Older physicians are less likely to use an electronic health record system than their younger counterparts. A recent Health Affairs study found that in 2011 30.8% of physicians older than age 55 were using a basic EHR system, compared with 40% of doctors younger than age 40 and 35.5% of doctors ages 40 to 55.
There are several reasons for the lower EHR adoption rates among older physicians. Some older physicians might not be as technologically savvy as younger doctors and thus are reluctant to transition to an electronic-based workflow. In addition, older physicians are more likely to work in solo or small practices, which face greater financial barriers to EHR adoption. Further, some older physicians say they'll be ready for retirement by the time they start to see any return on investment from EHR adoption.
Currently, older physicians who use a paper-based record system are not eligible for Medicare and Medicaid incentive payments under the meaningful use program. And, beginning in 2015, physicians who cannot demonstrate meaningful use of EHRs will be subject to a 1% reduction in Medicare payments. That penalty will increase by 1% in each subsequent year, eventually reaching 5%.
Push for a Hardship Exemption for Older Physicians
Arguing that older physicians face unique barriers when it comes to EHR adoption, some groups are pushing for CMS to include a hardship exemption category in the meaningful use program for doctors who are close to retirement.
In its comment letter to CMS on the proposed rule for Stage 2 of the meaningful use program, the American Medical Association called for an exemption for physicians who currently are eligible or will be eligible by 2014 for Social Security benefits.
AMA wrote, "It would be economically burdensome for physicians who intend to retire in the next several years to purchase, install and meaningfully use an EHR." It added, "We are also concerned that many of these physicians may decide to close their Medicare fee-for-service panels or opt out of Medicare to avoid penalties during the end stage of their clinical careers, which would adversely affect access to care for our nation's elderly and disabled."
An AMA policy expert said that EHR adoption is a significant investment both in terms of cost and time and that older doctors likely won't be practicing long enough to realize the benefits of health IT, such as improved patient care and efficiency.
She said that if a physician plans to retire within five years, it probably doesn't make financial sense to invest in an EHR system.
Without a meaningful use exemption for older physicians, such doctors could close their practices prematurely or limit the number of Medicare beneficiaries they treat, according to the AMA policy expert.
Rep. Renee Ellmers (R-N.C.) -- chair of the House Small Business Committee's health care subcommittee -- voiced similar concerns in a letter to CMS acting Administrator Marilyn Tavenner.
Ellmers -- who worked as a nurse for nearly 20 years -- wrote, "I believe that modern, well-equipped offices are vital to the practice of medicine, and that health information technology can help all health professionals to improve the delivery of care." However, she said that she believes the goals in the proposed Stage 2 rule "may be too ambitious" for physicians nearing retirement age, as well as those in solo or small practices.
Ellmers urged CMS to allow hardship exemptions for physicians who are nearing retirement -- those who are older than age 60 -- and for physicians in practices with five or fewer physicians.
EHR Adoption Still Worthwhile for Some Older Doctors
A CMS policy expert acknowledged that there is a generational divide when it comes to EHR adoption and that older doctors typically are more reluctant to make the transition to health IT.
However, he said that CMS has been very encouraged by the number of doctors in the older age brackets who are adopting EHRs and attesting for meaningful use.
Reavis Eubanks -- a solo-practice physician in western North Carolina -- adopted an EHR system in January 2011, at the age of 64. He attested to meaningful use Stage 1 in June 2011 and received $18,000 in incentive payments.
Eubanks said ignorance was the main thing that prevented him from adopting an EHR system earlier in his career. He said, "I really did not realize that it could be done affordably, and I did not realize the vast advantages that it would give me as far as efficiency and communication." Eubanks said, "If I knew what I know now, I would have done it a lot earlier."
Eubanks said his experience using a server-based EHR system at a hospital in his area gave him "insight into the some of the problems that could arise if [he] had his own in-house system." As a result, Eubanks selected a cloud-based EHR system from athenahealth.
One of the reasons Eubanks was attracted to athenahealth's product is that the vendor offered a guarantee to meet Stage 1 meaningful use certification criteria. Another big selling point was the significantly lower upfront cost.
He said, "You can adopt a cloud-based system at a much, much [lower] upfront cost. The thing that always comes up is, 'Yes, but you're having to pay that percentage [fee] every month.' But my retort to that is, 'Yes, but you're getting better and better services every month because the subscription-based company is not going to make any money unless the physician is making money.'"
Eubanks said EHR adoption "does have a learning curve and it does certainly have the potential of fairly adversely affecting the workflow," but "it doesn't have to be that way."
He said it is important that the physician doesn't "feel constrained to have to do it like the system tells him to do it, rather than the system being his servant and helping him accomplish things." Eubanks also said he made great efforts to ensure that his new EHR system did not detract from his interactions with patients.
As a result of adopting an EHR system, Eubanks said he has seen significant improvements in claims processing, documentation and communication.
Eubanks said he would encourage older physicians who are on the fence about EHRs "to adopt electronic records even if they weren't interested in meaningful use because of the benefits ... particularly communication with other people, good documentation and the fact that when somebody gets your record, they can actually read it." In fact, Eubanks said he would have adopted an EHR system even without the promise of meaningful use incentive payments.
Still, Eubanks sees a lot of value in the meaningful use program. He said the program "has asked us to do things that I believe any good physician should have been doing all along." He added, "And therefore even outside of return on investment, the criteria for meaningful use would be beneficial to anybody that's interested in providing good medical care."
The CMS policy expert said that the meaningful use is about improving patient care through better care coordination, reducing unnecessary procedures and boosting patient safety. He said that doctors of all ages understand how important better patient care is.
Eubanks said he does not believe there should be a meaningful use program exemption for doctors who are close to retirement age, noting that such a statement is "unusual for a very conservative individual to say as far as a government mandate." He said he believes the meaningful use program is trying to provide "good medical care ... so therefore, I don't think there should be an exemption."
Likelihood of a Hardship Exemption for Older Doctors?
In its proposed rule for Stage 2 of meaningful use, CMS asked stakeholders to weigh in on proposed hardship exemptions, as well as offer other exemption categories that they believe should be added.
Because CMS is in a period of rulemaking, the agency could not comment on the likelihood of the inclusion of a hardship exemption for physicians close to retirement in the final rule.
An AMA policy expert said AMA believes its recommendation for such an exemption is reasonable and noted that CMS listened to some of the group's feedback on Stage 1 of the program.
However, she said that AMA made similar hardship recommendations for CMS' electronic prescribing incentive program that were not incorporated into the final rule.
Still, the AMA policy expert said there's more at stake financially with the meaningful use program. She noted that EHR systems are significantly more expensive than stand-alone e-prescribing systems; the meaningful use program is long-lasting, while the e-prescribing incentive program ends in 2014; and the meaningful use penalties are more substantive than those in the e-prescribing program.
CMS plans to release its final rule for Stage 2 of the meaningful use program and detail the final exemption categories in late summer.