Despite the growing use of EHRs in recent years, major hurdles remain to widespread adoption in the U.S. According to a recent report to Congress by the Office of the National Coordinator for Health IT, barriers include inconsistent EHR adoption across the healthcare continuum, lack of interoperability, lack of national policies to support health information exchange and issues with health data security and usability.
CMS’ EHR Incentive Program compensates eligible doctors and hospitals as they adopt, implement, upgrade and show meaningful use of certified EHR systems. The agency’s Regional Extension Centers program is also helping to fuel adoption by supporting on-the-ground assistance for physicians transitioning to EHRs.
But while these incentives have been quite effective at driving EHR adoption in hospitals, they have been less so for provider practices, says Julia Adler-Milstein, a health policy expert who teaches at the University of Michigan.
This is likely to change with the Merit-Based Incentive Payment System and Alternative Payment Models and the Medicare Access and CHIP Reauthorization Act (whose implementation final rule proposal was released yesterday), because doctors will have to demonstrate meaningful use and EHRs as a component of Medicare and Medicaid payment, she says. “But until the systems get better, cheaper, easier to use, etc., I suspect that many providers will hold off investing.”
According to Adler-Milstein, lack of interoperability has limited the value of EHRs, but it’s not what’s impeding EHR adoption. Some physician practices may not have enough Medicare or Medicaid patients to see value from EHRs. But more often the problem is lack of capital and the technical expertise to effectively select and implement an EHR.
Physicians and hospitals need to have good technical support and change management processes, and these can be expensive and hard to find, she explains. “EHR adoption is incredibly disruptive and more so if not done well, and so, particularly for smaller provider organizations, there can seem to be more downside than upside.”
According to the American Medical Association, more than 80% of doctors are now using EHR systems. And now with MACRA and programs like MIPS and APMs, physicians actually need EHRs to participate.
It’s not that physicians need incentives, AMA argues. It’s that the available tools need to meet their needs — not federal requirements. By eliminating MU and other prescriptive reporting programs, vendors will be free to develop patient-centered health IT.
Jane M. Orient, executive director of the Association of American Physicians and Surgeons, goes even further and says that the government should get out of the EHR business and let the systems develop in a free marketplace. “Most doctors are technology lovers, and are often criticized for that. They resist EHRs because it impairs productivity, disrupts normal work flow, introduces serious errors, destroys privacy, impedes the patient-physician relationship,” she said in an email. “Many use it only because coerced to do so.”
In a 2015 report by the American Medical Informatics Association, a panel of experts attempted to address some of these “unintended clinical consequences” of broad EHR adoption. Among their recommendations were to simplify and speed documentation; refocus regulation by clarifying and simplifying certification and Meaningful Use, improving interoperability and reducing data entry; increase transparency; and foster innovation.
“As we outlined in our EHR-2020 report, incentives leading to actions or documentation that directly benefits the patient being cared for are best,” says Thomas Payne, medical director of information technology services at the University of Washington Medicine and head the 14-member panel that prepared the report, tells Healthcare Dive. “Those that detract the provider’s attention from the patient being care for, and require substantial additional time that detracts from patient experience, should be avoided.”
On the recently published final rule proposal, CMS acting Administrator Andy Slavitt and Karen DeSalvo, national coordinator at ONC, in a blog post wrote, "This proposal, if finalized, would replace the current meaningful use program and reporting would begin January 1, 2017, along with the other components of the Quality Payment Program."
In the post, the authors note the proposal attempts to move the dial for greater physician flexibility as well as reduce burden. Providers, under the proposal, can choose to get paid under MIPS or certain alternative payments models (APMs).
Eric Helsher, vice president of client success at Epic, says market forces — the shift to population health, more team-based care and a greater focus on overall continuity of care — are driving EHR adoption more than government incentives.
“Our customer base was trending upwards before Meaningful Use, and while there was a bit of a jump in growth, it wasn’t a significant jump,” he tells Healthcare Dive.
While Epic’s focus is on larger hospitals, health systems and medical groups, the company has found ways to provide it’s software to smaller hospitals and independent practices. One way of doing this is for a larger hospital to extend their “instance of Epic” out to the smaller entities so that they can coexist on the shared system. This benefits from the scale that the larger health system provides via IT administration, but also provides a single patient record in that community, he says.
For affiliate providers that use a different software or haven’t moved to EHR, Epic can provide a portal into the larger health system’s EHR, allowing them to see what’s happening with their patients and place orders or communicate with the care team there.
Even with greater EHR adoption, though, meaningful exchange of information will continue to be a problem unless there is a shared policy framework that all players in the industry can agree to, says Helsher.
Last year, Epic customers exchanged over a quarter billion patient records—including with 60 other EHR vendors, about 30 state and regional Health Information Exchange networks, the VA and Social Security. “Meaningful exchange is happening, but it’s certainly not the end state we’re looking for,” Helsher says.
That could change, though, and soon. A public-private collaborative called Carequality has developed a set of “rules for the road” that will allow health systems to exchange information in a secure, trusted way without having to negotiate individual point-to-point connections.
Since December, when the group released its shared policy framework, five major EHR vendors, including Epic, have signed on and some health systems have also agreed to abide by it, paving the way for greater and more meaningful data exchange.
This alone won’t solve the problem of EHR adoption, but it could give some reluctant providers an incentive to embrace the electronic age.