inadequate for modern medicine
    • EHRs will: improve the quality of medical care, improve patient safety, decrease inefficiencies/costs and produce aggregated data for mining
what is the government strategy
What is the government strategy?
  • In 2004 Executive Order 13335 mandated interoperable EHRs for every Americanby 2014 and created the Office of the National Coordinator for Health Information Technology (ONC)
  • To do this there was a need to also promote Health Information Organizations (HIOs) and the Nationwide Health Information Network (NHIN)
  • 2009 ARRA supports EHRs, HIOs and the NHIN
nejm article conclusions
NEJM Article Conclusions
  • Sample of 2758 physicians from the AMA physician register (62% response rate)
  • Survey excluded residents in training, osteopaths and federal physicians
  • Overall, 13% of physicians surveyed had some type of EHR but only 4% had a comprehensive type of EHR (CPOE and CDSS)
  • Satisfaction level was reasonably good
ambulatory ehr adoption
Ambulatory EHR Adoption













Level of EHR Function

Size of Practice

> 50 physicians

Basic System





Fully Functional

1 - 3physicians



DesRoches, N Engl J Med, 2008


paper charts are inadequate
Paper charts are inadequate
  • Often illegible
  • Non-structured data so can’t be mined or shared easily
  • Difficult to generate reports of any kind
  • Record rooms and chart pulls are costly
  • Difficult to retrieve past notes, labs, x-rays, etc
  • Paper charts missing 25% of the time. When chart is available labs, etc are missing 14% of the time
  • Can’t be accessed from home/hospital or shared by multiple users simultaneously
  • Can’t provide clinical decision support
do ehrs improve the quality of medical care
Do EHRs improve the quality of medical care?
  • Although there are a few studies that suggest physicians are more likely to follow outpatient (clinical practice guidelines) and inpatient (order sets) embedded EHR recommendations, there are an equal number of studies that suggest no impact on physician behavior or patient outcomes
do ehrs improve patient safety
Do EHRs improve patient safety?
  • Most studies have evaluated EHR generated drug-related alerts and reminders for preventive care
  • Most studies come from the same 4 medical centers
  • “Alert fatigue” a huge problem with e-prescribing
  • Reminders are ignored because there is not enough time to act on every preventive medicine measure
  • Bottom line: we have little evidence to suggest improved patient safety due to EHRs
  • Also, there is concern that any new technology may actually cause safety issues (“e-iatrogenesis”)
do ehrs save money
Do EHRs save money?
  • Yes, potentially through these mechanisms:
    • Decreased record room requirements and chart pull costs leading to decreased FTEs
    • Improved coding
    • Decreased fax and mail costs
    • Decreased transcription costs with use of templates and voice recognition
    • EHR generated “pay for performance” reports
    • Fewer “call backs” from pharmacists with e-prescribing
example of financial benefits
Example of financial benefits

Miller et al. Health Affairs 2005;24:1127-1137

benefits of aggregated data
Benefits of aggregated data
  • Relationship of Primary Care Physicians’ Patient Caseload with Measurement of Cost Performance

Nyweide DJ et al. JAMA 2009;302 (22):2444-2450

Conclusion: “relatively few primary care physician practices are large enough to reliably measure 10% relative differences in common measures of quality and cost performance among fee-for-service Medicare patients”

  • Large organizations like the VA and Kaiser-Permanente can show the benefits of aggregated structured data
ehr obstacles
EHR Obstacles
  • Cost (in the face of possible 21% Medicare cuts!)
  • Physician Resistance
  • Workflow changes
  • Legitimate privacy and security concerns
  • Possible need for in-house IT support
  • Initial loss of productivity
  • Integration with other systems: practice management, lab, PACS, HIEs, etc.
  • Lack of interoperability standards
  • Lack of high quality studies showing unequivocal patient benefit and clear cut ROI
how much do typical ehrs cost health affairs sept oct 2005
How Much Do Typical EHRs Cost ?Health Affairs Sept/Oct 2005

Miller et al Health Affairs 2005;24:1127-1137

some conclusions from this study
Some conclusions from this study
  • Wide cost differences in software often due to negotiating differences
  • Practices stopped using transcription
  • Average time for ROI was 2.5 years but one practice was projected to take 9 years and two others “never”
  • 3 practices had serious billing issues
  • Clinicians worked longer hours for average of 4 months
diffusion of innovation expect 50 to be slow adopters of any innovation
Diffusion of Innovation:Expect 50% to be slow adopters of any innovation

Diffusion of Innovation, Everett Rogers 1995

two recent negative studies
Two recent negative studies
  • November 2009: A. Jha (in press) looked at quality measures (example heart failure tx) and length of stay (LOS) in 3000 hospitals and tried to tie that to hospitals that had an advanced EHR, basic EHR or no EHR. Bottom line: No significant differences
  • January 2010: D. Himmelstein looked at hospital computerization, costs and quality of care at 4000 hospitals 2003-2007. Bottom line: marginal improvement in process measures of quality but no reduction in administrative or overall costs
health information technology for economic and clinical health act hitech
Health Information Technology for Economic and Clinical Health Act (HITECH)
  • Part of the American Recovery and Reinvestment Act (ARRA) of 2009
  • $14-27 billion to support the adoption of electronic health records for all Americans in the next decade
  • Multiple other ARRA programs support HIT
federal hit programs and grants
Federal HIT programs and grants
  • Medicare/Medicaid EHR reimbursement program
  • HIT extension program (70 centers)
  • Curriculum development centers
  • Community college consortia for HIT education
  • Program of assistance for university-based training
  • Competency exam for individuals completing non-degree training
  • Strategic health advanced research projects (SHARP)
  • Beacon community cooperative agreement program
  • State HIE cooperative agreement program
evolution of the ehr
Evolution of the EHR


on stone or











three important levels of hit
Three important levels of HIT


Office EHR

Local, state or regional HIOs







Patient Portal




ehr reimbursement by cms
EHR reimbursement by CMS
  • Physicians must be eligible for reimbursement by Medicare or Medicaid criteria
  • EHRs must be certified by an organization such as the Certification Commission for Health Information Technology (CCHIT)
  • Physicians must demonstrate “meaningful use” which we will define in future slides
federal meaningful use notices
Federal Meaningful Use Notices
  • CMS issued a notice of proposed rulemaking (NPRM) on Jan 13 2010 on “Meaningful Use” with an unclear date when it would be effective
  • ONC issued a interim final rule (IFR) on EHR certification criteria related to meaningful use on Jan 13 2010; effective Feb 12 2010
  • Comments on both are due Mar 15 2010
  • ONC will issue a NPRM relating to the testing and certification of complete EHRs and EHR Modules sometime in 2010
meaningful use
Meaningful use
  • MU Categories
    • Improving quality, safety, efficiency and disparities
    • Engage patients/families in their healthcare
    • Improve care coordination
    • Improve public and population health
    • Ensure adequate privacy and security protection
  • There will be three stages of meaningful use with stage 1 beginning in 2011
how will meaningful use be accepted
How will meaningful use be accepted?
  • The public will have 60 days to make comments, so expect changes
  • Already, many organizations have voiced concerns, primarily about new reporting requirements that will likely have glitches and cost physicians time and money
  • Will CMS be ready to receive reports?
  • Will payments to physicians be timely or slowed down by bureaucracy?
  • Will the cost to purchase an EHR increase as a result of matching meaningful use criteria?
vendors who offer guarantee their ehr will match all criteria
Vendors who offer guarantee their EHR will match all criteria
  • PracticeFusion, Allscripts, Ingenix, Athenahealth, ChartLogic, E-MDs, GE Healthcare, Medsphere, NextGen, Noteworthy Medical systems, eClinicalWorks and SourceMedical
medicare reimbursement41
Medicare Reimbursement
  • Payments = 75% of Medicare allowable charges (Part B claims; Part C for Medicare Advantage) for the year, subject to max payments of $18K, $12K, $8K, $4K and $2K for years 1-5
  • “Physicians” = MD, DO, Dentists, Oral surgeons, Podiatrists, Optometrists and Chiropractors
  • 10% extra incentive if practice is in under-served area
  • $0 if first year adoption is after 2014
  • Does not apply to hospital based physicians
  • Includes Medicare Advantage programs and hospitals
  • First year reporting period is 90 continuous days
medicaid reimbursement
Medicaid reimbursement
  • “Unlike the Medicare incentive programs, the Medicaid program allows eligible providers to receive an incentive payment even before they have begun to meaningfully use certified EHR technology”
  • “Medicaid clinicians would have to attest to having adopted, (that is, acquired and installed) or commenced utilization of (that is, implemented) certified EHR technology; or expanded (that is, upgraded) the available functionality of certified EHR technology and commenced utilization at their practice site”
  • States will receive 90% reimbursement from the federal government for administrative costs to administer the EHR program as well as the money to reimbursement physicians
more than 250 ehrs available
More than 250 EHRs available!





Less expensive


Open Source

Practice Fusion



Amazing Charts













free ehr search engine www ehrscope com
Free EHR Search Engine

Results after applying 13 filters = 16 matches

klas research firm
KLAS research firm
  • Firm rates EHRs and practice management systems each year
  • Ratings come largely from customers: EHR performance, vendor reliability, support, etc
  • Ratings are based on practice size
  • There is a charge for their services but physicians who are willing to complete a questionnaire on current IT use can evaluate individual vendors free of charge
klas results for 2009
KLAS results for 2009
  • Greenway Medical PrimeSuite was #1 for four years in a row for practices 6-25 physicians; #1 for two years in a row for practices of 2-5 physicians
  • Epic Systems was #1 for practices >100 physicians
  • eClinicalWorks was #1 for practices 26-100 physicians
important ehr decisions
Important EHR decisions:
  • In addition to whether you are eligible for reimbursement and whether your EHR is certified you must decide:
    • Do you need a combined EHR-Practice management system? Most experts recommend this
    • Do you want to host the data on your computers, backed up to a server (client-server model) or do you want to host the data remotely “in the cloud” (ASP model)?
    • How are you going to interface your EHR to external labs so you can send and receive reports?
client server vs asp model
Client Server vs. ASP model
  • Pros: Patient data stays in your office. Long term costs may be cheaper
  • Cons: May need in-house IT support. May have to pay for software upgrades. More hardware to purchase (servers, etc). Harder to upgrade. Require VPN to access remotely
  • Pros: Lower initial costs and no need for in-house IT support. Upgrades are easy. Access from anywhere
  • Cons: Higher long term costs. Must have adequate bandwidth. If your ISP is down, so are you
Do all certified EHRs cost $44,000?Most do not advertize actual costs!Most do not allow potential users to “test drive”
  • Free web based EHR that guarantees it will meet meaningful use criteria. They make money by selling de-identified data. They continue to add new features each month, such as e-prescribing and patient portal. They claim > 15,000 users
  • Hidden costs:
    • Need to interface with external practice management system
    • Need to interface with external labs, x-ray departments, etc
greenway primesuite 2011 ehr pms
Greenway PrimeSuite 2011 (EHR-PMS)
  • Security/Privacy
  • CPOE
  • Drug decision support
  • Problem list
  • E-prescribing
  • Med list
  • Med allergy list
  • Demographics
  • Advance directives
  • Vital signs
  • Smoking status
  • Lab results
  • Patient lists
  • CMS quality reporting
  • Patient reminders
  • Clinical decision rules
  • Progress notes
  • Insurance eligibility
  • Electronic claims submission
  • Patient copy of health information
  • Patient electronic access to information
  • Patient education resources
  • Patient clinical summary
  • Exchange clinical information
  • Medication reconciliation
  • Immunization registries
  • Reportable lab submission
  • Electronic syndromic surveillance

(Met or exceeded federal standards)

soapware pricing models
SoapWare Pricing Models
  • Physician owned EHR, easy to use for small practices
  • Client Server Model
    • Three choices: most expensive package is $3995/clinician; $1750/clinician/year for support and upgrades; staff not extra $
    • CCHIT certified
    • Interface with PM systems is extra
    • Multiple other modules are extra
  • ASP Model (EHR only)
    • $250 /clinician/month
  • CCHIT certified 2007
Caveat Emptor: more money does not necessarily buy higher EHR performance and greater user satisfaction
family practice survey february 2008
Family Practice survey February 2008
  • Self selected survey of 422 Family Practice Docs
good deal bad deal
Good Deal Bad Deal
  • Younger clinicians with longer retirement window
  • Tech savvy staff
  • Not change adverse
  • Adequate Medicare and/or Medicaid patients
  • ASP model
  • Adoption favors large and/or urban practices
  • Older clinicians
  • Not tech savvy
  • Change adverse
  • Inadequate Medicare and/or Medicaid patients
  • Would rather take Medicare penalty
  • Very small practice that can’t afford down time
  • Medicine is one of the last industries to digitize and automate
  • Electronic health records are a logical evolution, like electronic prescribing
  • Reimbursement by Medicare/Medicaid to purchase EHRs is a great new incentive but not all of the facts are in. There will be some pain!
  • “It’s not about the software, stupid”
  • Clinicians and practice managers must research EHRs in great detail before purchasing any system
stage 1 meaningful use criteria
Stage 1 meaningful use criteria
  • Computerized Physician Order Entry (CPOE) on all orders but NOT transmitted (80%*)
  • Implement drug-drug, drug-allergy and drug formulary checks (demonstrate this has been implemented)
  • Electronically submit prescriptions (75%of eligible prescriptions) and maintain active drug (80%) and drug allergy lists (80%)

* Medicare measurements that must be reported to CMS and Medicaid reported to states. (frequency percentages in red)

stage 1 meaningful use criteria70
Stage 1 meaningful use criteria
  • Maintain an electronic problem summary list using ICD or SNOMED CT to create structured data (80%)
  • Maintain demographics: preferred language, insurance type, gender, race and ethnicity, and date of birth as structured data (80%)
  • Record vital signs: height, weight and blood pressure and calculate and display body mass index (BMI) for ages 2 and over; plot and display growth charts for children 2 - 20 years, including BMI (80%)
stage 1 meaningful use criteria71
Stage 1 meaningful use criteria
  • Record smoking status for patients 13 years old or older (80%)
  • Incorporate clinical lab-test results into EHR as structured data (50%)
  • Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach (generate at least one list)
stage 1 meaningful use criteria72
Stage 1 meaningful use criteria
  • Report ambulatory quality measures to CMS for Medicare and report to states for Medicaid. NQF approved measures like % of adult diabetics with recent LDL-C level < 100. (attestationonly until 2012)
  • Send reminders to patients (over age 50) per patient preference for preventive/follow-up care (50%)
  • Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules (attestation)
stage 1 meaningful use criteria73
Stage 1 meaningful use criteria
  • Administrative
    • Check insurance eligibility electronically from public and private payers (80%)
    • Submit claims electronically to public and private payers (80%)
  • Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and allergies) upon request (80% provided within 48 hours)
stage 1 meaningful use criteria74
Stage 1 meaningful use criteria
  • Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) (provide access for at least 10% of patients)
  • Provide clinical summaries to patients for each office visit. The after-visit clinical summary contains an updated medication list, laboratory and other diagnostic test orders, procedures and other instructions based on clinical discussions that took place during the office visit. The clinical summary can be provided through a PHR, patient portal on the web site, secure email, electronic media such as CD or USB fob, or printed copy (80%) **
stage 1 meaningful use criteria75
Stage 1 meaningful use criteria
  • Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically (Performed at least one test of certified EHR technology's capacity to electronically exchange key clinical information)
  • Perform medication reconciliation at relevant encounters and each transition of care (Perform medication reconciliation for at least 80 percent of relevant encounters and transitions of care)
stage 1 meaningful use criteria76
Stage 1 meaningful use criteria
  • Provide summary care record for each transition of care and referral. The summary of care record can be provided through an electronic exchange, accessed through a secure portal, secure email, electronic media such as CD or USB fob, or printed copy (80%)
  • Capability to submit electronic data to immunization registries and actual submission where required and accepted (Performed at least one test)
stage 1 meaningful use criteria77
Stage 1 meaningful use criteria
  • Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice (Performed at least one test)
  • Protect electronic health information maintained using certified EHR technology through the implementation of appropriate technical capabilities (Conduct or review a security risk analysis)

* Determined to take 9 hours/clinician to report all measures during a reporting period!

stage 2 meaningful use 2013
Stage 2 meaningful use (2013)
  • “Encourage the use of health IT for continuous quality improvement at the point of care and the exchange

of information in the most structured format possible, such as the electronic transmission of orders entered using computerized provider order entry(CPOE) and the electronic transmission of diagnostic test results

and other such data needed to diagnose and treat disease”

stage 3 meaningful use 2015
Stage 3 meaningful use (2015)
  • “To focus on promoting improvements in quality, safety and efficiency, focusing on decision support for national high priority conditions, patient access to self management tools, access to comprehensive patient data and improving population health”