Article Date: 10/1/2009

Electronic Health Record Issues

Electronic Health Record Issues

Will they improve care? What's the transition like? Oh, yes, and when can you expect that government check?



Things were looking bleak for a small, Massachusetts-based software company late last year. With the economy in utter shambles, prudence and cutbacks dominated the 2009 business plan the owners had assembled for the 150-person operation.

But a scant four weeks later, all that changed when something called the American Recovery and Reinvestment Act (ARRA, or “the stimulus package”) promised to pump three quarters of a trillion federal dollars into the U.S. economy.

“As of Dec. 31, we had put together a game plan saying 'This economy looks like it is really getting bad. Why don't we be a little prudent?'” Massachusetts-based software company owner Girish Kumar Navani told The Wall Street journal in March. “It changed in four weeks to, 'You will hire for growth; forget hiring for need.'”

Fortune has indeed smiled on his and an army of software firms planning to cash in on the $19.5 billion the stimulus package has put aside to spur the growth of electronic health records (EHR).

Stocks of companies offering medical software “are simply on fire,” according to Seeking Alpha, a stock-picking blog ( And, every computer player from freelance code writers to titans, such as General Electric (GE), which this summer began offering zero-interest loans for its EHR product, expects a slice of the pie. The problem: There's no guarantee that what GE, among other software companies, currently offer will be relevant to the yet-to-be-announced government requirements for EHR.

Here's a closer look at the issues surrounding EHR and the experiences of your colleagues who have employed a system.

Incentive money

The EHR provision of the stimulus plan is known as the Health Information Technology for Economic and Clinical Health (HITECH) Act. Specifically, it allocates $36 billion in incentive money for healthcare practitioners to adopt EHR by 2014. But, the federal government promotes $19.5 billion as a "net cost" because it expects savings through “efficiencies” (yet to be defined) and Medicare penalties on those who fail to adopt EHR by 2015.

As a brief aside, only a fraction of doctors currently employ EHR. Last year, a federal study revealed 13% of practitioners used basic EHR, and only 4% employed “fully functional” systems (e.g. e-prescribing, for example).1 Estimates for EHR use by eyecare practitioners go as low as 6%. But, regardless of how the numbers are crunched, 80% of optometric practices maintain records via paper.

Because the government will distribute stimulus incentive money through Medicare payments, many O.D.s believe they won't qualify for the maximum payment (roughly $44,000 through five years). This is probably untrue, however, since to receive the full amount, a practice must only bill $25,000 to Medicare per year. The mean annual Medicare billing among O.D.s is roughly $25,000, according to an American Optometric Association survey, but this figure is probably artificially low since it includes O.D.s enrolled in the federal program but who don't bill Medicare because they work for an optical chain, are semi-retired, decline to treat Medicare patients, etc. If a practice does see Medicare patients, it very likely bills at least $25,000 to the government. For example, a solo-doctor practice with 10 fulltime employees interviewed for this article billed $280,000 to Medicare last year.

The government will pay the bulk of the incentive money — roughly $27,000 — during the first two years of the program, 2011 to 2012. As a disincentive for not getting on board with the program immediately, smaller payments will occur in 2013 to 2014, and incentives will only total about $2,000 in the last year, 2015, at which time penalties for failing to adopt EHR commence, in the form of reduced Medicare payouts.

To qualify for HITECH money, you must demonstrate four things:

  1. The use of a government-certified EHR technology with e-prescribing capability;
  2. Connectivity of the EHR software to other healthcare providers or stake holders to exchange information electronically; though this has not yet been defined;
  3. The ability to show “meaningful use” of the technology to the government.
  4. The ability to report on measures, such as clinical quality, if the government can receive the information.

Unfortunately, the government has yet to define “meaningful use,” and certification — al- though software experts can make a pretty good guess at what these definitions will entail. (See “The EHR Bureaucratic Tangle”)

The EHR Bureaucratic Tangle

So, how can the federal government ask you to install an EHR system without providing certification criteria? Like so:
A non-profit organization called the Certification Commission for Health Information Technology (CCHIT) will almost certainly be one of the certifying bodies (others may emerge later). The CCHIT has been certifying EHR systems for five years. State governments and private insurers that have been offering incentives to adopt EHR for several years now often require its stamp of approval. Doctors will continue to receive these incentives in addition to the HITECH incentives.
Many practitioners mistakenly believe that if their existing EHR system is CCHIT-certified, they automatically qualify for federal stimulus money. In fact, the CCHIT plans to develop a certification track specifically for HITECH. Thus, existing EHR systems, while not required to start from scratch, will likely need at least some minimal upgrading to qualify. Although the CCHIT hasn't provided an example of a “minimal upgrade,” interoperability (e.g. the sharing of patient data with other practices without compromising security or privacy) will be required. Several current EHR systems don't do this, and the ones that do may not meet the to-be-announced government-mandated standards.
U.S. Department of Health and Human Services (HHS) advisory committees have been discussing meaningful use and certification issues and receiving feedback from software manufacturers, health industry groups and consumers through this past summer. In fact, the CCHIT was to publish provisional “test scripts” (e.g. written documents explaining to software programmers the certification requirements) on Sept. 24.
The Office of the National Coordinator for Health Information Technology (ONC), the final authority on the certification process, had planned to propose EHR certification requirements this summer and approve them by year's end. But it pushed back that deadline to spring 2010, likely due to time constraints. In addition, the final CMS ruling on the official definition of “meaningful use” isn't expected until spring 2010 either.
A Medicare spokesperson contacted by Optometric Management says the implementation issues are complex, and the government is developing regulations that will be issued with ample opportunity for public comment. He further says that the ONC has the lead on certification and will issue interim final regulations by the year's end, and that CMS is responsible for defining meaningful use and will issue proposed rules by the year's end, with a 60-day comment period. Final meaningful use regulations will be published next spring, the spokesperson says.
Meanwhile, despite all the ambiguity, the federal government is urging doctors to launch 2011 certification efforts post-haste.
Perhaps to ease worry, the CCHIT put the word out that certification and meaningful-use requirements “will be the same, or less stringent than current [HHS] committee recommendations.”
Topic experts widely interpret this as the bureaucratic equivalent of saying: “Even though no official definitions have been made, if you follow the provisional criteria as it stands now, your EHR system stands a good chance of being approved.” However, as a non-profit organization with no real power, the CCHIT is in no position to influence what the ONC will ultimately do.

From paper to pixels

Among O.D.s who have already made the EHR leap, finding anyone to interview who regrets it is difficult. They say that choosing the right computer vendor can be a challenge, the transition is always tough, and staff training takes time and effort, but once they overcome these trials, efficiencies in manpower and money seem always to follow. However, since EHR devotees tend to be those who could network their own DOS systems in the 1980s, one shouldn't rule out sample bias in their observations. The following are their experiences in making the transition work and the outcome of doing so.

Although converting paper records to electronic files looms large as an obstacle to adopting EHR, one sizeable practice (eight M.D.s, eight O.D.s) in Maryland found a way to combine staff training with this daunting task. Specifically, the practice's technicians performed “virtual visits” with established patient files one or two days before the patient's exam. They entered all the pertinent data into the EHR, enabling them to become familiar with and, therefore, learn the new system. And when the patients arrived for exams, their records were already in the system.

“Each clinical staff member spent several hours per week doing this [making “virtual visits”] for a couple of months,” says Richard Edlow, O.D., chief operating officer of Katzen Eye Group, the Towson, Maryland-based practice. “One of the keys to a smooth implementation [with EHR] is to have everyone who will have their hands on the EHR system be completely familiar with everything it has to offer before seeing the first patients.”

He adds that due to this preparation, hardly any patient-flow slowdown occurred when the practice transitioned to EHR.

John R. Scibal, O.D., who operates a single-doctor practice in Morehead City, N.C., took more of a catch-as-catch-can approach.

“I took a lot of time setting up templates [on the EHR software, which weren't specifically designed for eye care] on what would be the most common patient encounter,” says the doctor, whose office has been paperless since 2001. “At the end of the day, I entered the patients I'd seen that day into the EHR, and doing that allowed me to improve my templates because I'd see the same thing repeatedly entered.” As Dr. Scibal improved the templates, he began entering as much data as possible electronically during the exam, with paper records as backup.

“From the time my templates were somewhat complete to the time we went 'cold turkey' [from paper records] was about three months,” he says.

The main outcome of implementing EHR has been an increase in practice efficiency, say those interviewed. For instance, when a patient called the Katzen Eye Group for a prescription refill pre-EHR, the receptionist delivered the message to a file clerk who had to locate the patient's file. This could take between a few hours to an entire day. The chart required review by a technician or doctor, who then called the pharmacy to order the refill. During this process, files often became lost or misplaced, says Dr. Edlow.

“Nowadays, the call is immediately transferred to a clinical staff member who opens the electronic record to confirm the medication and ability to renew it,” he says. “The prescription is electronically sent to the pharmacy and automatically documented in the chart,” all in single phone call. “We have not lost a chart in more than five years, and it is a real pleasure.”

Further, since adopting EHR, the practice's accounts receivables have gone from an average of 54 days to 20 days, Dr. Edlow says. The EHR program automatically completes the coding and billing before the patient leaves the exam room, billing everything electronically through a clearinghouse the next morning. And, the clearinghouse brings incorrect billing to the staff's attention immediately.

EHR Resource Web Sites independent HITECH info expected to be one of, or the only, EHR-certi-fying agency The Healthcare Information and Management System Society, a coalition of stakeholders in health information technology a source of topic articles Another good source of topic articles

“A clean [error-free] Medicare claim is typically paid within 14 days, and payments are electronically posted, saving additional staff resources,” Dr. Edlow adds. Now, a staff member enters Medicare's explanation of benefits with a keystroke rather than typing the dozens of pages by hand.

The hours of saved staff time have been incalculable, he says. Further, the practice saved $1,000 a month in paper and office supplies in Katzen Eye Group's first year of EHR use, says Dr. Edlow.

Another point of practice efficiency: EHR facilitates marketing opportunities, as you can search patient records for gender, age and location, and mail flyers and advertisements to promote new drugs and products to specific patient populations — campaigns that large pharmaceutical companies and lens manufacturers are often more than happy to underwrite, Dr. Scibal says.

Also, the software enables you to view the patient's whole medical record, including clinical photos, via your home computer, says Joseph B. Studebaker, O.D., F.A.A.O., whose Englewood, Ohio practice converted to EHR 18 months ago. This is a real benefit when patients call him at home regarding flashers and floaters, he says.

Those considering switching to EHR should be prepared for substantial upgrades to their computer infrastructure, however, says Dr. Studebaker. A fully functioning EHR system required a new so-called “mirrored,” server, which saves simultaneously to two hard drives, plus an external hard drive that is taken off the premises each night (in case of a fire, tornado, etc.). The practice also upgraded to faster Internet access and a wireless network, which precludes having to wire every room for Web capability. Finally, Dr. Studebaker keeps an IT professional on retainer for computer-related troubleshooting, an expense he considers worth every penny.

“… You really need experts who are out there in networking to help your practice along during this process.”

In addition to the leg work EHR implementation involves, the current EHR systems have room for progress, says Kim Castleberry, O.D., chief executive officer of Plano Eye Associates in Plano, Texas, who currently employs EHR and has helped programmers design EHR software. An example:

“We still have to spend too much time documenting the patient encounter,” he says.

For instance, when his optical coherence tomographer takes a retinal image and the device identifies the image as a specific anomaly, he has to enter by hand the OCT's report on the EHR.

“If the instrument already knows that [the anomaly], it should automatically drive that data to the record…” he says.

So, should you buy an EHR system, upgrade your current system, or wait until the government establishes specific required EHR criteria? Unfortunately, the answers to these questions aren't blanket “Yes” or “No's.” Instead, they're relative to your interpretation of the information as it relates to your practice. (See “EHR Resource Web Sites,” above.) OM

  1. DesRoches CM, Campbell EG, Rao SR, et al. Electronic Records in Ambulatory Care—A National Survey of Physicians. N Engl J Med. 2008 Jul 3;359(1):50-60.
Mr. Celia is a freelance healthcare writer based in the Philadelphia area.

Optometric Management, Issue: October 2009