Anyone who keeps up with iHealthbeat knows by now that our friends at the IRS recently took a stab at removing another of the seemingly endless barriers to getting doctors to use electronic health records.
The IRS document, a short memo whose subject is "Hospitals Providing Financial Assistance to Staff Physicians Involving Electronic Health Records," is intended as an internal policy guide. If you haven't read it yet, take a moment to do so. It's a curious document.
Clearly, the IRS is trying to be helpful. It seems that its objective is to allow not-for-profit hospitals to provide financial support to doctors who have staff privileges and are seeking to acquire interoperable EHRs. The IRS states that it "will not treat the [health IT] benefits a hospital provides to its medical staff physicians as impermissible private benefit or inurement" if the benefits fall within the range of HHS health IT fraud and abuse safe harbor and exception," which HHS published in August 2006. Very nice, good to see interagency coordination. So far, so good.
But wait a second. IRS goes on to say there must be a "health IT subsidy arrangement," which provides that "the hospital may access all of the EHRs created by a physician using the health IT items and services subsidized by the hospital."
I think the IRS goes off the track here. What if a physician, with staff privileges at more than one hospital, uses the EHR for all of her or his patients? What about patients who have never been to the particular hospital providing the subsidy? Does the hospital get access to all of the doctor's patients' medical records?
While the IRS memo uses the word "interoperability," I suspect IRS officials understand the technical implications of the word but don't quite get the policy implications. Interoperability is not just about different health IT systems being able share data accurately and seamlessly. As HHS rightly articulated in its policies, interoperability also is intended to avoid having physicians technologically tied to a particular hospital. The IRS should clarify that EHRs subsidized by a particular hospital may be used by the physician in caring for her or his patients, regardless of whether the patient has been to that hospital.
Hold on another second. The health IT subsidy arrangement requirement seems to create a one-way street; hospitals get access to the physician's records, but what about physicians having access to the hospital's records for their patients? EHRs have to be bidirectional if they are to help clinicians achieve the levels of quality and efficiency that patients, providers and payors require. Doctors need access to images, lab results, chart notes of other physicians and other data stored in a hospital's systems if they are to have a complete view of a patient's health status and history of care.
I hope the IRS didn't intend to limit clinicians from using hospital-subsidized EHRs for all their patients or preclude two-way data sharing. But reading the words of the policy sure leaves that implication. Hopefully, there will be a quick clarification. If not, the value of the new policy -- intended to facilitate EHR dissemination -- would be limited to the point of being meaningless.
Even then, let's not kid ourselves. Removing fraud and abuse law and tax barriers -- real or perceived -- to allow hospitals to provide physicians with EHRs is a good thing and will help to accelerate the use of EHRs. But the challenge of physician utilization of EHRs is far more complex then simply installing technology in physician offices. Physician use of EHRs will really take hold when physicians perceive them to be tools of real value that allow for the delivery of better care more efficiently.
Reducing regulatory barriers to the use of EHRs is important, but other steps are likely to be more essential. Some of those steps are:
- Making available EHRs with intuitive interfaces that allow the technology to the be transparently integrated into the process of care;
- Re-engineering the clinical processes of physician offices -- including office architecture and design, staffing and patient flow -- to optimize the implication of EHRs; and
- Perhaps most importantly, achieving better financial results for physicians. This could include creating new reimbursements or simply permitting doctors to practice more efficiently, which would allow them to care for additional patients (or maybe get home a half hour earlier to see their kids).
Having pretty much knocked down the regulatory barriers, it's time for federal decision makers to begin to look at other ways to accelerate physician use of health IT.
The GAO: Time to Profile Physicians
The convergence of the expanding dissemination of health IT, increased clinical data reporting and the drive toward greater clinical efficiency and quality seems to be accelerating. But IT is just one part of the solution. Another major factor in efforts to improve care quality is making sure that physicians are performing at a high level.
Before a May 10 hearing of the House Ways and Means Committee's Subcommittee on Health, the Government Accountability Office testified that there is sufficiently reliable data to begin identifying physicians based on the quality and efficiency of their care.
GAO at the hearing testified that, "Medicare's data-rich environment is conducive to identifying physicians who are likely to practice medicine inefficiently." Further, "CMS has the tools to make statistically valid comparisons, including comprehensive medical claims information, sufficient numbers of physicians in most areas to construct adequate sample sizes and methods to adjust for differences in patient health status," according to GAO.
This is big stuff! The use of data by the largest health care payer to identify doctors who underperform in comparison to their peers is huge! It's transformative! It's disruptive! We're talking real system change here.
So what's to be done with this data? Well, at the same hearing, there was talk about using the data in private discussion with the poorly performing physicians to show them the errors of their ways and, in doing so, to get them to improve. It makes sense and has been shown that underperforming physicians, when confronted with comparative data, have changed their style of practice.
But is that enough?
GAO suggests going further: "In our view, Medicare should adopt an approach that relies not only on physician education but also financial or other incentives -- such as discouraging patients from obtaining care from physicians who are determined to be inefficient."
Is such an approach politically feasible? It just might be. Doesn't providing patients with information on inefficient doctors fall squarely within HHS Secretary Mike Leavitt's transparency and value-driven health care initiatives? Certainly tying financial incentives to efficiency is part of the "pay-for-performance" strategy that is being slowly advanced by the feds (but which has already shown real effect in California).
In the hopefully not-too-distant future, consumers and payers health care decisions will be informed by the kinds of comparative data that will result from ubiquitous use of EHRs. The efforts of the IRS, GAO and other federal agencies seem to be headed in the right direction, even if in fits and starts.
About the Author:
Bruce Fried is a partner and co-chair of the Health Care Group at Sonnenschein Nath & Rosenthal LLP. He can be reached at bfried@sonnenschein.com.
The views expressed in this column are those of the author and do not represent the views of the California HealthCare Foundation or the Advisory Board Company.