VI. Key Issues: Financing and Delivery >> A. Health Spending >> Health Cost Containment >> Improve Administration >> Health IT (last updated 10.5.14)
Lead Editor – Dana Beezley-Smith, Ph.D.
2. Health IT Legislation
3. Electronic Health Records
5. Health IT and Hospitals
The adoption of various forms of health information technology (HIT) may have disparate impacts, including improvements in access/continuity of care, quality, patient satisfaction or privacy of medical information. However, a principal motivation for pursuing HIT is the expectation that it will lead to system efficiencies that result in net savings in the short run or long run. Because most HIT innovations have multiple effects, this section examines the benefits and costs of a full range of HIT innovations for which there is real-world evidence even if their purpose or impact might be quality improvement at the expense of cost containment. Discussion of health reform policy proposals related to HIT (i.e., policy options under discussion and not yet adopted or implemented) is contained at Health IT under Health Reform, Components of Reform, Cost Containment.
Electronic Health Records (EHRs)
Meaningful Use Program
Meaningful Use (MU) is a Center for Medicare & Medicaid Services program that pays an incentive for “meaningful use” of an electronic health record (EHR). It is a separate program from PQRS (Physician Quality Reporting System). Those eligible for the Meaningful Use include doctors of medicine or osteopathy, dental surgery or dental medicine, podiatry, optometry, and chiropractic. (NOTE: Those attesting to Meaningful Use also submit PQRS Quality Measures in addition to MU and receive a PQRS Incentive payment. Those who don’t participate in PQRS will receive a 2% penalty in 2016.) Meaningful use is defined as use of certified electronic health record (EHR) technology to: Improve quality, safety, efficiency, and reduce health disparities; Engage patients and family; Improve care coordination, and population and public health; Maintain privacy and security of patient health information.
Ultimately, it is hoped that the meaningful use compliance will result in: Better clinical outcomes; Improved population health outcomes; Increased transparency and efficiency; Empowered individuals; More robust research data on health systems.
Stages of Meaningful Use
2011-2012 Stage 1: Data capture and sharing
2014 Stage 2: Advance clinical processes
2016 Stage 3: Improved outcomes
Stage 1 EHR Meaningful Use Requirements
- Use of a certified EHR in a meaningful manner (e.g. e-prescribing)
- Use of a certified EHR for electronic exchange of health information to improve the quality of health care
- Use of certified EHR technology to submit clinical quality measures (CQM).
Qualifying for Stage 1 Meaningful Use of an electronic health record (EHR) means that:
- The EHR meets all 20 objectives for meaningful use.
- Six clinical quality measures are reported.
- The EHR and has been in use for at least 90 days during the first year and 12 months for all subsequent years.
- Three core measures plus three additional measures must be reported. If the provider does not qualify for the three core measures, three alternate core measures must be reported.
Stage 1 EHR Meaningful Use Specification Sheets. The Centers for Medicare & Medicaid Services (CMS), which administers the Medicare and Medicaid EHR Incentive Programs, provides these sheets to help professionals and hospitals understand the requirements of each objective and demonstrate meaningful use successfully.
- EHR Meaningful Use Specification Sheets for eligible professionals (EPs) [PDF - 348 KB]
- Meaningful use specifications for eligible hospitals [PDF - 360 KB]
Stage 2 EHR Meaningful Use
On September 4 2012, CMS published a final rule that specifies the Stage 2 criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to continue to participate in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. All providers must achieve meaningful use under the Stage 1 criteria for two years before moving to Stage 2.
To help providers better understand Stage 2 Meaningful Use requirements, CMS developed Stage 2 Meaningful Use Specification Sheets for EPs and Eligible Hospitals that provide detailed information on each Stage 2 objective.
EHR News and Analysis
- Solo and Small Practices Increase EHR Adoption, Survey Finds.”Results of a telephone survey of more than 270,000 US medical sites reveal that the EHR adoption rate for single-physician offices grew 11.4% to 53.7%, up from 42.3% the prior year, SK&A, a healthcare information research firm that tracks adoption rates for the government, said in its annual report. The adoption rate for offices with 26 or more physicians increased only 1.6%, to 77.5%. Overall, the rate of EHR adoption grew from 50.3% to 61% compared with the previous year, the report noted… Physician specialties with the highest adoption rates are dialysis (80.6%), internal medicine/pediatrics (75.8%), nephrology (70.5%), pathology (69.4%), and radiology (69.2%)…The top 3 vendors are Epic Systems Corp, eClinicalworks, and Allscripts.” (Medscape Medical News, 3.26.14)
- e-Prescribing: Over Half of Prescriptions Go Online for First Time in 2013. “For the first time, the majority of US prescriptions — not including those for controlled substances — were routed electronically to pharmacies through Surescripts in 2013, according to the company’s National Progress Report on health information technology (IT). That’s more than one billion prescriptions, or 58% of all noncontrolled-substance, eligible prescriptions written last year. Passing the halfway mark is a ‘large milestone,’ said Steven Waldren, MD, senior strategist for t the American Academy of Family Physicians’ (AAFP) Center for Health IT. ‘I think it demonstrates that we’ve solved the e-prescribing part of interoperability.'” (Medscape Medical News, 5.23.14)
- Docs Ask for Delay in Hardship Deadline for EHR Meaningful Use. Last week, the American Medical Association (AMA) and the Medical Group Management Association (MGMA) asked the Centers for Medicare & Medicaid Services (CMS) to delay a July 1 deadline for submitting a hardship exception application that could spare physicians a 1% Medicare penalty in 2015 for failing to demonstrate EHR meaningful use. That penalty applies specifically to physicians who have not previously achieved meaningful use before 2014 and who fail to do so this year as well. The penalty increases to 2% in 2016 for physicians who successfully achieved meaningful use in a previous year, but not in 2014. The deadline for requesting a hardship exception for the 2016 penalty is July 1, 2015. (Medscape Medical News, 6.30.14)
- Medscape EHR Report 2014, July 15, 2014. Medscape invited physicians to participate in a survey of current EHR use; 18,575 physicians across 25 specialties responded during the period from April 9, 2014, through June 3, 2014. Fifty-six percent were employed in a hospital or health system.
- Effect on Practice Operations: Despite complaints that EHRs make documentation too burdensome, 63% of our respondents said that an EHR improves documentation, and 39% felt that EHRs improve collections. Thirty-four percent of participating doctors maintained that an EHR improves clinical operations, yet 35% said it worsens them. Thirty-two percent felt that an EHR improves patient service; 38% said it worsened patient service.
- Effect on Patient Encounters: Seventy percent of respondents said the EHR decreases their face-to-face time with patients, and 57% said it decreases their ability to see patients. Still, 35% said the EHR improves their ability to respond to patient issues, and 33% said it allows them to more effectively manage patient treatment plans.
- Use Over Time: Eighty-one percent of respondents agree that their EHRs have become easier and more comfortable to use over time.
- Patient Privacy Concerns: In the 2012 Medscape EHR Report, 77% of participating physicians said they had no patient privacy concerns. In 2014, only 17% of survey participants said they had no EHR-related patient privacy concerns.
- Where Do Physician Stand on Meaningful Use? Seventy-eight percent of participating physicians said they were attesting to meaningful use Stage 1 or Stage 2 in 2014. Sixteen percent said they will never attest to meaningful use requirements, and another 6% of participants said they are abandoning meaningful use after meeting the requirements in previous years. Thus, 22% of physicians surveyed this year are opting out of or disregarding the meaningful use program.
- Cost per Physician to Purchase and Install: Almost a quarter (23%) of respondents said their EHR system cost over $50,000 per physician to install. More than half of the respondents were unaware of the cost of the EHR.
- Monthly Fees per Physician for a Web-Based EHR System: In 2012, only 4% of survey respondents said they were paying over $700 per month for monthly fees; in 2014, 12% are paying that amount.
- Why Physicians Don’t Use an EHR (Note: Survey respondents were allowed to choose more than one answer.)
- EHRs interfere with the doctor-patient relationship (40% of responses).
- EHRs are too expensive (37% of responses). Besides the cost of the EHR, there are expenses involved in switching all current paper records to electronic records and lost work time during the transition and switchover. For doctors nearing the end of their careers, the cost and effort are not worth it.
- The incentives offered and penalties levied by the CMS aren’t worth the hassle of adopting an EHR (32% of responses).
- Hazards Tied to Medical Records Rush: Subsidies Given for Computerizing, But No Reporting Required When Errors Cause Harm. “President Obama and Congress poured $30 billion in taxpayer subsidies into the push for digital medical records beginning in 2009, with only a few strings attached and no safety oversight of the vendors who sell the systems. The move was touted as a way to improve patient care and help rein in medical costs. Five years later, the explosion in the use of the electronic records has created the potential for efficiencies and safety benefits but also new risks for patients, the scope of which still is not fully understood…The systems can be complex, time-draining, and frustrating to use, especially early on. Hospital staff members routinely override automatic warnings, cut corners, and develop ‘workarounds’ as they struggle to balance caring for patients with the demands of cumbersome drop-down menus and other forms that appear on their computer screens.” (Boston Globe, 7.20.14)
- Big Data Peeps At Your Medical Records To Find Drug Problems. “To do a better job of spotting unforeseen risks and side effects, the Food and Drug Administration is trying something new — and there’s a decent chance that it involves your medical records. It’s called Mini-Sentinel, and it’s a $116 million government project to actively go out and look for adverse events linked to marketed drugs. This pilot program is able to mine huge databases of medical records for signs that drugs may be linked to problems…Their health records include nearly 180 million Americans. If you have insurance through a private health plan, the chances are ‘pretty good’ that your data may have been used in one of these studies, says Dr. Richard Platt, the principal investigator for Mini-Sentinel and a professor at Harvard Medical School’s Department of Population Medicine.” (NPR, 7.21.14)
- Clinical Intelligence and Analytics: The Future of Healthcare Delivery. “As the spread of electronic medical records (EMRs) continues by both hospitals and physician practices, healthcare organizations are increasingly showing significant interest in clinical intelligence applications to enhance patient care, improve safety and efficiency, and reduce costs—interest that has only exploded since ACOs and value-based reimbursement trends have started to disrupt the industry, and more has become known about the reliance on analytics that they will require. Interest is a relative term, however. Even with the rapid adoption of EMRs across the globe, the bulk of clinical data available to feed such intelligence applications remains siloed and fragmented across disparate systems and numerous departments in the typical hospital. This makes access to and sharing of patient information difficult, or even non-existent, as systems are unable to communicate with one another—and when they can communicate, information exchange is likely limited to a fraction or subset of overall data that they contain.” (EMC, 7.31.14)
- Are Your Medical Records Vulnerable To Theft? “As more doctors and hospitals go digital with medical records, the size and frequency of data breaches are alarming privacy advocates and public health officials. Although health care providers face serious penalties if they allow patients’ electronic records to be breached, thieves also have tremendous incentives to get around protections because health records contain so much valuable information.” (Kaiser Health News, 8.21.14)
- Internet Brownout Exposes Risk of Cloud-Based EHRs. “The Internet cracked a bit under its own burgeoning weight last week, and as a result, internist Erik Ilyayev, MD, in Flushing, New York, could not access his cloud-based electronic health record (EHR) system for an entire day. ‘Why can’t I log in?’ Dr. Ilyayev wrote in an angry post on the Facebook page of Practice Fusion, his EHR vendor. ‘What do I tell the patients who are in the office now?’ Other Practice Fusion customers experiencing downtime asked the same questions. The answers are not comforting for physicians who increasingly use Web-based software for patient care, as well as billing and collection.” (Medscape Medical News, 8.22.14)
- Inside the Struggle for Electronic Health Record Interoperability. “In a study published in the September 2014 issue of Health Affairs, a number of analysts — including some working for ONC — found that:
- While the rates of hospitals adopting basic EHRs continue to rise, only 5.8 percent of hospitals surveyed were able to meet all of 16 core objectives put forth in HHS’ Meaningful Use Criteria. The areas in which hospitals were most lacking were providing patients with the ability to view and download their information and sending care summaries between care settings.
In another study that examined EHR adoption in office settings, only four in 10 physicians had any electronic exchange with other health providers, and one in seven exchanged clinical data with providers outside their organization.
- Both studies found that in some respects, the more resources available to a hospital or an office, the more likely they were to have already implemented EHRs. In the study that focused on hospitals, more than half of all rural hospital respondents said they had ‘less than basic’ EHR implementation in 2013. In the study dedicated to office-based care, solo practitioners and specialty physicians lagged behind larger practices or primary care physician.
- Even with ONC and the Centers for Medicare and Medicaid Services delivering marching orders for providers to follow, Somplasky said smaller practices are considering taking the financial penalties that come with failing to meet the HHS meaningful use goals.” (FedScoop, 8.20.14)
- Eight Malpractice Dangers in Your EHR. “‘The Health Insurance Portability and Accountability Act (HIPAA) specifically states that the healthcare provider is the covered entity responsible for maintaining the integrity of the patient’s medical record — not the EHR vendor, not the consultant, not the systems integrator,’ he says. ‘A doctor can be held liable because most vendors’ contracts essentially say, “We do not practice medicine; it is up to the physician to make sure this EHR is being used correctly.” Practices must understand what they’re using and verify that the system is appropriately set up to document the care they provide.'” (Medscape Business of Medicine, 8.26.14)
- Texas Hospital Makes Changes to EHR After Ebola Patient Turned Away. “The Dallas hospital that mistakenly sent home a man who had Ebola says flawed software and not human error caused doctors to miss the diagnosis. Health officials and local residents have been asking how the hospital could have missed what would have appeared to be an obvious potential case of Ebola: a Liberian citizen who said he recently traveled from Liberia, with fever and abdominal pain. ‘Protocols were followed by both the physician and the nurses,’ the hospital said in a statement issued Thursday night. The nurse who took Thomas Eric Duncan’s medical history did the job correctly, the hospital said. ‘However, we have identified a flaw in the way the physician and nursing portions of our electronic health records (EHR) interacted in this specific case,’ it added.” (NBC News, 10.2.14)
- Dallas Hospital Retracts Explanation for Missed Ebola Diagnosis. “The Texas hospital that failed to initially identify and isolate the country’s first Ebola patient in its emergency room is now backtracking on its explanation for the error… ‘There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event,’ the hospital said in a written statement. But as of Saturday afternoon, no other explanation for the oversight has been given. Emails to the hospital with specific questions from Yahoo News have not been returned for days.” (Yahoo News, 10.4.14)
- Did Bad EHR Software Lead to Ebola Patient Being Sent Home? “We may never know exactly what happened in the Texas ER. But we do know that poorly designed EHRs can impede physician workflow and jeopardize patient safety.” (Forbes, 10.5.14)
- Former Senators Join Forces to Advance Telemedicine. “In their post-Senate careers, the three former lawmakers have relocated to K Street, home to lobbyists, and are working on behalf of the Alliance for Connected Care, a nonprofit collection of health care providers, insurers, pharmacies, technology firms and telecommunications companies, to pursue legislative and regulatory changes to let more Americans essentially get much of their health care remotely…All three former lawmakers said they became interested in the potential of digital technology to deliver health care when they were representing states with pockets of poverty, where access to health care can be difficult for geographic and economic reasons.” (New York Times, 5.20.14)
- New Push for TeleHealth in Accountable Care Act’s ACOs. “NAACOS has co-signed a letter to HHS urging CMS to grant a waiver to permit all ACOs to use and bill for TeleHealth services. HHS clearly has the authority but so far has been unwilling to exercise it.” (National Association of ACOs, 6.6.14)
- Online Psychotherapy Gains Fans And Raises Privacy Concerns. “Some studies suggest that therapy online can be as effective as it is face to face. ‘We have a lot of promising data suggesting that technology can be a very good means of providing treatment,’ says Lynn Bufka, a clinical psychologist who helps develop health care policy for the American Psychological Association…Family therapists, mental health counselors and clinical social workers are licensed to practice by individual state boards. But it’s unclear whether a practitioner who lives in one state can or should treat someone who lives elsewhere.’ We’d like to see a little more mobility and flexibility with that, because certainly for licensed psychologists the standards are pretty similar across state lines,’ Bufka says. Perhaps, she adds, therapists could get a special certification that would allow them to practice in multiple states or countries.” (National Public Radio, 6.30.14)
- Pediatric eHealth Interventions: Common Challenges During Development, Implementation, and Dissemination. “The challenges associated with eHealth interventions and their proposed solutions are multifaceted and cut across a number of areas from eHealth program development through dissemination. Collaboration with a range of individuals (e.g., multidisciplinary colleagues, commercial entities, primary stakeholders) is the key to eHealth intervention success. To ensure adequate resources for design, development, and planning for sustainability, a number of public and private sources of funding are available. A study design that addresses ethical concerns and security issues is critical to ensure scientific integrity and intervention dissemination. Table I summarizes key issues to consider during eHealth intervention development, testing, and dissemination.” (Journal of Pediatric Psychology. 2014;39(6):612-62)
- The Cleveland Clinic: Coming to a Kiosk Near You? Health System to Offer New Telehealth Options. “The Cleveland Clinic has signed a letter of intent to partner with HealthSpot, a provider of telehealth services based in Ohio, to provide care to patients via walk-in kiosks located in non-traditional health care settings, like workplaces, universities, and retail stories. The kiosks are private, eight-by-five foot spaces outfitted with medical devices, videoconferencing capabilities, and medical devices. They allow Cleveland Clinic providers to see patients through the kiosks, and each kiosk is staffed by a medical assistant.The clinic will integrate patient data from the kiosks into its electronic health record system.” (The Advisory Board Company, 5.22.14)
- Telecare Collaborative Management of Chronic Pain in Primary Care: A Randomized Clinical Trial. “The Stepped Care to Optimize Pain Care Effectiveness (SCOPE) study was a randomized trial comparing a telephone-delivered collaborative care management intervention vs usual care in 250 patients with chronic (≥3 months) musculoskeletal pain of at least moderate intensity (Brief Pain Inventory [BPI] score ≥5). Patients were enrolled from 5 primary care clinics in a single Veterans Affairs medical center from June 2010 through May 2012, with 12-month follow-up completed by June 2013…Telecare collaborative management increased the proportion of primary care patients with improved chronic musculoskeletal pain. This was accomplished by optimizing nonopioid analgesic medications using a stepped care algorithm and monitoring.” JAMA. 2014;312(3):240-248
- New Push for TeleHealth in ACOs. “NAACOS has co-signed a letter to HHS urging CMS to grant a waiver to permit all ACOs to use and bill for TeleHealth services. HHS clearly has the authority but so far has been unwilling to exercise it.” (National Association of ACOs, 6.6.14)
- Medicare Increases Telehealth Coverage…a Bit. “The Centers for Medicare & Medicaid Services (CMS) proposes to increase incrementally the telehealth services that Medicare will cover, including wellness visits and some behavioral health services. However, CMS continues to restrict telehealth coverage to rural areas and offers a very circumscribed definition of the telehealth technology that can serve as the basis for coverage…Years ago, Dr. Bashshur recalled, CMS refused to cover telehealth at all, and it is still taking a very restrictive approach because it is afraid of the potential for overuse. On the basis of his own research, Dr. Bashshur has estimated that CMS paid only $12 million for telehealth last year.” (Medscape Medical News, 7.16.14)
- FSMB Compact Could Ease MultiState Licensing. “The Federation of State Medical Boards (FSMB) has unveiled a draft interstate compact for physician licensure that, it said, should make it easier to practice telemedicine across the country. The compact, which the FSMB expects to finalize in the next month or two, offers a ‘streamlined alternative pathway’ for physicians who want to practice in multiple states, according to a federation news release. Under current state medical board policies, physicians must be licensed in the state where a patient is located to diagnose or treat that patient, a stance that the FSMB recently reaffirmed in its model policy for telemedicine. As a result, physicians who consult remotely with patients in other states must be licensed in those states. That can create barriers to telehealth consultations, especially for on-call physicians who are not licensed in every state where patients may contact them online. The FSMB’s interstate compact would allow physicians to apply once and receive licensure in all states that are party to the compact.” (Medscape Medical News, 8.5.14)
Health IT and Hospitals
- The Healthcare Chief Information Officer MindMap. “It’s a beautiful display of everything that’s happening in healthcare IT. Although, it’s also an illustration of the challenge we hospital CIOs face. Is it any wonder that so many hospital CIOs feel overwhelmed?” (EMR and HIPAA. 4.8.14)
- Expert: U.S. Hospital Breach Biggest Yet to Exploit Heartbleed Bug. “Hackers who stole the personal data of about 4.5 million patients of hospital group Community Health Systems Inc broke into the company’s computer system by exploiting the “Heartbleed” internet bug, making it the first known large-scale cyber attack using the flaw, according to a security expert…Community Health Systems, one of the biggest U.S. hospital groups, said the information stolen included patient names, addresses, birth dates, phone numbers and social security numbers of people who were referred or received services from doctors affiliated with the company over the last five years.” (Reuters, 8.20.14)
- Health Information Technology (Health Affairs topics page)
- See Information Management under Health Care Delivery System.
- HealthVault (Microsoft). Health care management site.
- Blue Button. Federal protocol permitting veterans and Medicare beneficiaries to share medical history with providers.
- Kaiser Health News. Health IT.