Q&A: Dr. Steven Waldren On What's At Risk With E-Health RecordsQ&A: Dr. Steven Waldren On What's At Risk With E-Health Records

Dr. Steven Waldren
American Academy of Family Physicians

Dr. Steven Waldren is director of the Center of Health Information Technology at the American Academy of Family Physicians, a group that represents about 94,000 family physicians and medical students. He's closely following the government's effort to craft a definition of what constitutes the meaningful use of electronic health records and prepare to kick off the federal incentive program to get doctors using EHRs. He recently spoke to information senior writer Marianne Kolbasuk McGee about the upcoming requirements, what's at stake if doctors don't adopt EHRs, and the challenges physicians face.

information: What's the biggest risk for doctors' practices if they don't adopt health IT?

Waldren: The biggest risk is not being able to move forward with other reforms in the way we pay. Currently, the vast majority of payments are fee for service, based on volume, not about quality in the care doctors provide to patients. There's a lot of talk about changing that. If physicians don't adopt technology to support them in this paradigm shift, they're at a much higher risk at not being able to keep up with the demands of quality reporting in order to thrive in this new model.

information: So not getting on board with HIT put doctor practices at a great disadvantage for the other reform changes under way?

Waldren: Yes. And in the very short term if they don't get moving, the issue is capacity in the market place. A lot of vendors, depending on what numbers you pick, estimate that on the high side 30% of the physician market has product. But that 30% was built up over the last two decades. If another 30% try to get on board in the next year, I don't think the vendors have the capacity to meet that demand. So, there's a concern that if people wait too long because the uncertainty's gone, because we have a final meaningful use rule, because products are now certified and I can be pretty confident that the products that I pick will allow me to meet meaningful use requirements, then those vendors may end being so saturated that it will be impossible to get up and running in the first year to qualify for the incentive money.

information: What about hospitals that are offering hosted EMRs and free software under the federal Stark regulations, as well as the Regional Extension Centers and the Beacon Communities. Will they help with the mad rush?

Waldren: They will help some. But there are two pieces to adoption. There's the selection and preparation process, and then there's implementation and ongoing work to get up to meaningful use compliance. The Regional Extension Centers and hospitals have the ability to facilitate that selection and preparation. Implementations are specific to the vendor so the vendor has to do that. Some of these Regional Extensions Centers might take over that but I don't think that's a very viable model.

After the go-live, where you get into process redesign and using the system, there are some opportunities for Regional Extension Centers and hospital folks to help.

The notion of being able to offer a hosted service model is appealing to a lot of docs. One thing we've seen over last couple years is that for hospitals, the incentive to offer subsidized software to doctors under Stark rules was limited. What was the real value for a hospital? It wasn't "If we get all the docs and community connected, we'd be so much better off from a business standpoint." It was more about loyalty and those types of things. So the hospitals said, "You can use our hospital based product," so if they had Cerner or Meditech, they'd offer the ambulatory component to that. But that might not be the best product for a small or medium practice. That was one of the concerns about small practices and Stark: Physicians were being offered product that really wouldn't work for them. But now we're starting to see with reform and the potential of readmission to the hospital in 30 or 60 days being "never events" [not reimbursed by payers] that hospitals are getting more concerned. They want practices to work more efficiently because hospitals won't get paid by Medicare and other payers for those readmissions.

information: Are doctors afraid of becoming too beholden to hospitals if they accept free software or let a hospital host their patient data?

Waldren: I think hosting data gets a little tricky. Technically and in the real world there's not much difference between a hospital and a vendor hosting data as an ASP model versus a client server model in a practice as long as the privacy policies and data use policies are appropriate. But the big concern is once I get on a particular product offered by the hospital with some sort of package support, am I actually going to be able to get that support and what happens if it doesn't work for me, where do I go?

There's an opportunity for hospitals to offer some technical assistance, so if a practice needs to set up its network, maintain computers do some basic troubleshooting, help with connectivity, I don't think there's a dependency issue there. If I decide to stop, I still have control over the technology. In the marketplace, you'll see a wide group of doctors who don't want anything from a hospital to those that are happy to take the hosted product and have hosted data.

information: Some think there's potential for a lot of consolidation among small practices. For example, if small practices team up with others or larger groups, maybe they'd have an easier time tapping the technical resources they all need. What do you think?

Waldren: It's been a pendulum swinging back and forth. There were a lot of practices that were independent and solo, and then in the late '80s and '90s with managed care, all these hospitals bought up all these practices. Then in the late '90s, hospitals sold them all back to the doctors. And everyone is independent again.

Now there's talk about hospitals wanting to buy a lot of these practices up again to create Accountable Care Organizations. There's a chance that might happen, but I think there's an opportunity for independent practices to create these virtual ACOs with the technology available today helping to virtually integrate these disparate entities. With the technology, you don't have to have the actual integration where, "I now own you," or "I now join his group," though I think some of that will happen.

information: Where do you see technology fitting in with the ACOs? Is it for coordination of care or helping to facilitate quality care as a team?

Waldren: The technology we built over the last couple decades as an industry really isn't the right technology. It's all about billing and documentation. It's not really about delivering good, high quality care reliably. And that's what ACOs are trying to do. There's a component of technology that needs to be there for basic communication, making sure the information can flow where it needs to flow in a secure manner. So when there's a primary care doc who sends a patient to the cardiologist, all the data and what the primary care doc wanted the specialist to know is right there and readily available when the specialist sees the patient or even before.

There's another set of technologies to do more things more effectively than you do today, like e-visits, e-consults, virtual visits with specialists so that instead of seeing the endocrinologist, a video screen pops up in the primary care doc's exam room while the patient is there, and the doctor talks to the specialist about the patient's condition and decides whether the patient should be seen or what the patient can try instead. Those types of things ACOs allow with a different pay model.

The whole ability to measure quality and managed populations, those are chunks of technology ACOs will need to do. There's also the communications piece, population management and analytics, and the ability to leverage technology for new delivery models that are more efficient than what we have today.

information: The meaningful use rules aren't finalized yet and assuming the final rules stay close to what's been proposed, what are the biggest hurdles for doctor practices to meet the criteria and be eligible for incentive payments from the federal government?

Waldren: The uncertainty right now is the biggest challenge. When we get the final rule, we still won't know what'll be required for Stage 2 in 2013 or Stage 3 in 2015. So as people are trying to select vendors, you can quickly say you can achieve Stage 1 compliance, but there's uncertainty you'll be able to do Stages 2 or 3.

Another big challenge with Stage 1 as the rule's proposed is the "all or nothing" rewards. I have to do all 25 HIT functions and potentially eight measures for primary care, and if I miss one of those, I get no money.

So, from the standpoint of the physician, if you purchased a product that's certified and you do everything, and you report it appropriately, you'll get your checks for five years. But if you miss one measure, you don't get 80% or 50%, you get zero. So physicians have to take on faith that they'll get to that point of getting $44,000 [the max incentive for Medicare doctors]. Some kind of partial payment or tiered approach is needed.

We've had a pretty poor track record with the Physician Quality Initiative, or PQI, [in which Medicare] was supposed to give docs 2% if they submit quality data. A lot of physicians submitted this data for a year and never received their checks or if they did, it was two years late. It's been a poorly managed process. And there's worry that this will be the same. We've talked to folks at Centers for Medicare and Medicaid Services and Office of National Coordinator, and they assure us that they recognize this problem, and they won't have that same problem with meaningful use. But doctors already have that sour taste in their mouths.

information: What's at stake if doctors and hospitals don't achieve data exchange?

Waldren: When it comes to hospitals' readmission rates and the potential for "never events" where payers won't pay for them, that's the bigger financial impact to hospitals than the meaningful use bonus. So hospitals will be trying to figure out interoperability with those primary care practices so that when patients get discharged, they see their primary care doctors for appropriate follow-up care so that they're not back in the emergency room in 30 days. That's what will really drive this interoperability. That's what driving hospitals at a business level to buy these practices or partner with them because then you can put them under contract where you say, "if you don't see these discharged patients in 30 days, then there's a penalty associated with that." Or "you can get a bonus if you see so many patients within a two-week period after discharge."

information: What’s your best estimate in the percentage of doctor practices meeting the meaningful use requirements and avoiding the penalties?

Waldren: Avoiding the penalties, I have no idea because they don't start till after people have to be moving to Stage 2. Where Stage 1 is defined now, I would say it will be very difficult for practices to achieve meaningful use, and I would put it in 5% to 15% of physicians will be able to qualify with the proposed rule. And I've heard this from many officials in CMS and ONC--the proposed rule is a trial balloon. It was a bit aggressive, and they knew it was open for comments and that they could refine it. So I think the final rule will change significantly from the proposed rule. But again, as it stands today, it will be very difficult for physicians to qualify for the proposed requirements.

information: There are some groups pushing for the meaningful use deadlines to be pushed later to give healthcare providers more time. Do you think there's a chance that will happen?

Waldren: I don't think the timing will change much because there's so much in the law that restrains the regulations. I was pleased that they allowed for the first year of reporting to be only 90 days instead of the full year. That gives people almost an extra nine months to work on this.

information: Will the maximum of $44,000 in incentives for Medicare doctors be enough to cover the cost of these technology investments by physicians?

Waldren: It will likely cover the technology itself, but the cost of the process adoption, probably not. But I think it would pay for a large chunk of that. The bottom line for me when I'm talking to our AAFP members is that they shouldn't be trying to achieve meaningful use to get to the $44,000. They should decide to move forward, because it's the right thing to do for their patients, their practice, and for them. Then say, "ok, now that I know what I want, I know what my vision is, I know what I want my practice to be and how technology folds into that, let's look at meaningful use and what I need to do. Then I step up my timetable to meet the meaningful use demands and required reporting to get the $44,000."

In my view, if you try to get the cheapest technology you can to meet the meaningful use Stage 1 check list, you'll probably spend more money than if you say "I want to deliver high quality care for my patients, and I want to use technology to do that."

$44,000 is a big chunk of money for a medium-sized practice; EHRs in client-server environments have cost $30,000 to $50,000 per physician. So it's an incentive physicians should try to gain access to.