Cardiologists make progress but still face problems adopting electronic health records

Few financial incentives exist for individual practitioners to adopt EHRs.

Cardiologists continue to forge ahead in adopting electronic health records, but universal access to a comprehensive, paperless EHR may be decades in the making.

Cardiologists have extensive backgrounds in the medical use of computers for applications such as recording and graphically displaying vital signs and lab work in hospitalized patients, measuring hemodynamics during cardiac catheterization, interpretive electrocardiograms and arrhythmia monitoring, measuring of echocardiograms, and sophisticated digital image processing and storage of a wide range of diagnostic images.

In fact, most cardiovascular diagnostic images – echocardiography, nuclear, catheterization, CT, CMR – are now stored in digital archives with no “hard” copy. Hospital lab and x-ray reports, vital signs, pharmacy and other patient care data are usually presented in digital format. A few hospitals have adopted electronic order entry systems. Most cardiology offices use electronic billing and scheduling systems. And a small but increasing number of cardiology practices are even adopting electronic records for outpatient office visits, abandoning handwritten and dictated paper records entirely.

Obstacles remain

One might correctly conclude that, compared to 25 years ago, we cardiologists already have a largely electronic health record. Clearly, cardiology has made enormous progress in adopting an EHR. But many obstacles still must be overcome to realize the Bush administration’s 10-year goal of implementing a national health information network and a comprehensive electronic health record for most Americans.

Many have noted that computers provoke both unreasoned fear and extravagant expectations. Although it is attractive to believe that adoption of an electronic health record will lead to improved safety, greater efficiency, higher quality and reduced costs, little evidence currently exists to support any of these hypotheses, at least when applied in the general community outside highly controlled environments.

Many cardiologists have heard stories from their early-adopter colleagues who have spent tens and even hundreds of thousands of dollars and thousands of hours on an office EHR system only to be disappointed by its lack of functionality and the absence of return on investment. Much of medical practice is appropriately idiosyncratic. Tedious and expensive efforts to turn complex and nonstandardized data into a digital record are not automatically rewarded with improved outcomes or increased operating efficiency.

Cardiologists are only too familiar with multiple “legacy” computer systems within a single home, office or hospital that don’t “speak” to one another, even when manufactured by the same vendor. Many cardiologists attend at more than one hospital and are exposed to multiple incompatible hospital IT systems, receive laboratory results from many different laboratories and reports from other physicians using their own incompatible software and hardware. These are all electronic records but hardly constitute a truly integrated EHR.

Compared to many other physicians, cardiologists are fortunate in that much of the expertise and expensive software and hardware needed to support electronic reporting and storage of cardiology data are supported by hospitals, which have infrastructure and financial resources to provide both the personnel and equipment necessary to incorporate vast quantities into an organized and efficient electronic record.

Infrastructure, financial resources

CMS and OIG have recently announced plans to relax restrictions on hospitals and health care systems that discourage these institutions from sharing hardware and software for EHRs with their referring physicians. While this support is welcome, hospitals understandably use their IT infrastructure to tie physicians to individual hospitals and have little reason to cooperate with competing hospitals or physicians who work in them.

Few financial incentives exist for individual practitioners to adopt EHRs. While payers, including the government and private insurers, stand to reap considerable financial benefit from EHRs, they have been reluctant to pay for such systems. All parties recognize that complex systems, including hardware, software and personnel — all needed to forge clinical data into a cohesive electronic record — are very costly and implementation is extremely disruptive. CMS has made it clear that it does not intend to pay for computer hardware or software, but that it will foster implementation of EHRs indirectly. Some term these efforts “unfunded mandates.”

Modest returns

Many hope that CMS and private payers’ “pay-for-performance” initiatives will make adoption of EHR’s financially attractive. The benefits of the EHR, however, seem to accrue mostly to the payers, not to the practitioners, who face major expense, but only modest returns of perhaps 5% increase in payment. In an era of zero sum budgets for physician payments, with no new money allocated for increased expenses, it is likely that the 5% pay-for-performance bonus will come from a 5% cut somewhere else in physician payments.

One way EHRs can offer a return on investment is through more accurate coding. Increased revenue can be generated by documenting and billing for higher intensity patient encounters. But some carriers, as they have observed practices using EHRs to appropriately bill more complex and higher paying codes, have blocked even this source of revenue by combining higher intensity codes into a single, lower payment category.

EHRs in their current form lack standardization and interoperability. Private practice cardiologists, particularly those in smaller groups, generally do not have extensive resources for information technology in their offices and may work in more than one hospital system.

Because of these problems, fewer than 20% of cardiology practices have adopted outpatient EHRs. Some large single-specialty cardiology practices, such as Prairie Cardiovascular in Springfield, Ill., Midwest Heart in Chicago and Ft. Wayne Cardiology in Indiana, are leading the way in adoption of comprehensive EHRs in the outpatient as well as inpatient setting.

They hope to gain a return on their investment through improved efficiency and cost effectiveness and are actively developing decision support software and data-mining programs that will not only facilitate and document improved care but may also provide revenue from pay-for-performance programs being promoted by both Medicare and private payers.

Use of aggregated clinical data collected not only from limited observations in the hospital setting but also from outpatient encounters may be a fertile area for pharmaceutical and device research.

Making progress

Despite significant obstacles, cardiology is making progress in adopting more comprehensive EHRs. More recent cardiology trainees entering practice have trained in hospital-based academic group practices that have greater experience in comprehensive EHRs than smaller private practices. Younger cardiologists have encountered and embraced the digital world and may drive the health care system to more quickly adopt what is commonplace in the rest of their world.

The American College of Cardiology and others are hard at work developing standards for collecting and reporting cardiology data. Traditional practice guidelines will be transformed into practice friendly decision support tools. Industry is spending heavily to develop better systems to replace existing fractured, idiosyncratic legacy systems. We in cardiology will adopt a universal, comprehensive EHR but it will not be easy and it will not happen soon.

Samuel Wann, MD, is chairman, department of cardiovascular medicine, Wisconsin Heart Hospital, Wauwatosa. He is editor of Cardiology Today’s Health Policy, Patient and Practice Issues section. Suma Thomas, MD, is attending cardiologist, Lahey Clinic, Burlington, Mass.