Many doctors are not convinced that data collection leads to better care or that the federal government can help them do their jobs better.
Dr. Larry Garber has been preparing for Washington’s $17 billion booster shot for the adoption of electronic health records for months, if not years. Now that the money is about to pour forth, his practice in western Massachusetts expects to be one of the first in line to apply for a portion of the stimulus law funding.
The big question is whether his colleagues across the country will follow his lead. Although technology and innovation have transformed medicine and pharmacology in the past 20 years, doctors remain late adopters of tools such as e-mail and digital records. Many are not convinced that data collection always leads to better care or that the federal government can help them do their jobs better by requiring collection and analysis of their patient data.
For Garber, who is medical director for informatics at the Fallon Clinic of Worcester, Mass., meeting the administration’s just-released requirements for meaningful use of electronic health records should be a snap because the 250-doctor practice he helps manage has been using EHR systems for several years. “We are on top of this,” Garber said. “We are very close to becoming meaningful users in 2011.”
The Health and Human Services Department’s goals in fostering EHRs are to reduce costs and improve efficiency and quality of care. The quality goals contained in the new regulations are the most ambitious element because they set the stage for creation of an unprecedented new infrastructure to collect clinical data from doctors, rate doctors’ quality of care and provide feedback to spur improvements.
The future of that strategy now lies in physicians’ hands. Doctors must decide whether they want to adopt health information technology systems and become meaningful users according to HHS’ rules, which is a condition for accepting money from the stimulus pot. As part of HHS' requirements, doctors must begin sharing some of their clinical data by 2011 for the purpose of improving overall quality. That's a tall order for doctors who have not done the early groundwork that Garber has done at the Fallon Clinic.
Physicians are making those buying decisions now. They are weighing the cost of purchasing the systems and judging the ease of installation and use. Quality is a potential benefit, to be sure, but the regulations bring new administrative requirements and — many physicians fear — a possible loss of autonomy as caregivers.
“Physicians want to satisfy the ethos of their profession,” said Dr. Stephen Sergay, a neurologist in Tampa, Fla. “Influencing people to provide quality through regulation does not necessarily bring out the best in people.”
Congress Sweetens the Pill
The federal government has been pushing doctors and hospitals to adopt EHRs since at least 2004, but it was not until Congress passed the economic stimulus law a year ago that incentive payments sweetened the deal. HHS is ready to inject at least $17 billion into the health care system to reward doctors and hospitals that buy and use the systems. It might be the impetus the medical profession needs to push it into the Digital Age.
But did the Obama administration go too far too fast when it linked health IT adoption with a large new system of data collection and exchange to help meet health care quality goals? It is too soon to say, but the early reaction from doctors is ambivalence.
Family doctors are considering many factors, said Dr. David Kibbe, senior adviser to the American Academy of Family Physicians. “For physicians with busy practices, this is not on their radar,” he added. “This new system is very confusing. The busy family physicians will look at this with real concern and with real caution.”
Much of the attention in Washington has been focused on the potential cost savings that EHRs could bring to an exceedingly inflation-challenged industry. Quality of care has received less attention.
There is evidence that digital records can reduce medical errors, especially in drug interactions, and that the availability of electronic data could lead to improved quality. The idea is to collect and analyze patient data to identify the best treatments based on outcomes and deliver that information to doctors when and where they need it most, especially the examining room. That is possible only with electronic systems.
“Simply put, health professionals will be able to give better care,” said Dr. David Blumenthal, HHS’ national coordinator for health IT, at a recent conference about linking stimulus dollars to higher-quality care.
Blumenthal and other policy-makers are hopeful of immediate quality rewards — a reduction in medication and prescription errors, a drop in the number of allergic reactions, and the avoidance of transcription problems caused by poor handwriting.
Other quality-of-care improvements will emerge after doctors broadly collect and share information, which is happening on a small scale in select practices, hospitals and state Medicaid programs. Health IT already has generated some quality improvements. For example:
- About 4,200 doctors are participating in the Community Care of North Carolina Medicaid incentive program. It focuses on quality in seven areas, including care for people with diabetes and congestive heart failure. The providers feed standardized data into the system and receive timely, actionable information in return, said Dr. L. Allen Dobson, president of Community Care. The results have been positive, including lower rates for asthma-related hospital admissions. Providing feedback to the physicians — including immediate actions for specific patients — is especially important because it gives the doctors a direct benefit for their effort, Dobson said. Overall, the quality ratings are helping to boost “a new level of competition based on quality,” he added.
- In San Diego, officials at the Veterans Affairs Department and Kaiser Permanente said at a press event Jan. 7 that their program to share patient data electronically has been successful in boosting quality. Instead of paperwork taking weeks, records can be shared in seconds. One of the first patients to benefit was a veteran Kaiser Permanente diagnosed as having severe allergies. When the veteran sought care from VA, his allergy records were available immediately. That increased the patient’s safety and reduced the risk of a prescription error, said Dr. Stephen Ondra, VA’s senior policy adviser for health affairs.
- Computer Sciences Corp. helped the Defense Department set up an e-prescribing system called the Pharmacy Data Transaction Service in 2005, with more than 9 million eligible participants. The system automatically checks new prescriptions against a patient’s medical history to avoid potentially life-threatening drug interactions. The system has helped DOD reduce prescription errors, said Dr. Robert Wah, chief medical officer at CSC. “There is a huge role for technology to improve quality,” he said. "Health IT is just a facilitator."
Doctors Remain Skeptical
In physicians’ offices, the quality regulations are likely to have a more complex impact. Although doctors generally support quality goals, they are skeptical of the way those goals are being pursued — in the form of data collection by regulation. The HHS-proposed meaningful-use regulation, published Jan. 13, outlines 29 data collection measures, of which 27 concern quality.
Even health IT’s strongest supporters, such as the Fallon Clinic's Garber, concede that HHS’ framework of quality regulations is getting a lukewarm reception.
Doctors believe they are providing the best quality care to meet patients’ unique needs, Garber said, and they tend to be wary of statistical generalizations about quality of care, which in the past have been drawn mostly from insurance claims data. From his viewpoint, doctors want digital systems to ease their administrative burdens and reduce medication errors from drug interactions. But for most doctors, a chance to take part in the national quality infrastructure will not persuade a doctor to invest in the systems, Garber said.
Physicians are also concerned that the government could eventually use the quality data to raise or lower payments for services performed for Medicare and Medicaid patients. In the past, some medical professionals have warned of unintended consequences — such as avoidance of the sickest patients — if physicians and hospitals are judged and paid based on the government's quality measures.
For example, one proposed quality measure is tracking the percentage of a doctor’s patients who are obese. Doctors are concerned that their future incomes might drop if they depend on whether obese patients follow advice to exercise, eat properly and lose weight, which doctors consider to be beyond their control, said Dr. Steven Waldron, director of the Center for Health IT at the American Academy of Family Physicians.
“There is a concern that the quality incentives won’t have adequate data about case mix and patient noncompliance,” Waldron said.
But appropriate rules could ease those concerns. For now, HHS is focusing on collecting the relevant data from participating doctors. Rules for sharing and using the data for quality purposes will come later. “In introducing any new technology, you need a thoughtful approach and strong incentives to counter unintended consequences,” said Janet Corrigan, president of the National Quality Forum, a nonprofit group that supports data collection to improve health care quality.
Another point of contention is that many physicians would like HHS to require that EHR systems include space for physicians' narrative notes. Those are the notes a physician writes when meeting with a patient, describing — often in the patient’s own words — why he or she has sought care and how the patient characterizes his or her symptoms. Digital systems typically do not have a place for such notes. Instead, they offer doctors a list of items to check off to describe a patient’s situation.
In a December 2009 survey by Nuance Communications, 94 percent of the 17,000 doctors interviewed said physician narratives are important to have in digital records and 96 percent were concerned about the consequences to patient care if those narratives are absent.
“I strongly believe that the quality of care is based on a meaningful dialogue between the physician and patient,” said Sergay, the Tampa neurologist. “Talking to people is so much better than filling in boxes.”
Some doctors also have doubts about receiving the stimulus law payments because they have not yet been reimbursed for their participation in the federal Physician Quality Reporting Initiative that began in 2006 and ended in 2008.
“The good news is that everyone has the same goal of high-quality care,” said Rob Tennant, senior policy adviser at the Medical Group Management Association. “What is problematic is that the way HHS has crafted the rule may be a deterrent.”
Doctors and policy-makers are also weighing other concerns about the link between health IT systems and improved quality. Studies have suggested that some systems might create new errors, such as choosing the wrong name or medication from a long list of choices. And a recent study at Harvard Medical School found that hospitals' health IT adoption has so far not led to higher quality.
Other studies have shown that the process of transitioning to EHRs brings multiple headaches and that dependence on an electronic system could lead to vulnerabilities. For example, the Government Accountability Office recently chided VA because a power outage-related computer glitch had a negative effect on patient care at VA facilities in Texas.
Although former President George W. Bush urged doctors and hospitals to go digital by 2014, the adoption rate has been slow. A recent survey showed that only about 17 percent of doctors and 8 percent of hospitals are using at least a single type of EHR application. The systems span a number of applications, including computerized physician orders for drugs and of tests, decision support, and physician notes.
Moreover, large parts of the health quality data infrastructure have not yet been conceptualized. Standardizing the data so that it has common elements and can be securely exchanged among users is a challenge. “We have not thought this through yet,” Blumenthal said. “The vision is there, and the path is beginning to be conceived.”
How long it will take to realize the vision and get physicians to buy into it remains the $17 billion question. “We have to work on refinement of the clinical care improvements,” said Richard Moore, chief information officer at the nonprofit National Committee for Quality Assurance. “It will take a lot of time to go from a fragmented system to an integrated one. But is it three years or 10 years?”
In the end, quality improvements through health IT must be accompanied by bigger changes. “It’s not just buying a system; you have to redesign the delivery of care,” said Dr. Anne-Marie Audet, vice president of quality improvement and efficiency at the Commonwealth Fund.
As physicians wait to see the outcome of health care and payment reforms, one of their strategies might be to delay adoption of health care records until they have a fuller picture, Kibbe said. Ultimately, though, many doctors are amenable to the idea of receiving rewards for high quality, even though data could be used to reduce income for some doctors, he said.
“I hope we’ll see opportunities for hospitals and physicians to be rewarded for better quality, not just quantity,” Kibbe said.
Despite the complexity of the issues involved, many doctors and policy-makers agree that although it's not a foolproof strategy, striving to improve quality through health IT might be one of the best chances to bring the quality of health care in the United States up to a level that meets everyone’s expectations.
“You cannot improve what you cannot measure,” Waldron said. “There are risks to anything you do, but the benefits in this case outweigh the risks.”