VI. Key Issues: Financing and Delivery >> A. Health Spending >> Health Cost Containment >> Improve Administration >> Health IT (last updated 7.20.14)
Lead Editor - Dana Beezley-Smith, Ph.D.
3. Electronic Health Records
5. Impact of Health IT Program Implementation
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
- 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.
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.
Meaningful Use News
- 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. Ffty-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: 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).
- 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, 7.16.14)
Impact of Health IT Program Implementation
- 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 and hospital CIOs face. Is it any wonder that so many hospital CIOs feel overwhelmed?” (EMR and HIPAA. 4.8.14)
- 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.