ACC NEWS
President’s Page: Achieving the Heights of Quality With Electronic Health Records
James T. Dove, MD, FACC, President, American College of Cardiology*
* Address correspondence to: James T. Dove, MD, FACC, American College of Cardiology, c/o Padmini G. Rajagopal-Moorehead, 2400 N Street NW, Washington, DC 20037
In a recent issue of Cardiology magazine, a physician wrote of his frustration with the pressure to adopt electronic health records (EHRs) and health information technology, and he questioned the real value and cost-effectiveness of doing so (1). Given the expense of EHRs, the continuing lack of common equipment standards, and issues of interoperability, one can perhaps understand his frustration and even sympathize with it. For smaller cardiology practices, these costs can be huge issues. However, sympathy and frustration serve little purpose concerning the adoption of EHRs; the question about its adoption is no longer if but when you will adopt a system.
In reality, making the move to EHRs is more about quality than it is about cost savings. In the paper chart system, many offices within the same practice group have their own way of recording and filing information in the chart. That alone presents significant difficulties in the handoff of care and has been identified as a significant contributor to medical errors. Documentation of why a patient was given or was not given a specific medication is more obvious. If the electronic chart only brought some order to the chaos of the current paper chart system, it would be a dramatic improvement in the quality of care and decrease the errors of handoff.
The potential, however, is much greater than just organizing the chart. Medication lists, allergies, laboratory tests, and procedure results are readily accessible through Health Level 7 (HL7) interfaces. No longer are these results lying around on someone else’s desk to be filed and unavailable for the physician on call.
In reality, the main beneficiaries of electronic records are the patients and the quality of care they receive. Properly used, electronic records can and will change the way we practice medicine. They hold the potential of creating a structure for a disease management approach in caring for a patient. Application of appropriateness criteria reduces unnecessary or duplicate testing. All members of a patient’s care team will have full access to the chart as they see the patient. Interconnectivity in regional care systems will simplify coordinating care.
Added quality benefits can come from incorporation of practice guidelines and performance measures into the system of care. When this is available at the point of care, pay for performance becomes an easy target to hit. We think that we adhere to these measures well, but when tracked chart by chart, we fail. An EHR makes 100% compliance a reality. That is, the medication was given or a legitimate exception was documented.
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Where Adoption Rates Stand
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President Bush established the Office of the National Coordinator for Health Information Technology (ONCHIT) in 2004 and set a goal of widespread EHR adoption by 2014. Since then, the Medical Group Management Association estimates some 10% to 20% of all medical practices have moved to EHRs. In a recent interview, David J. Brailer, former ONCHIT coordinator, noted statistics from the Centers for Disease Control Prevention that show an increase of 20% more hospitals with EHRs last year than the year before (2). As far as the organizations that have adopted EHRs, Brailer believes that it has been mainly the large hospitals and large practices, entities that planned for the change and were able to make it happen financially. He refers to this adoption time as the "period of the willing."
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Overcoming Adoption Issues
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As with switches to technology in other sectors of the economy, the initial outlay is expensive and the early benefits are often compromised by the costs of implementation, training, and the pain of change. The first purchase cost is estimated to be between $15,000 and $50,000 per physician. The yearly maintenance can be as high as $3,000 to $15,000 per year per physician.
In medicine, payers, such as the government, may realize the short-term cost savings; however, for a medical practice it will take some time for those savings to occur because of the early slow down in operations. There are, however, cost savings that can be recovered in better documentation of evaluation and management visits for proper billing and elimination of loss billings. Few practices have evaluated the cost of pulling a paper record or time spent on looking for a lost record. The ability to access records from home or fill prescriptions on the first call saves important time in not having to track the patient down again to deal with the problem.
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American College of Cardiology (ACC) Efforts Continue
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Hospitals and practices that have implemented EHRs already recognize its impact. However, the impact of health information technology will not be fully realized until most providers are using it and interoperability issues are resolved. For some, there is also an innate resistance to change, especially technological change. The ACC has taken many steps in the last few years to help its members with these issues.
The ACC, with the Healthcare Information and Management Systems Society and the Radiological Society of North America, has sponsored the multi-year, international Integrating the Healthcare Enterprise (IHE) program.
The IHE program is a professional collaboration of medical societies, clinicians, and vendors organized to find practical solutions to the complex issues of clinical system integration. The IHE program does not make standards; however, it promotes open standards, refines interface specifications, and rigorously tests vendor implementations.
The goal of IHE is to improve patient care by harmonizing health care information exchange and provide a common standards-based framework for seamlessly passing health information among care providers, enabling local, regional, and national health information networks.
The ACC is developing a tool kit based on the Certification Commission for Health Information Technology criteria that will help members evaluate EHR functionality for cardiovascular practices. The kit will list specifications that a system should have to meet the practice needs and provide a list of vendors who are able to meet those specifications. In addition, there will be a list of implementation issues to address as the system is selected and incorporated into a practice.
When it comes to pay for performance or any quality implementation, it will be hard to fulfill it without an EHR. Yes, it can be done with paper, but the difficulty of transferring paper information into the required electronic billing system will be inefficient. Also, the capacity to recognize and respond to a deficiency in performance is more complicated than doing it at the point of care. The value of the EHRs is real, but it has a cost and learning curve that is significant. However, it is a hill that we need to climb. During this year, the ACC will continue supporting efforts that help members in making the climb.
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References
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- Benton S. EHR: a reality check on value? Cardiology 2007;36(1):4.
- Milstein A. Health information technology is a vehicle, not a destination: a conversation with David J. Brailer Health Affairs 2007;26:w236-w241.[Abstract/Free Full Text]
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Where Adoption Rates Stand
Overcoming Adoption Issues
