Do providers face an electronic health record learning curve? (Part I)

Jim Schibanoff of the Milliman Care Guidelines, Scott Armstrong of Group Health, John Hammarlund of CMS, and Joe Scherger of Lumetra discuss physician adoption of electronic health records.


Q: Jim Schibanoff, we’ve talked a bit about the cost and investment requirements of adopting these systems. I’m curious also about the impact on providers of learning these new systems, learning how to use them effectively. Is this potentially a larger burden for healthcare providers?

Jim Schibanoff: Well, it’s great to hear Scott describe Group Health’s experience, the after, because most physicians are dealing with the before, which they see as great disruptions to their routines of care, more inefficiencies in their practices. They feel under financial pressure already and here it’s taking more time to use this electronic health record. So getting over that hump is a significant issue. And in systems like the VA, Kaiser, I believe Group Health, there is much more of a group culture. There’s a financial mechanism, a delivery mechanism. The physicians are more integrated into the system, as opposed to all the physicians in private practice who are in one or two physician offices and may go to one or two hospitals.

This is a significant challenge in health care, and there’s a famous example at Cedars-Sinai Hospital in Los Angeles, which is one of the leading hospitals in the country where they had to abandon the computerized physician order entry. That one thing was really effective in reducing medication errors. They had to abandon that effort and restart because of physician resistance. So we cannot minimize the importance of physicians. And we at the Care Guidelines think about physicians using the Care Guidelines as an information tool at the bedside, which is sort of the holy grail of hospital care. The first thing we think of is physician usability. We need to design systems that are usable by physicians. For some who are on the older side who are not really that comfortable with technology, this is a major, major hurdle.

Q: Scott Armstrong?

Scott Armstrong: Just two brief comments, Jim, one in response to your points. It’s true, and I’ve been through the transition with our medical group, and it’s not easy. But I would also tell you that we are getting more applicants out of graduate school for every one of our open positions today than we have in the past because they don’t want to practice anywhere where they don’t have this electronic record, and so we need to remember that. Second point I would make is back to your question about, “Well, what’s it going to take for us to standardize this information and make it portable?” I would argue that whether it’s Microsoft or the VA or Kaiser or Group Health, we have very exciting pilot projects going on right now. And they are projects that we’re going to learn a lot from. And I can’t speak to the technical issues, but I’m sure we can solve a lot of the connectivity issues and so forth. But frankly, until we change the economic comparative, it’s not going to happen. It’ll happen by sheer force of will or some economic interest of disparate companies. But the question would be, “When will the care delivery system be economically motivated to invest in a clinical improvement that comes from electronic records?” It doesn’t exist today. It only exists in these closed systems. I would argue, and Ron was making this point earlier, electronic records will become ubiquitous much more quickly, universally connected, too, at a point when they represent a real solution to how the care delivery system can be successful, promote better quality, and return a decent margin on the bottom line for the health care organizations across our country.

Q: So are you saying that absent reform that would reduce or eliminate fee-for-service medicine, we’re unlikely to see incentives for investment for these records?

Scott Armstrong: I can’t predict the future. And I believe that many organizations, like those represented here, will do heroic work to leverage existing technology and to try to create portability. But I don’t think it becomes universally applicable, like our financing system or our travel industry, until we change certain features of the payment process and reform the system more broadly.

Q: John Hammarlund, what do you think? You represent the largest payer at this table, in fact  the largest payer of healthcare in the world.

John Hammarlund: Let’s be clear that oftentimes, payment policy becomes healthcare policy, and there’s no doubt that we can incentivize providers to embrace technology. In fact, that’s what we’re doing in these demonstration projects I mentioned earlier, whereby we’re paying bonus payments to small and medium practices to adopt and use electronic health records to report on quality data. Now the direction that we are headed actually, you mentioned whether we abandon fee for service medicine or not, I don’t know. The direction that we’re ultimately to head though, is for paying for greater value of healthcare and not volume of healthcare. Now we can’t get there without having a lot more transparency. You can’t get to that transparency without having more of this data available. So that’s sort of the step process we have to go through before we get to that point.

Joe Scherger: I think it’s appropriate to put some numbers out there. The cost to implementing an electronic health record is about $30,000 per doctor as an up-front fee. And then maintaining the record will run at about $500 a month or at least a half of an employee. So something needs to make sense to the doctor to do that. Now most of the benefits of an electronic health record don’t go directly to the doctor. They go to the payer, the insurance plan, or the patient themselves in safer care. But there’s no business model to a private practicing doctor to recoup that $30,000 up-front investment and the ongoing $6,000 a year cost per doctor. Now payment for quality and changing incentives can change that. Now I talked about online care. There are medical home models being proposed by CMS and others where physicians who coordinate care for people with diabetes and other conditions are paid a care coordination fee that allows them to work with patients to coordinate care, but that requires an electronic health record because unless you have the data, you can’t really do it well. And let’s say you paid $50 a month per diabetic for care coordination, well, for 600 diabetics, that’s $360,000 a year of care coordination income that a practice might get. So actually those kinds of thoughts could not only modernize, especially primary care, the most on the ropes struggling area, yet it’s the foundation of our healthcare system, that if primary care physicians are paid for care coordination of people with chronic illnesses and the cost of those information systems could easily be borne by such a fee. And the example is that if Medicare, for example, paid a care coordination fee with strings attached that it was real, it was real quality improvement, they’d actually save money. Because if you take better care of diabetics, they lower health care costs immediately. If you improve a diabetic, you can save $2,000 per diabetic per year in their medical complications. I mean, the amputations disappear, the dialysis rates go way, way down, hospitalizations go way, way down. So there really are win, win, win scenarios out there that could even include doctors in private practice.

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