Progress and Continuing Challenges in the Adoption of Electronic Health Records
The CMS EHR Incentive Programs
The adoption of health information technology like electronic health records (EHRs) and health information exchange (HIE) has been a top priority of the United States federal government since the administration of George W. Bush. The Obama administration has accelerated the push towards health IT with approximately $30 billion in incentive payments earmarked for various initiatives as part of two key pieces of legislation - the American Recovery and Reinvestment Act of 2009 (ARRA) and the Patient Protection and Affordable Care Act (PPACA) of 2010. The CMS EHR Incentive Programs, part of AARA, will provide incentive payments to eligible professionals, eligible hospitals and critical access hospitals (CAHs) as they adopt, implement, upgrade or demonstrate “meaningful use” (MU) of certified EHR technology. Eligible professionals can receive up to $44,000 over five years under the Medicare EHR Incentive Program. Incentive payments for eligible hospitals and CAHs may begin as early as 2011 and are based on a number of factors, beginning with a $2 million base payment.
Tracking the Progress of Health IT Adoption
Given the potential for health IT to significantly improve some of the most glaring inefficiencies and quality concerns that plague the health system today, health policy analysts are keeping a close watch on how providers are progressing in the move to digital technologies. In addition, the large amount of tax-payer funds involved with health IT drives the need to collect robust metrics and pinpoint potential areas of concern. The nonprofit Robert Wood Johnson Foundation (RWJF), which is the largest philanthropy in the nation devoted exclusively to public health issues, works with the Office of the National Coordinator for Health Information Technology (ONC) to report on various health IT issues, including tracking progress toward the universal adoption of EHRs. A series of reports have been issued by RWJF since 2006 and ONC will use a portion of this year’s study (Health Information Technology in the United States: Driving Toward Delivery System Change, 2012) to report to Congress on the status of health adoption. The newest report expands on previous analysis on health IT trends by investigating providers’ (hospitals and physicians) readiness to meet the requirements of the CMS EHR Incentive Program and also explores the role of health IT in other health care reform initiatives. Included in the report is a look at EHR adoption data from surveys of U.S. hospitals and office-based physicians; recent data on the progress and challenges of HIE at both the state and federal levels; the importance of health IT to health reform initiatives including patient-centered medical homes and accountable care organizations; and several other issues relevant to health IT.
Adoption Trends as Reported by RWJF
The authors found steady increases in the level of EHR adoption for physicians and hospitals throughout the United States. For physicians in ambulatory practice, the authors report on data collected by the CDC's National Center for Health Statistics (NCHS) as part of its National Ambulatory Medicare care Survey (NAMCS): Electronic Medical Records Supplement (funded by ONC). The most recent survey was sent to 10,301 physicians in 2011 and had a response rate of 64 percent. The NAMCS surveys show that the proportion of physicians reporting the use of any EHR (defined as either all electronic or part paper/part electronic) increased from 17.0 percent in 2002 to 57.0 percent in 2011 while the proportion of physicians with at least a basic system rose from 12.0 percent in 2007 to 34.0 percent in 2007. In terms of the rate of EHR adoption relative to physician characteristics, the data showed primary care physicians are increasing EHR adoption at a faster rate than specialists and that physicians in practices with more than two physicians and those in the Northeast are adopting at a faster rate than others. As for intentions to qualify for EHR incentive funds (either Medicare or Medicare), data from the NACMS showed that 51.3 percent of physicians reported that they intended to apply. However, only 10.5 percent of those intending to apply actually have an EHR system with the appropriate functionality to meet MU requirements as stipulated by the EHR Incentive Program. The data also showed that those physicians working in physician-owned practices were significantly more likely to apply for EHR incentive funds. As for hospitals, the authors report on data collected by the American Hospital Association (AHA) Health Information Technology Supplement (also funded by ONC). The AHA survey of health IT adoption is sent as a supplement to AHA's Annual Survey. Data for the 2011 survey was collected from October through December 2011 from 2,646 hospitals, approximately 50 percent of all acute care hospitals in the United States. For this survey, EHRs are characterized as basic or comprehensive depending on various functions and extent of use. The AHA survey found that hospitals’ use of basic EHRs rose from 11.5 percent in 2010 to 18.0 percent in 2010 and the use of comprehensive EHRs rose from 2.6 percent to 8.7 percent. Of concern, the authors report that the gap between the use of EHRs in larger, urban teaching hospitals and smaller, rural hospitals is growing. Data show that adoption among lager hospital increased by 17.3 percentage points compared to 10.1 percentage points among smaller hospitals. The authors also point out concerns around hospitals' ability to fully meet MU based on key functionalities required (e.g., drug-drug and drug-allergy checks, quality reporting and CPOE).
Progress is Impressive but Providers Need Hands On Assistance to Meet Meaningful Use
As the RWJF report clearly shows, the adoption of EHRs has been on an upward swing for some time but has significantly accelerated since the passing of AARA and PPACA. The latest data being reported from CMS (March 2012) shows that a total of 225,765 providers have registered for the CMS EHR incentive programs - 222,282 eligible professionals (physicians, nurse practitioners, dentists, etc) including 148,476 under the Medicare program and 73,806 under Medicaid, and 3,483 hospitals. Payments, which began in May 2011, have totaled approximately $2.4 billion. While things are certainly moving in the right direction, albeit somewhat slowly, data from the RWJF report and CMS verify some key trends and potential concerns around EHRs that we have been tracking for some time. First, many physicians and hospitals are moving to digital technologies because they simply must in most cases. This is due to a number of factors in addition to incentive funds including growing complexities in reimbursement from both government and commercial payers; the need to drive cost efficiencies and streamline operations; the proliferation and growing familiarity with information technology; an explosion of data and information due to technological and scientific advances; and, most imperative, the need to improve the quality and safety of patient care. However, the adoption of EHR technology does not automatically translate into MU - that is, meeting the government’s core objectives around specific functions designed to improve patient care. This is due to technical issues around EHRs (i.e., some providers have EHRs that are not equipped with core MU functions like clinical decision support, etc) as well as logistical issues that providers face in actually adapting to workflow changes, some of which are quite daunting.
Technology Vendors Must Be Highly Proactive in Helping Clients Achieve Meaningful Use
As we are seeing more and more, getting to MU, and ultimately sustaining the process, is complex and multi-dimensional entailing significant changes in technology use, workflow, communication, and culture on both organizational and personal levels. MU is a living, breathing entity that must be continuously nurtured as the government adopts ever more stringent requirements to qualify for incentive funds. The drumbeat round MU complexities is growing louder, particularly since CMS released the proposed requirements for Stage 2, set to begin in 2014. While the government may continue to be flexible around timelines and some aspects of MU requirements, it is unlikely that requirements will significantly relax. What this means from a market perspective is that those vendors who have technologies and services that are particularly adept in helping clients meet and sustain MU will continue to gain. It will come as no surprise that the need is particularly acute for ambulatory providers and small hospitals. Vendors must be extremely proactive about understanding and meeting client challenges around MU, both technical and logistical. Selling the EHR technology is not enough – ongoing communication and support are critical for survival in this increasingly competitive market. Technology vendors must be willing invest time and resources in helping their clients succeed.