CMS builds a model for health e-records

<b>Four-state pilot, now being expanded nationwide, shows doctors how it’s done</b>

Most doctors have no idea how to implement an electronic health records system and have little trust that the federal government does either.

One California doctor, for example, met with 200 vendors over five years trying to figure out exactly what hardware and software his office needed, to no avail.

But then, in the span of four months in 2004, officials from Lumetra of San Francisco showed the doctor how.

Lumetra, a nonprofit organization that works with health care professionals to improve the quality, safety and integrity of health care, walked the doctor and more than 210 other physicians through the process of selecting and em- ploying health IT in the first year of the Doctor’s Office Quality-IT program.

Take the lead

Under the DOQ-IT program, Lumetra won a two-year contract in 2003 from the Centers for Medicare and Medicaid Services to be the lead quality im- provement organization in partnership with the American Academy of Family Physicians Center for Health IT. Lumetra over the last two years conducted a pilot to recruit doctors’ offices to implement electronic health records in four states—Arkansas, California, Massachusetts and Utah.

“The DOQ-IT program accelerated the learning curve in helping small practices come to a decision that is cost-effective and meets their needs,” said Antonio Linares, Lumetra’s vice president of medical affairs. “We focused on how to create a model for electronic health record adoption.”

The goal of the program, Linares said, is not for doctors’ offices to just use technology for billing, scheduling and keeping patient data, but to use it to improve the overall care of their patients and advance the care of patients across the country.

Linares gave one example from the DOQ-IT program in which two doctors treating 60 patients with diabetes used e-health records to create a system of interventions, making sure the patients were meeting their treatment goals.

“We can only go so far with data collected from insurance claims, but if we can generate good clinical data, we can really im-prove health care,” said Karen Bell, CMS division director for quality improvement and policy for ambulatory and chronic care. “This concept has been around for four years or five years, but the fact [that] it is being adopted and developed in the federal government is a strong statement of how important it is. We need to support health IT in physician offices.”

The problems most physicians face is that implementing health IT is both expensive—some estimate the cost between $15,000 to $30,000 per doctor—and intimidating because of the changes technology brings, said Chuck Parker, DOQ-IT team leader and the director of health care IT for MassPro, a doctors’ office quality program.

“The practices don’t understand health IT and have heard stories or read articles about a practice that spent a lot of money and has nothing to show for it,” he said. “Through the DOQ-IT program, we provide them help in getting through that and help them get the most bang for their buck.”

MassPro, working with Lumetra, helped 486 practices adopt electronic health records in 18 months.

Lumetra, which worked with MassPro, developed a three-step process for doctors to follow when considering health IT:
  • Conduct a physician practice assessment to detail the workflow and why the doctors want to move to electronic health records. This first step also includes a readiness assessment, staff training and a business plan for adoption.

  • Implement a system to select a vendor and manage the project using a phased approach.

  • Establish a care management system to help upgrade the way doctors’ offices collect and use data.

“We sent templates to the four states and they modified them to meet their local communities,” Linares said. “Now we are going to the other states and using these tools.”

CMS, using Lumetra’s model and lessons learned from the pilots, awarded contracts Aug. 1 to other doctors’ office quality im- provement organizations to ex- pand the program to all 50 states, the District of Columbia, Puerto Rico, Guam and the Virgin Islands, CMS’ Bell said.

Although more than 1,000 physicians signed up in the four test states, Bell said the lack of national software and hardware standards is holding back some doctors, as is the slow development of CMS’ data warehouse by the Iowa Foundation for Medical Care of West Des Moines, Iowa.

The data warehouse would collect all patient information from each practice—while meeting Health Insurance Portability and Accountability Act privacy re-quirements—and provide doctors’ offices with clinical data to better care for their patients.

Waiting on standards

“CMS, over time, will demonstrate [that] actual improvement in medical care has occurred because of health IT,” Bell said. “Part of the delay is we need the vendors to agree to standards.”

Some organizations, including MassPro, are developing regional exchanges in part because the central database is not ready yet and because of the uncertainty of sending raw data to CMS, Parker said.

Additionally, Parker would like to see the government promote health IT through a loan program, similar to one for students. Doctors could receive a low-interest $25,000 loan to cover front-end costs, and have a set time to pay the money back. Parker said the guaranteed loan could be reduced if doctors meet certain performance metrics.

CMS also started a pay-for-performance program with the four original pilot states, in which 250 practices from California and Mass- achusetts and 150 from Arkansas and Utah can receive up to $10,000 per year for adopting e-health records, and another $10,000 per year for meeting a portion of the 37 preset clinical measures.

“The DOQ-IT program has done a lot to advance the interests of small and medium-size medical practices,” said David Kibbe, the director of the center for health IT at the American Academy of Family Physicians. “The program has helped to establish the need for common set of measures for quality and performance at the physician level.”

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