Physician Plans for Adoption of Health IT Systems

A recent study on physician plans for adoption of health IT systems found that ARRA and hospital incentives will drive rapid adoption, with 80% of physicians under 55 year of age (and 58% overall) planning to implement an EMR within the next two years.

Healthcare Technology News sat down with Greg Parston, the lead researcher and director for Accenture’s Institute for Health and Public Service Value. 

HTN:  This study is focused on the 10 and under physician market in US?

Greg Parston: That’s correct.

HTN:  The physicians have pretty aggressive plans.

Greg Parston:  Because of what’s happening with incentives provided by ARRA and sometimes being provided by hospitals we are at a tipping point.  There have been many physicians who appear to have been looking into what EMR can do for them.  They’ve been reluctant for many reasons that we identified in the study. But because of these incentives and in part because they can anticipate minor Medicare reductions for non-use, they are becoming more interested. The indications of aggressiveness, if you can call it that, are pretty astounding.

80% of physicians under the age of 55 we talked so say they are going to adopt an EMR system within the next two years and that’s a pretty big shift.  Right now we’re talking about a physician population of about 15% using on EMR and now we were talking about much bigger numbers within 24 – 36 months. 

 HTN:  There’s always been a prediction that the EMR adoption was right around the corner. 

Greg Parston:  Physicians have been looking.  It’s not as if they’re coming to this totally uninformed.   Many practices have been taking a look at different kinds of systems.  They’ve been considering the benefits.  They’ve been talking to people who have a system today.  I don’t think they’ve been doing enough of that. But they’ve been doing enough of it to indicate that they been thinking about it.  So if we’re talking about 58% now, a good portion of that would have been thinking about adopting it in the coming years.  What ARRA has done is to provide the tipping point to make a much larger percentage of small-group practices decide that they're going implement a system.  But also because of the deadlines it’s brought their plans closer.  You’re right to say that there was a time we thought this was going to happen and there was going to be a big surge.  What ARRA has done is to provide the added push and the timetable for that. 

What’s most interesting is the difference in attitude amongst those physicians under 55 and those over 55.  These systems are not inexpensive.  For very small packages it’s a sizable amount of money.  For the older guys they’re there taking a look at when are these reductions going to come in.  How much is it going to cost me?  When am I going to retire?  Those sorts of questions are making them in some cases perhaps a bit more skeptical of it.  More wary of it.  More reluctant.  When you take a look at the younger guys, 2015 (when the penalties kick in) is still within their working lives.  They’re taking a look at how they can avoid any penalties now and put in place a system which potentially has great benefits for them. 

HTN:  Your study cited a key driver for EMR adoption being federal legislation - 61% cited penalties for non-adoption and 51% cited federal incentives.

Greg Parston:  You can’t just look at their reaction to ARRA.  You also have to take a look at their reaction to the potential of local hospital subsidy.  Many local hospitals are offering support of one type or another and some of that support is actually financial.  There’s also aftercare – we’ve heard of doctors who have had a systems crash and have waited up to three weeks for the geek squad to fix it.  Hospitals are offering 24x7 services.  Hospitals are offering training.  Hospitals are offering assistance in transition from written records to electronic records. All of those things along with ARRA are providing a basket of benefits for clinicians. 

And while the study does cite the penalty as the single most importat thing, when you combine the benefits of both the government and their potential networked hospitals, these incentives seem to be the overwhelming influence.

If doctors move to full functionality EMR systems, however meaningful use is finally defined, and if they negotiate well with their local hospitals this could be a rather inexpensive investment for them.  As they’re thinking about this, they’re thinking about how they could network in to hospitals.  This brings them advantage, not just in terms of billing but in terms of patient flow through their referrals.  In another study we found that 75% of the American public want their doctors to have electronic medical records and that must put pressure on practices as well.  They’re sitting there saying:  “This looks pretty good - I can get up to X thousands from the government to put in the system and my local hospital is willing to put in training and support for me - Now is the time.”
 
HTN:  The study found a strongly held belief in the value of an EMR system to the practice.  The summary in the study was about changing the way the practice works for the better.   I hear various arguments:  Are the majority of of practices using it just to comply with billing and payment requirements for reporting outcomes?  Or are they really into this for better patient care? What is your insight on how this changes the way the practice works for the better?

Greg Parston:  Patient care came up but it wasn’t the top. What was top was trying to develop more streamlined administrative systems within the practice.  And that’s fine.  These guys run businesses and they’ve got to make sure that those businesses are giving them the kind of support and administrative ease that allows them to focus on their patients. 

When we ask doctors who currently have systems whether the systems benefitted them, 90% said they did.  There wasn't any one thing that was identified as the overwhelming benefit.  Doctors use these systems in various ways for various advantages in various places.   Places that have used systems for a very long time like Kaiser Permanente have learned how these systems can not only streamline administrative practices but can also streamline and improve the quality of the patient care process.  There are organizations that really know how to use the EMR.  I’m not sure that doctors who are in small practices are cognizant of all the potential benefits and changes possible with an EMR system in place. 

HTN:  The study noted the exaggerated perception of the difficulties in using EMR systems.  How did that manifest itself?

Greg Parston: It manifested itself in the fear and hesitancy about the systems.  There is another important observation here that came out of the research.  Many of these physicians self-report themselves as being less conversant and less comfortable with computer and Internet technologies than their predecessors.  So the first wave who are already using it – the 15% who are already there - they identify themselves as more IT literate.  Some develop these systems because they want to be on the edges of modernity.  You and I have friends that have every piece of technology around the house because they have to have it.  There are doctors like that too.

The next generation if we can call it that – the people we were talking in that 58% (or under 55, that 80%), they’re more fearful.  They don't feel as comfortable with these technologies.  They certainly don't feel able to service it themselves.  So they raise bigger questions about how difficult is it going to be implement it or how difficult it’s going to be to get service.  Am I going to find that it’s going to crash and am I going to run into real problems in my practice?  Those questions don't come from looking at the systems.  Those questions come out of their own personal lack of total comfort with new technologies.  That’s something that’s going to have to be overcome through learning more and through use of these systems.  And here I think that vendors and hospitals that are trying to network doctors in can be of enormous help in providing much more education and support and understanding to make them much more comfortable more quickly. 


HTN:  What was the timing of your survey?  Was this pre- December 30, before the meaningful use rules were issued? 

Greg Parston:  Yes it was.  It was also right during the height of the health reform legislation.  We had been timing this study to occur in the Autumn and we took a judgment about whether or not we should do it during the midst of that debate.  We decided we should because people would be even more cognizant   and sensitive to the issues.  Healthcare reform legislation is going to change American healthcare.

HTN:  What do you think would be the impact of the meaningful use rules on physicians planning to adopt an EMR? 

Greg Parston:  There’s 600 pages there and I only know one person who’s read all 600 hundred. And they’re still being modified as we speak.  Meaningful use is essentially about trying to get people to use the system to full functionality, cognizant that people are concerned about privacy issues and lots of other things.  Meaningful use will drive people to take a look at what they get from that next step of functionality.  By linking the incentive payment to increased meaningful use physicians will begin to explore more. 

They’re not going to jump all the way into whatever the top level of meaningful use is simply to get the money.  But knowing that the money is there, they’ll begin to explore further the edges of their systems.  And they’ll begin to think about how they can use them in a new ways. 

I’ve already mentioned Kaiser Permanente.  There’s a quote in recent article about Kaiser Permanente – about how the system can actually change things - about how doctors will use these technologies to adapt their practices.  The quote goes something like this: that if you give a lumberjack, who’s been using an ax his whole life, a chainsaw and he starts hacking at the tree it’s not going to help him. It's only when you begin taking a look at how this chainsaw works and what a difference it can make that it can make a difference in his life.  I think that’s the same with an EMR. 

This is a new technology that’s going to allow people to do lots of different things.  Meaningful use is a carrot as well as an instruction about how you can learn how to use the chainsaw in the way it was designed to be used. 

HTN:  You mentioned the striking impact the health reform legislation will have.

Greg Parston:  It’s going to force people to take a look at what we mean by connected health.   I don't mean that in a technology sense. I mean it in the sense of really connecting agencies together to try to deliver value for the public in health terms, not just in health service terms.  And that’s pretty exciting to me.  This legislation will unleash a whole new part of the market on the demand side.  And there are people on the supply side that are very good at innovation and thinking about how they can serve the needs of people who have not been served before. And a lot of that isn’t episodic acute care.  I think we could see a very different health system in two decades from what we've got now.  What we’ve got now is one that largely focuses on episodic transactional care.  I think we can get something which is much more about helping me deal with my health through the continuum of my life.
 ________

Greg Parston is the director of the Accenture Institute for Health & Public Service Value. Prior to joining Accenture, Dr. Parston was the chairman of the Office for Public Management, a nonprofit organizational development company that he co-founded in 1988 and led as chief executive until 2003. Dr. Parston has consulted widely with top managers, focusing on governance, strategy and change and has worked as a manager in the public, private and not-for-profit sectors. Until taking up his current post, he also was a director of the Priory Group, responsible for public service partnerships.

EHR Certification and Transition Steps Defined

On September 3, the Certification Commission for Healthcare Information Technology (CCHIT) unveiled their plans for certification under ARRA. CCHIT plans two program concepts: 1) comprehensive certification which meets or exceeds federal standards and and 2) modular certification related to security, privacy and interoperability meeting federal standards.

Federal standards for HHS Certification will mean that a system meets the "minimum government requirements for security, privacy, and interoperability, and that the system is able to produce the Meaningful Use results that the government expects." HHS Certification will not be a 'seal of approval' nor an indication of the relative value of systems.

CCHIT's action were in response to ONC's Certification and Adoption Workgroup recommendations presented at the August 14 HIT Policy Committee meeting.

The Certification and Adoption Workgroup's recommendations include:

• Focus Certification on Meaningful Use
• Leverage Certification process to improve progress on Security, Privacy, and Interoperability
• Improve objectivity and transparency of the certification process
• Expand Certification to include a range of software sources: Open source, self-developed, etc.
• Develop a Short-Term Certification Transition plan

The Certification Workgroup emphasized the need for more explicit requirements for information exchange

Unlike CCHIT today, certification criteria should be established independently of the organizations performing the certification. Multiple certification organizations will be allowed to perform testing after they become accredited. Vendors need certification from any one testing organization.

Wes Rishel (Gartner) has argued that "when the choice of certifiers is made only by the vendor, not the organization that relies on the certificate, this creates an inevitable pressure to be the certifying organization that is the least thorough in its process"... "Arguably, if physicians could chose the certifying organization they would not pick the one with weakest accreditation. After all, they have to live with and use the product. But under the “any certifying organization will do” approach, this is not the option that will be presented to physicians. They will be asked to choose among products each of which is rated by several organizations, some of which are focused on the baseline requirements for certification and others of which use any number of criteria for judging products."

As such, accreditation is a lynch pin in the Workgroup's recommendations to "insure that multiple certification entities use identical criteria and provide a 'level playing field' so that all certification organizations offer the same level of scrutiny."

HHS Certification would also serve as qualification for the Stark exception.

Providers would be allowed to achieve meaningful use through use of certified components.

In one sure-to-be-controversial recommendation, the Workgroup recommended that the “lock down” requirements of EHR software should be removed to address concerns of the Open Source community.

Self-developed software may also be certified, on a site by site basis.

The transition

The certification transition "includes a concept of 'Preliminary HHS Certification' so that vendors, who take a risk on the content of the final regulations, can be ready as quickly as possible when final regulatory approval is obtained" which should be valid through 2011."

"This certification is called “preliminary” because the meaningful use criteria and the certification criteria will not yet have completed their paths through the regulatory process.
When the regulatory process is completed for Meaningful Use, presumably in early 2010, then, if necessary, establish a short “regulatory gap certification” for any necessary changes from preliminary certifications. After completing this “regulatory gap certification”, the National Coordinator should certify those products as qualifying under the statute, with a goal of having HHS Certified products in the marketplace in early 2010."

"For vendors who already completed CCHIT 2008 certification, we recommend providing an optional shorter, expedited process. Request that CCHIT submit, as soon as possible, a proposal for “2008 Gap Certification,” which will apply only to vendors who already completed 2008 Certification. The 2008 Gap Certification must cover any missing privacy capabilities (e.g., audit trails, consent) required by statute It must also cover capabilities for Meaningful Use, and expanded interoperability capabilities. Once approved by ONC, the completion of 2008 Gap Certification should also qualify products for “Preliminary HHS Certification.” Those products will be required to complete the “Regulatory Gap Certification Process” before the National Coordinator similarly certifies those products. Working with CCHIT and the Policy Committee, the ONC should investigate whether similar gap certifications are appropriate for products that achieved 2007 certification."

CCHIT To Provide 3 Certification Options

On June 18, the Certification Commission for Health Information Technology (CCHIT) announced that it is extending its certification options in response to concerns from open source developers and in an effort to better position itself to vie for appointment as the certification agency required under the HITECH provisions of the American Recovery and Reinvestment Act (ARRA).

The three options include:

• "A rigorous certification for comprehensive EHR systems that significantly exceed minimum Federal standards requirements. This certification (EHR-C) would be targeted to the needs of providers who want maximal assurance of EHR capabilities and compliance
• A new, modular certification program for electronic prescribing, personal health records, registries, and other technologies. Focusing on basic compliance with Federal standards and security, the EHR-M program would be offered at lower cost, and could accommodate a wide variety of specialties, settings, and technologies. It would appeal to providers who prefer to combine technologies from multiple certified sources.
• A simplified, low cost site-level certification. This program would enable providers who self-develop or assemble EHRs from noncertified sources to also qualify for the ARRA incentives."

These certification options are targeted to be available for 2011-2012 certifications which kick off in January 2010.

CCHIT has been criticized for too close a relationship to Health IT vendors, led most visibly by David Kibbe and Brian Klepper, who have asked "If the HITECH monies are spent on CCHIT certified EHRs that can't do any of these patient-centered tasks, or EHRs that don't come equipped with the features and functions to extend health IT capability to the patients and consumers, do we really think that the money will have been spent wisely? But that's the pathway we seem headed down, led by the vendors." Mark Leavitt, Chair of CCHIT, has responded forcefully to this criticism.

CCHIT's announcement addresses the concern that certification was previously only available to vendors able to deliver monolithic solutions covering all EHR requirements.

HITECH Interoperetta

Dr. Ross Martin presents an original work brought to you by "The American College of Medical Informatimusicology" as performed by its founding member (Dr. Martin). Stick it out for the grand finale. Thanks to HISTalk for reporting on this goofy gem.

Getting By or Getting Better?

There are 20 billion reasons to be hopeful about the passage of the stimulus plan’s HITECH provisions. Certainly the plan will drive greater physician and hospital adoption of EHR's and will ultimately help improve coordination of care across health care settings. The CBO believes that there is a roughly 3:1 financial return on this investment. That’s all good news.

But will the stimulus plan provide the lift that hospitals and systems need to realize the full potential of EHR’s, improving outcomes and reducing costs? Or will hospitals do just enough to justify reimbursement and to avoid future fee penalties?

The investment and implementation choices that are made today will be with us for a very long time. And there is reason to be concerned with the outcome.

I recently spoke with the president of a publicly traded large healthcare tech company that does business with most hospitals in the US. I asked for his take on the stimulus program and its effect on his business. His response was that the stimulus plan was certainly needed, but was insufficient to restore hospital capital spending on technology. His view is that the US Treasury's plan for the capital markets is much more critical to financial recovery in healthcare.

The best way to test this hypothesis is with the credit rating agencies that evaluate risk and financial health of healthcare organizations. Fitch Ratings recently released their special report on 2009 Nonprofit Hospitals and Healthcare Systems Outlook which found that hospitals "will be severely tested and under intense pressure over the next 12- 18 months."

The outlook is "negative" (a very strong word for a credit ratings agency) based on "constrained access to capital, a deteriorating payor mix, elevated interest rates, severe investment losses, ... increasing uncompensated care and higher capital costs." They forecast that government reimbursement will remain constrained by the economic crisis, employers will continue to shift healthcare costs to employees and small employers will face greater challenges providing healthcare for their employees. "These factors, coupled with increasing unemployment and declining utilization will likely depress operating profitability well into 2010... Economic stimulus initiatives and healthcare reform efforts could be beneficial over the longer term but are not expected to provide significant immediate relief."

Financial market conditions including swap risk, the collapse of variable-rate demand bonds, the lack of fixed-rate debt, pension fund obligations and higher capital interest costs are all contributing to reduced liquidity for hospitals.

For many hospitals, the level of days cash on hand, a key financial operating metric, has fallen 20-30% from 2007 to 2008. In addition, hospitals are facing operating pressure related to increases in uncompensated care and declining utilization, which is expected to reduce profitability for 18-36 months. Fitch expects that hospitals will respond by "curtailing or deferring capital spending, reducing staffing, cutting costs to bolster profitability... (and) anticipates these actions to continue throughout 2009..."

Hospitals can expect "volumes to continue declining as consumers delay or postpone non-urgent procedures and as unemployment levels continue to rise." While reimbursement levels should be adequate, hospitals should anticipate "continued increases in bad debts and charity care..." A recent AMA study on the impact of the economic crisis on hospitals reinforces many of these findings.

Fitch contends that hospitals are going to need to focus more on driving revenue and productivity gains. (For examples of these initiatives, see High Margin Revenue Cycle Strategies.) Reflective of a more strategic view of healthcare technology, "the degree to which providers have invested in health information technology can also influence Fitch’s assessment of long term viability."

Fitch concludes that "while much work remains to be done in defining, funding and implementing meaningful change in the healthcare industry, a common theme of various federal and state reform proposals centers on creating payment incentives that encourage value – the delivery of effective, appropriate care in an efficient manner."

With this backdrop, it’s easy to imagine a few scenarios where hospitals treat healthcare technology as a strategic enabler, and many other scenarios where hospitals work to just get by, doing enough to reap the financial reward but no more.

In one of its few moments of inspiration, Congress gave HHS the authority to define "meaningful use" of healthcare technology. The "meaningful use" metric determines whether providers are paid for their EHR investments.

Historian Paul Johnson said that "the word 'meaningful' when used today is nearly always meaningless." Given the many pressures on hospitals to just get by, this one key definition, and the way it is operationalized, may define the trajectory, results, patient outcomes and costs that we live with for years to come.

Best Links to HITECH

To understand the implications of the stimulus legislation on health IT in 3 clicks or less, here are the places to turn:

Health Care and the American Recovery and Reinvestment Act. New England Journal of Medicine. 2/17/2009.

Stimulus Bill dramatically modifies HIPAA rules. Wisconsin Technology Network. 2/18/2009

A Shared Vision and Roadmap for Health IT. By the chairs of the National eHealth Collaborative, HITSP and CCHIT. 2/10/2009.

Reductions in Mortality, Complications and Cost Linked to Healthcare Technology

On January 26, the Archives of Internal Medicine published a study on Clinical Information Technologies and Inpatient Outcomes which found that greater automation of hospital information was linked with reductions in mortality, complications and costs.

The study was conducted in 41 Texas hospitals representing a cross-section of hospital types and sizes with data on 167,233 patients over the age of 50.

The key finding: “Hospitals with automated notes and records, order entry, and clinical decision support had fewer complications, lower mortality rates, and lower costs.” The study does not conclude that there is any causal relationship from technology to outcomes and cost, but does describe the very strong correlation between them.

One of the study's authors, Dr. Ruben Amarasingham, Associate Chief of Medicine for Parkland Health and Hospital System, graciously agreed to sit down with Healthcare Technology News (HTN) to describe these results.

HTN: Congratulations on your study - - very compelling results, on such a large scale.

Amarasingham: Thank you very much. We think its one of the largest studies to evaluate the relationship between technology, clinical effectiveness and cost. We looked at this using a new framework for measuring health information technology, the Clinical Information Technology Assessment Tool (CITAT).

HTN: Can you explain CITAT? Please break it down for us.

Amarasingham: We started to develop the tool 5 years ago, starting in 2003. When we looked at HIS systems, we found that there was no good method to evaluate hospitals against each other. If hospitals say they've implemented an EMR, it's impossible to know if the definitions, functionality, usability and maturation are the same across hospitals. We therefore started with a universe of activities that physicians do in a hospital - - thousands of activities. If the activity is electronic, regardless of the specific software/technology, we asked physicians how would they respond to the following:

1) Do you have electronic support for this activity?

2) Do you know how to use the technology for this activity?

3) Do you choose to use the technology for this activity?

From that we created an instrument based on what we, and others, thought were the most important clinical activities and scaled a hospital based on whether its physicians are using the technology. We set a very high bar – the hospital needed to have the technology and the physician not only needed to know how to use the technology, but then had to choose to use it over other processes (like falling back to paper or having an assistant deal with the technology). It’s entirely possible for a hospital to spend millions and still fail on these criteria.

HTN: What piqued your interest in this?

Amarasingham: I'm an inpatient physician myself so it is a natural set of questions to ask. As a Robert Woods Johnson Clinical Scholar at Johns Hopkins, my mentors pushed me to define how to quantitatively measure information technology and the effect on clinical outcomes. Many of the technology studies were worrisome - it was not clear that the technology measure could be generalized. There was less attention to real usability. After studying the human factors research, particularly Vimla Patel's work at Columbia, it became clear that these three criteria of physician use were very important. We published an earlier study that described and validated the CITAT tool.

HTN: The data is so compelling regarding the reductions in mortality and complications. Do you have any sense for the key drivers?

Amarasingham: We suggest some possibilities in our paper. Smaller earlier studies found similar reductions and specifically examined in qualitative ways how technology might mediate these outcomes. I think that hospital medicine is extraordinarily complex with ever more studies and more innovations. Every day physicians are presented with multiple choices of treatment and diagnostics. Which parameters should be monitored? How do we track an illness over time? Information systems help manage all the information that is available in terms of decision support.

On top of the knowledge explosion, care is increasingly fragmented. There are multiple teams of physicians and para-physicians, shift work, etc. - - a growing and large number of actors just within the theater of medicine. A good IT system may help coordinate care; becoming perhaps a member of the team by helping to facilitate communication among staff who are working different shifts and schedules. In my opinion, the coordination of care makes an enormous difference in an increasingly fragmented medical system.

Good information systems also possess a certain degree of artificial intelligence. Physicians may not track the small trends in the patient’s condition. Presenting alerts and information in an objective way that may help physicians know where to look is so important. Conversely, poorly constructed systems have the potential to be harmful.

HTN: Why wasn’t Length of Stay related to use of technology?

Amarasingham: Length of Stay (LOS) is probably at the lowest it could be in American hospitals. A 2005 National Discharge Survey examined LOS over 30 years. It has been systematically driven down by a number of pressures, including attention by payers and regulators. Given the very small lengths of stay, it's possible that information technology provides efficiencies but not enough to change an already low LOS.

HTN: You published a report earlier this year which found that academic affiliation and larger IT operating, capital, and staff budgets are associated with more highly automated clinical information systems. Basic conclusion: more investment, more highly automated systems – simple. So why in this study do you find that higher levels of automation of test results, order entry and decision support are all contributing to lower costs? It seems almost contradictory.

Amarasingham: Great question. We found the hospitals that had better use of information technology had lower cost per hospitalization, adjusted for patient severity of illness. It may be that you need a certain economy of scale to implement these systems. Once you have those systems in place your per hospitalization costs are reduced - - overwhelmingly lower. We adjusted for a lot of the characteristics that are typically associated with the higher costs that makes this a robust finding. When you are seeing a patient and have a breadth of options - if you have really sophisticated decision support that is easy to use - - that tool may become an effective agent to help physicians make clinically sound choices that also control costs.

HTN: How much does the effective and extensive use of automation relate to the degree to which physicians are employees of the HCO?

Amarasingham: We didn't look at that particularly. We did look at the hospital organization. We found that the benefits cut across all hospital types. Regardless of the physician practice model, these benefits accrue to the hospital. It’s clearly a challenge for hospitals to ensure that training is provided and protocols followed. If the physicians aren't motivated and engaged with design and training, there’s the potential for very poor outcomes. We didn't look at nursing in our study, but the same applies there as well.

HTN: The stimulus package includes the HITECH Act which includes provisions for federal payments by Medicare and Medicaid for the “meaningful use” of EHRs. As I listen to you talk about CITAT, it strikes me that is exactly what CITAT is measuring.

Amarasingham: Great point. Measuring the presence of technologies would be an inadequate measure. CITAT evaluates whether the 1) technology is present in the organization, 2) the physicians have the know-how to use the technology and 3) the physicians choose to use it over other methods. Government will need to measure some sort of effectiveness outcome like this. Our research suggests that investment in healthcare technology is a wise investment. But it needs to be adopted properly. If it is rushed, not focusing on the socio-technical environment that we discuss in the paper, it could be ineffective. By setting a standard around meaningful use, I think HITECH would be headed in the right direction.

$23 Billion HITECH Stimulus: Senate Debate Kicks Off

The Senate debate kicks off today on the Superbowl of stimulus packages including HITECH, the Health Information Technology for Economic and Clinical Health Act.

It will take a carefully calibrated bi-partisan 60% to get past any Senate filibuster. So what will "careful calibration" look like? Imagine the Steelers' blockers making way for James Harrison's explosive 100 yard interception return. Or imagine the ballet of Santonio Holmes hauling in the winning pass in the far corner of the end zone with 35 seconds to go.


If it passes the Senate, it goes to conference committee to finalize the legislation. We can expect that no changes would be made that risk a Senate challenge to the final bill, like the challenge to a Roethlisberger apparent TD that fell short by 2 inches.

With that in mind, if it passes the Senate we can expect to see many of the following elements in the final bill:

Legislative endorsement for key National Health IT organizations

• Office of National Coordinator for HIT (ONCHIT)
• HIT Policy and Standards Committees through the National eHealth Collaborative (aka AHIC Successor) subject to ONCHIT endorsement.
• Standards and certifications bodies: While unnamed, the Health Information Technology Standards Panel (HITSP) and the Certification Commission for Health Information Technology (CCHIT) are likely beneficiaries in support of standards and certification requirements.

ONCHIT Strategic Goals

• Electronic exchange and the enterprise integration and use of health information, including establishment and governance of the nationwide health information network (NHIN)
• Utilization of an electronic health record for each person in the United States by 2014.
• Privacy and security protections for the electronic exchange of personally identifiable health information
• Security methods for authorization, authentication and encryption of health information
• Use of health information technology in improving the quality of health care, reducing medical errors, reducing health disparities, improving public health, and improving the continuity of care among health care settings.
• Evaluation of open source health information technology systems for "federal safety net providers".

Meaningful Use

Financial incentives are tied to "meaningful use" of certified EHR's by physicians and hospitals. "Meaningful use" is defined somewhat circularly in the criteria:

• Use of "EHR technology in a meaningful manner" (which for physician incentives shall include the use of e-prescribing).
• Electronic exchange of health information to improve the quality of care such as promoting coordination of care.
• Reporting on clinical quality measures (which shall become more stringent over time).

Physician Incentives for Adoption and Meaningful Use of Certified EHR Technology

• The Carrot: $41,000 in Medicare payments per eligible physician: Year 1 - $15,000; Year 2 - $12,000; Year 3 - $8,000; Year 4 - $4,000; Year 5 -$2,000. If Year 1 for a professional is 2011 or 2012, then the Year 1 payment is $18,000. No incentive payments if first adopting in 2015. No incentive payments after 2015. Exceptions for rural physicians and later adopters are also specified.
• The Stick: Fee schedule reductions will apply to physicians not using certified EHR technology starting in 2015, with fee schedule reductions of 1% in 2015, 2% in 2016 and 3% in 2017 and beyond.
• These incentives do not apply to hospital-based physicians
• For a summary of this, HISTalk just published a table of bonuses and penalties.
  

Hospital Incentives for Adoption and Meaningful Use of Certified EHR Technology

Medicare incentives to hospitals (both carrot and stick) are set up in a similar model as physicians, with a more complex calculation and bigger dollars tied to their meaningful use of certified EHR's. Incentives are calculated based on an initial amount ranging from $2 - 4.6 million (based on number of discharges) multiplied by a Medicare share and a declining "transition factor" for each of four years (1, .75, .5, .25).

Medicaid Incentives

100% federally funded Medicaid incentives are included in the legislation, without back-end reduction in Medicaid fees for non-compliance. Eligible Medicaid physicians are non-hospital based with 30% Medicaid patient volume. Eligible hospitals include 1) children's hospitals, 2) acute care hospitals receiving at least 10% Medicaid patient volume and 3) health centers or rural health clinics with at least 30% Medicaid patient volume.

News Analysis - HITECH's Impact

In a look at the slightly smaller house version of this bill, the Congressional Budget Office (CBO) estimates that $19.8 billion will be spent on HITECH which will, among other things, accelerate adoption of EHR's. The acceleration will deliver US health system net savings of 0.3% betweeen 2011 and 2019, or greater than $60 billion in savings. While this is a good return, 0.3% won't by itself substantially dampen the trajectory of health care spending (see Health Care Costs: A Principal Driver of Long-Term Deficits).

The CBO projects that without the stimulus package "about 45% of hospitals and 65% of physicians will have adopted qualifying health IT in 2019. CBO estimates the incentive mechanism would boost these adoption rates to about 70% for hospitals and about 90% for physicians."

CBO's savings estimates are based on the acceleration of benefits including "reducing the number of inappropriate tests and procedures, reducing paperwork and administrative overhead, and decreasing the number of adverse events resulting from medical errors. Health IT could also improve the quality of care provided to patients by improving the information available to clinicians at the time of treatment, by encouraging the use of evidence based medicine, and by helping physicians manage patients with complex, chronic conditions. The use of health IT could also increase some costs because improved adherence to treatment protocols could increase the amount of care provided."

John Glaser has pointed out that "meaningful use" will need to be clearly spelled out in 2009, leaving only one year for implementation in order for physicians and hospitals to realize the full benefit of the incentive programs. "This is a tall order. And it means that providers should start moving now (if they aren’t already) even though the dust has yet to settle on the specifics."