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Are policy makers’ expectations for EMR adoption by 2015 too high?
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Design, interoperability and clinician use have to all evolve simultaneously if we are going to get to a true interoperable EMR that can really support coordination of care for patients across conditions, providers and settings. Policy makers make the assumption that if you put an EMR in someone’s hands that coordination of care will magically occur, but that’s simply not true when we do not have the incentives within the system in the first place.
First of all, no one is paying clinicians to communicate with one another. The incentives in our current fee-for-service systems are not for care management and care coordination. The nature of the reimbursement system as it currently exists encourages using EMRs to document not just clinical information, but to document billable information. EMR design and clinician use will not change until basic payment incentives change and are realigned around doing what is best for the patients.
The second problem is, just because a physician has an EMR in their practice does not mean that that EMR can talk to another EMR in another physician’s practice or hospital. Most of the time, any communication between practices or between inpatient and outpatient setting is still done by paper. Right now we just don’t have in place yet the common data exchange standards and we don’t have cooperation among EMR vendors to create tools that are completely interoperable. This really creates problems for clinicians. When it comes time for communicating with physicians outside of your office, unless you’re in a big HMO or an integrated delivery system, this becomes difficult.
Third, policy makers and EMR developers need to listen to feedback from clinicians, especially those in small-to-medium- sized practices in terms of the challenges they face using EMRs as tools to support coordination of care. With new legislation around ARRA and HITECH, there’s some language about creating regional centers to support these practices in particular. I think that there’s real potential for those regional centers, not just to offer technical assistance and guidance on best practices, but also to maybe use those or something similar as an avenue to aggregate feedback from clinicians to the vendors and policy makers.
Ann S. O’Malley, MD, MPH, is a researcher with the Center for Studying Health System Change in Washington, D.C. She is co-author of the study “Are electronic medical records helpful for care coordination? Experiences of Physician Practices,” which was recently published in The Journal of General Internal Medicine.
I don’t think EMR systems are totally effective in pediatrics because of a lot of technical difficulties with use. I think we are almost there, but the huge cost is a major stumbling block. The economic stimulus plan, which provides funds for using EMRs, does not help the majority of pediatricians. At least 20% of your practice must use Medicaid in order to benefit. Most people who are practicing in middle America will not qualify for that money. Then there is the unwillingness of managed care companies to raise fees for providing care. Financially these are hard times, and I certainly hope that EMR adoption will not be mandatory.
Do I think EMRs are the way to go? If I were a young physician, yes. They certainly solve a lot of liability issues with penmanship, etc. But I don’t see how EMRs would have any effect on coordination of care. If I want to provide a copy of my notes, it is probably faster and more economical. But will it help me remember? Whether it’s an electronic chart or a handwritten chart, everything is still housed in the chart. EMRs may save you a little bit of time with having to flip through paper records, but I personally don’t think it has that much of an effect on coordination of care.
One of the issues that I have concerns with being a CPT coder is that many times the EMR can prompt you to do things that really aren’t necessary, therefore promoting up-coding. I’m just concerned that EMRs may promote inappropriate use. I think it can help people who have already done the documentation… and who are under coding.
The fact of the matter is that the United States has been lagging behind the rest of the world and worldwide health care as far as technology is concerned. In that aspect the 2015 goal definitely helps with information gathering. But the way EMRs are used in pediatrics needs to be better before this whole thing becomes mandatory.
Richard Lander, MD, practices pediatrics with the Essex-Morris Pediatric Group in Livingston, NJ and is part of the Infectious Diseases in Children Editorial Board.