Dennis Ramus, M.D., is ahead of the curve when it comes to the use of electronic health records. His seven-physician Bay Area Family Physicians in Chesterfield Township installed a NextGen Healthcare EHR system in 2006.
But even Ramus and his partners expect to struggle this year to meet a new federal rule that requires, in part, sharing of electronic records with specialists and hospitals that have different electronic record systems.
Thousands of Michigan physicians face similar challenges to meet “meaningful-use” incentive program regulations. Meaningful use is defined by a tiered system; providers that use electronic records to improve quality and efficiency earn different levels of certification.
For example, stage one systems are used internally, stage two systems are shared with multiple other providers, and stage three systems show documented improvement in patient outcomes.
Physicians, hospitals and others must meet all three stages to receive a total incentive of $44,000 over five years from Medicare and $63,750 for qualified Medicaid providers.
But many physicians have delayed purchasing EHR systems. Reasons include high cost, technical complications, practice disruption and resistance to change office routines.
Another complication to doctors, and others: Some systems aren’t fully compatible with each other.
E-record report card
Starting Jan. 1, physicians who don’t meet the meaningful-use requirements by Dec. 31 face a 1 percent cut in Medicare reimbursement. The payment cuts are cumulative for each year a physician is not certified, for up to a 5 percent deduction.
In 2013, only 48 percent of office-based physicians in Michigan have installed a basic electronic health record system, compared with 25 percent in 2010, said MPRO, a Farmington Hills-based quality improvement organization. Nationally, basic EHR adoption also is about 48 percent, up from 17 percent in 2008, said the federal Office of the National Coordinator for Health IT.
“We were one of the first adopters of EHRs. We hired a Chrysler process engineer to help us convert what we did on paper to EHRs. We also hired an office manager (a former naval officer) who knew about information technology. It was fortunate because it is very hard for the average physician to figure out,” said Ramus, chairman of The Physician Alliance, a 2,300-member physician organization closely affiliated with St. John Providence Health System in Warren.
Bay Area Family met meaningful-use stage one criteria in 2011, Ramus said. Meaningful-use stage one criteria includes electronically capturing patient information in standardized format, tracking key clinical conditions and using that information to discuss care with patients.
Sharing outward
This year, physicians will have first crack at meeting meaningful-use stage two criteria. The most significant difference between stage one and stage two is showing a practice can communicate and share data with other physicians and hospitals not in the practice’s immediate network.
One of the 17 requirements also states that physicians must use computerized physician order entry systems, including e-prescribing, on 30 percent of their patients. The initial standard was 80 percent of patients.
“If meaningful-use one was algebra, (meaningful-use two) is calculus,” Ramus said. “You have to coordinate with outside physicians, hospitals and communicate with specialists,” and there are problems with that because most EHRs don’t communicate directly with each other, he added.
Under stage two requirements, providers also must meet criteria that include e-prescribing, exchange of laboratory results and transmission of patient care summaries that will assist in coordinating care between unaffiliated providers, facilities and different EHR systems.
Despite the growth of health information exchanges in Michigan, Ewa Matuszewski, CEO of Roches-ter-based Medical Network One PC, said there still is a major gap in communication through EHRs. Mainly, it centers on the ability of non-hospital-employed physicians and those not closely affiliated with hospitals to exchange EHR data with other providers through health information exchanges.
“Health systems can do that internally for physicians, but we are not that far along in moving that information outside of those closed systems,” she said.
But Doug Dietzman, executive director of Grand Rapids-based Michigan Health Connect, the largest of several health information exchanges in the state, said most independent physicians should be able to use Michigan Health to meet meaningful-use stage two regulations.
“If an (EHR) vendor doesn’t help them meet meaningful-use two, we can help them comply,” said Dietzman. “Not a lot of physicians are coming to us yet because the certification period just started. Our services are set up to be able to do that for them.”
Current guidelines and requirements for EHRs cover the years from 2011 to 2021.
Dietzman said most Medicare-certified EHRs with 2014 software updates should be equipped to meet stage two requirements.
This year, Michigan Health Connect agreed to merge with Great Lakes Health Information Exchange. The two organizations would include more than 2,000 physician provider offices and 100 of the state’s approximately 117 hospitals.
Mike Williams, M.D., president of Bingham Farms-based United Physicians PC, a 2,400-member physician organization, said the ability of physicians to interconnect with hospitals and physicians on different EHR systems is a major barrier to meet federal requirements.
“The market will demand that physicians share information. That will drive the use of EHRs — more than meaningful use,” Williams said.
Obstacles
Despite four years of financial incentives, Williams said, there is a wide gap between physicians who have simply installed EHRs and those who use them well. Then there are those who have not installed them at all.
“We have some on both ends in our physician organization,” said Williams. “Some doctors just don’t see meaningful use, at this time, really helping their patients. It is expensive, time-consuming and the payoff isn’t there yet.”
Jack Billi, M.D., associate vice president for medical affairs at the University of Michigan Health System in Ann Arbor, said many independent physicians are putting off EHR installation because of office hassles.
Physicians say “I will lower my head and continue to do my paper record; I know incentive money out there that I will leave on the table, but this is so big a transformation that I can’t get my head around it,” said Billi, a board member of the Michigan State Medical Society who heads up its committee on quality, efficiency and economics.
Williams said United Physicians has strived hard to help physicians interconnect with other EHRs to conduct population health management and share medical records for referral purposes.
Williams said United’s 2,400 physicians use 70 EHRs with varying levels of effectiveness in connecting with other systems.
“It would be much easier if there were five or six EHR vendors” selling products, Williams said.
To help physicians and hospitals with vendor-related problems in meeting meaningful-use rules, the Centers for Medicare and Medicaid Services will grant providers a one-year “hardship exception” if their EHR vendor fails to help physicians meet the deadline.
R. David Allard, M.D., chief medical information officer with Henry Ford Health System, said Henry Ford’s implementation of Verona, Wis.-based Epic Systems‘ EHR is nearing completion this year for its five hospitals, 1,000-physician medical group and 12 private practices.
“Meaningful-use two is a difficult set of criteria. We won’t meet it until next year,” Allard said.
Like a school project, Allard said, completing your practice’s part of the project is only one piece of the puzzle, he said. The other participants also must do their parts for the project to be complete, he said.
“The larger systems have more infrastructure and resources to set up the (electronic) interfaces,” he said. “It is more difficult for independent physicians to make the connections.”
Because of the complexity and costs, Matuszewski said, many physicians are still using patient disease registries instead of EHRs to track patients on their visits, chronic diseases, medications used, lab records and other medical facts.
Disease registries are collections of medical data on individual patients within a practice. They can be used to set up tasks or to ensure that medical staff members ask certain questions.
Costly upgrades
More than 80 percent of physicians said they use some form of electronic data sharing, which includes an EHR or data registry, up from 42 percent in 2008, after financial incentives began to flow to doctors and hospitals under the 2009 stimulus bill, said the National Ambulatory Medical Care Survey.
“The barrier is as before — cost,” Matuszewski said. “It is not just buying an EHR (that can cost more than $40,000 per physician in upfront costs to install). It is paying the annual maintenance fee, training is huge and creating the templates for all the physicians is very costly,” she said.
Ramus said the individual EHR cost per physician was $30,000 to $50,000 for hardware, software and initial setup. Bay Area has received $38,000 per physician in financial incentives from Medicare, with another $6,000 expected for meaningful-use two compliance, for a total of $308,000, he said.
“The payments were heavily front-end loaded, which is good for the doctors,” he said. “We spent $250,000 to $300,000 for the entire system.”
But to maintain and staff its EHR, Bay Area spends about $100,000 a year.
“We have many demands for data (from private payers and Medicare),” said Ramus, who also is a certified public accountant. “The unfortunate thing is, so many physicians are behind the curve.”
However, Billi said, patient data can now be exchanged through UMHS, St. Joseph Mercy Health System and participating medical groups and physicians.
But exchanging patient data to unaffiliated providers through health information exchanges, which are designed to allow for connections across EHR platforms, “is not there yet,” he said.
Physician education
Mike Madden, CEO of The Physician Alliance, said education of physicians, mostly specialists, is a main task of physician organizations because EHRs can highly disrupt normal work flow.
“We know there is a significant concern about meaningful-use two,” Madden said.
One of the key projects for the Physician Alliance is tracking 35 data elements from participating physicians to make sure the data is valid and the systems are operating efficiently.
The Physician Alliance also merges the claims data and disease registry data of physicians, monitors the performance of physicians, and transmits the data to Blue Cross Blue Shield of Michigan as part of the physician group incentive program, which financially rewards doctors for hitting quality and cost saving targets.
The incentive program proves more than 40 initiatives by which physician organizations can earn bonus payments.
Based on Blue Cross’ PGIP program, United Physicians has 1,384 physicians who participate. Of that amount, 301 of 416 primary care physicians, or 72 percent, use an EHR and 584 of 968, or 60 percent, of specialists use one, he said.
Over the next several years, said John Vismara, United’s vice president of information technology, EHRs will be used more often to participate in managed care contracts, prove quality performance and communicate with other providers.
“It will be less about meaningful use and more about participating in a network and staying in business,” Vismara said.
