The federal stimulus funding of electronic medical records—up to $44,000 over five years—was constructed cleverly: Get the EMRs, doctors have been told, and use them in a way that meets the standards. If you can’t meet the standards, forget about the $44,000.
So said Michael Oppenheim, MD, chief medical information officer at North Shore Long Island Jewish Health System, New York, when he spoke Oct. 29, 2010 before the Compass Group of IDN Laboratory Leaders. They met at North Shore LIJ for one of their biannual gatherings, and Dr. Oppenheim was one of two facilitators of a roundtable on EMR adoption by health systems and physician offices. (The Compass Group is composed of lab leaders from not-for-profit integrated delivery network, or IDN, health care systems.)
“We found that for a lot of our physicians, the $44,000 was not enough,” Dr. Oppenheim told the IDN lab leaders, reciting the litany of reasons he heard: It won’t be enough to cover my expenses. I’ll lose productivity. I’m going to be retired by 2015 (when the payment penalties kick in). It’s going to be another Cash-for-Clunkers giveaway.
So North Shore LIJ set out to entice its physicians further, he says. “We created a program in which we would subsidize, above and beyond whatever the Feds are giving the docs,” based on the Stark safe harbors and through a partnership with Allscripts.
To the doctors, North Shore said: “If you just want the EHR to pop data back and forth when your patients come to the hospital”—to share data for treatment, that is—“we’ll subsidize you 50 percent of what is allowed under Stark.” That’s what North Shore LIJ calls its connected program, Dr. Oppenheim said. If the doctor chooses to be in what North Shore calls its integrated program, the subsidy rises to 85 percent.
What do the physicians have to do for the 85 percent subsidy? “Submit quality data and specific specialty metrics that we mutually agree to—that is, support North Shore’s population health initiatives.”
Was the dollar differential enough to overcome physicians’ suspicions—“Why are you doing this?” and “You’re just out for my data”—and have them opt for the integrated program? Yes. Ninety-eight percent of all who have signed up in the year since the program was launched chose the integrated program. “So money talks,” Dr. Oppenheim said, noting Forbes Magazine’s take on the program in a Sept. 27, 2010 story titled “Bribing doctors to go electronic.” (North Shore’s salaried physicians are in on the plan, of course, but so too are the physicians in the community.)
As of the Compass Group gathering last fall, 90 physician practices had signed on. Twelve were already live, and 10 were in the implementation phase. “Others are queued up beyond that,” Dr. Oppenheim said, “and we’re continuing our outreach and continuing to see interest.”
Compass Group members shared what their own laboratories and health systems are up to with electronic records. But first, Robert Stallone, vice president of laboratories at North Shore LIJ, and Dr. Oppenheim exchanged a few thoughts. Here is just some of what they and others said around the table.
Robert Stallone, North Shore LIJ Health System: I feel like I’ve been here before. It was a years-long battle about who was going to own the physician’s desktop. We ran to get portals put into physicians’ offices, the idea being that if I had a PC on a physician’s desk, he would use the lab and it would be hard for him to move.
Now we have the government jumping in and more clinical information and perhaps models that say there’s going to be value in physicians using and sharing data to improve care. And the government says, ‘I’ll give you $44,000 to do this.’ So it sounds like the 300,000 physicians out there may want to do this, if $44,000 over three years means anything to physicians. Or is it that they don’t know what’s going to happen in 2015—whether they may start losing money?
Michael Oppenheim, MD, North Shore LIJ: I’ll speak to the response we got from our physicians. I think very few of them would have jumped for the $44,000 alone. The subsidy alone probably would not have done it for our doctors and most of them were already calculating what they were going to lose on the two percent Medicare penalty in 2015 over what they were expecting the cost of the EMR to be and what the productivity loss might be to their office. That’s always one of the biggest concerns for physicians: Will automating the office make me less efficient for my patients? And in some cases it probably would.
So the value proposition was unclear. The more forward-thinking physicians in our population are seeing the writing on the wall. Not so much for the $44,000 or the two percent penalty or the North Shore stimulus per se, as much as: This is an inevitability of medical practice, and at some point the patients are going to start voting with their feet and saying, ‘Who would go to a supermarket today where someone was punching in numbers and producing a register tape to add up.’ You wouldn’t walk into that store.
The more forward-thinking physicians are recognizing this is a reality of practice in the next decade or two decades and ‘God help me if I’m catching up later. Let me take the opportunity of the stimulus bill and/or the North Shore subsidy to get ahead of the curve and get in before I suddenly start losing patients.’
But I’m not sure the financial incentives alone ever would have been sufficient.
Robert Stallone: Our experience with EMR vendors is that the time frame for interfaces is related to the fact that many of them are smaller. They don’t have resources. You could wait six months for a vendor to work with you. Never mind what you could do. Your own resources are irrelevant in many cases.
That said, what are our options? We can provide our own EMRs, such as North Shore and others are doing, but you can’t mandate the practices use your lab. You can partner with an EMR company with which you can go in shoulder to shoulder. Or you can just do interfaces. So, you have three options: You have an EMR, you partner with somebody to put one in, or you interface to one. All of those have components that are out of our control.
How do we, as health systems, if we’re putting these in, tell the story? Is it a strong enough story to say that if you use the one with the health system, that EMR from a laboratory standpoint would add more value to your practice and the way you treat your patients? That’s an integration question. And do we have enough information, and is there a good enough story to tell, that gives us an advantage over our competitors? I would like to believe that, but I’m not sure.
Michael Oppenheim: The story of completeness of data sells well in the EHR piece of this in that we’ve created the EHR offering with a series of interfaces or planned for a series of interfaces that incorporates just beyond laboratory but also radiology, eventually the hospitals, other things. It becomes a differentiator in the EHR piece whereas Joe Salesperson, who’s selling eClinicalWorks or Logician or whatever they’re peddling, can’t make the same commitment to a broad set of data. When it comes to any one subset of data and a story of completeness, the doctors will hear the same story from competitor labs who will tell them that through a RHIO [regional health information organization] or through other arrangements, they’ll get everything they need anyway and so there’s no need to worry about it.
I don’t think we know yet. We have only 12 practices. We just started doing this. The amount of data our laboratory has because of hospital encounters and other things is potentially of tremendous value, but we have yet to see whether the market is going to buy it, whether the doctors are going to believe what we’re telling them, whether they’re going to believe what the competitors are telling them. We don’t know the answer yet.
Priscilla Cherry, president of laboratory services, Fairview Health Services, Minneapolis: We use Sunquest as our laboratory solution and we have about two direct interfaces with a physician office EMR that took us an enormous amount of time to implement due to limited IT resources.
We use Atlas as our outreach solution and we will be using Atlas in the future to connect to any physician office that has an EMR due to our limited IT resources. We are in the midst of an implementation that is using all of our IT manpower.
We use Epic now in all of our outpatient clinics and we are just employing Epic into our hospitals. Allscripts is used now but will be replaced by Epic.
We recently offered to a highly affiliated group of physicians, not employed by Fairview, what we call Epic Light, which qualifies them for the government money and fits the meaningful use criteria. With Epic Light they have to agree their information can be sent to a data warehouse, and they have to agree to common protocols, common order sets, because we’re in the process of building a network of medical homes. This is important so that the care is the same throughout the patient experience. We want to build loyalty with these physicians so they will send their patients to Fairview, which provides continuity of care by connecting the inpatient and outpatient experience. It also provides the patients, if they go to one of the medical homes, the ability to use a ‘My Chart’ feature that enables them to look at their results online, e-mail their physicians, get messages, etc. It’s a neat product.
We’ve had good participation from the physicians who are not Fairview employed who are taking advantage of the Epic Light offer. They seem to like that product with the incentives, and it’s tiered, in terms of how much they have to pay, depending on the level of help they want with implementation.
It’s hectic and chaotic now with having both Epic inpatient and Allscripts inpatient EHRs, and we just went live with Epic in two hospitals, but that problem will clear itself up by this time next year when everyone will be live on Epic. We went live with the two small hospitals first to try to figure out what the problems would be.
Ronald Workman, MD, vice president of system laboratory operations, Sutter Health, Sacramento, Calif.: Sutter Health is a very large system. It has a regional governance model, so a variety of decisions on physician EMR deployment have been made. We have also concluded that the portal concept isn’t viable and that the multiplicity and variety of physician EMRs aren’t going to allow the system to accomplish its clinical integration objectives either. The variation and complexities may not fit with the medical home concept, for example.
Also, as an outgrowth of our physician strategy we believe we need fewer but deeper relationships. There are about 5,000 physicians in our market with whom we seek these relationships. About one-third of them are members of our not-for-profit clinics and on Epic already. Of the remaining two-thirds there is a relatively low rate of adoption of ‘real EMRs’ that have the ability to share data, do order entry, and so on. And we think the quickest way to close the gap is with that Epic Light type of product or suite of products, similar to what Fairview Health System uses. We believe that will help physicians meet the meaningful use requirements.
Some have tried to put a pencil to the cost estimate of the subsidy and investment it would take to do this. It might be more than $100 million. As a result, we have concluded it does not make sense to invest in any non-Epic products for our ambulatory care relationships.
However, we will support some EMR connectivity relationships while this transition or investment process and adoption goes on, and those will include NextGen, Allscripts, and Centricity. And we have also concluded that we don’t want to rely on a primarily laboratory-based outreach plan or relationship as a driver, going forward. Instead, we want to try to conduct the laboratory relationship in conjunction with other services through a connectivity solution with physician EMRs through such systems as the Medicity or RelayHealth products.
Like others, we’ve made a substantial commitment to Epic, but we have not felt that the lab information system part of Epic is ready for deployment, at least as of now.
Frederick Plapp, MD, PhD, St. Luke’s Health System, Kansas City, Mo.: St. Luke’s Health System has settled on McKesson as its information provider, and we use that for laboratory, pharmacy, just about every module we have for inpatients.
About 50 percent of our physicians now are employed and for those practices they’re installing Allscripts as the electronic medical record. We also have partnered with RelayHealth, which is now also a subsidiary of McKesson, as a Web portal, and it’s being offered to physicians who have EMRs and to those who don’t as a way to communicate with the health system.
For providers, RelayHealth offers results distribution including lab, radiology, and transcription. It has an order manager. It offers e-prescribing, and it has doctor-to-doctor and doctor-to-patient messaging capabilities.
For patients, RelayHealth allows them to make appointments, to renew their prescriptions, to keep their personal health record online, and it allows them to synchronize with Health Vault or Google Health or any of those applications. They can also look up laboratory results. That’s something we’re still working with, what we call St. Luke’s Care, to decide at what time they’ll allow us to release those records directly to the patient. There is also education on the site to educate the patients about their conditions.
Eventually, RelayHealth is going to have a progress notes writer included with it, and that may allow it to serve as a mini EMR for those few very small practices that might survive in the future. That might be a solution for them without their having to invest in a full EMR, and the company thinks eventually it would achieve [meaningful use] certification.
We have an organization called St. Luke’s Care. It’s our best-practices physician organization. Physicians get financial incentives for joining this organization, but in return they have to agree to use our practice guidelines and to share their quality information. If they are a member of St. Luke’s Care, then the St. Luke’s Health System has committed to help subsidize the installation of their electronic medical records and RelayHealth. Laboratory orders are not now coming through RelayHealth but the plan is for them to do so.
Sheryl Wilson, senior executive director of laboratory services, Alegent Health, Omaha: Alegent Health uses Siemens Soarian as the enterprisewide HIS and has chosen NextGen as its physician office EMR. Our employed physicians have this EMR or are in the process of implementing it. About 50 percent have implemented NextGen, which includes order entry and results reporting from the laboratory.
Implementing an EMR has been disruptive to the clinics’ processes. They feel they have lost a lot of efficiency because now they’re doing the lab’s work of placing the electronic order for their specimens, which takes more of their time than filling out a paper requisition. The clinic staff don’t own that process, so do not always complete the ordering correctly, making it disruptive for the laboratory as they’re doing a lot of rework on the back end.
Soarian is interfaced to a statewide project, called Nebraska Health Information Initiative, or NEHII, and all of our lab results, including outreach and outpatient results, are posting into that database and have been for about the past year and a half.
Jessie Salk, CEO, TriCore Reference Laboratories, sponsored by Presbyterian Health System and University of New Mexico Health Sciences Center, Albuquerque: We support two separate and distinct health systems, University and Presbyterian, that are competitors in the market but collaborate on laboratory services.
We have a complex environment. We provide all laboratory services for the university, which uses Cerner, and Presbyterian, which uses Epic and McKesson, and six rural hospitals that use their own hospital information systems. Although the laboratories all use Sunquest, it creates a complex interfaced environment.
In New Mexico we have a fledgling HIE [health information exchange]. The same organization leading the HIE initiative is also developing an ‘extension center.’ New Mexico has been granted $6.4 million over a period of several years to implement and support EMRs for physician practices of fewer than 10 physicians. The extension center and the $44,000 subsidy will escalate the pace at which EMRs are implemented in New Mexico and test our capability to provide connectivity to multiple EMRs. We use Atlas and Cloverleaf now and are in discussions with other vendors to streamline the process.
Norman Gayle, executive director, Regional Medical Laboratory, St. John Health System, Tulsa, Okla.: As it relates to the laboratory and interfaces we are extremely busy, so much so that we have a team dedicated to the interface process, and over time we have perfected to some extent the art of interfacing. We have an interface project lifecycle, which we follow to achieve success. There’s truth to the statement that if you’ve seen one interface, you’ve seen one interface. However, we’re making significant progress.
We were one of the early adopters of the Atlas LabWorks product—we have more than 200 deployments of LabWorks. About 120 of those are bidirectional, and the others are results only. We can implement Atlas quickly. Our CEO believes that, as a major player in the greater Oklahoma/Southeast Kansas market, our arsenal has to have everything in it. We have to be ready to meet the demands of our diversified community.
We have also implemented interfaces to some of the major integrators such as Emdeon, Ignis, etc... We have done and continue to do an extensive amount of EMR direct interfaces—everything from the NextGen, Allscripts, GE Centricity, eMDS, eClinicalWorks, etc... We have done major interfaces with practices of 30 or more physicians to single physician offices. We have also implemented interfaces to systems that are specialty specific as well as interfaces to major hospital-based EHR systems.
Stan Schofield, MS, MT(ASCP), president, NorDx, MaineHealth, Scarborough, Me: Our story is similar: numerous challenges, numerous systems, fragmented health system. The health system, though, in the past year has been moving quickly to an Epic enterprise solution for all sites, all facilities, all 600 employed doctors.
The Epic system has a shortcoming with the laboratory information system, so we will remain at NorDx with SCC Software with its multisite capability, and all the hospital laboratories will go to the Soft system because we’re managing and running most of the hospital laboratories today. The rest will still work off of our system.
We have interfaced several hundred electronic health records. We have our own Cloverleaf devices. For connectivity we use NorDx Now, which is a Copia product that we helped Orchard Software develop, and it works well. In the past year, we’ve done more than 60 EHR interfaces from every brand, ranging from your mom’s garage to the big ones.
Of the physicians in the state 10 years ago, 30 percent were employed. Almost 60 percent of all physicians in the state are now employed by a hospital or health system. It’s moving quickly and includes numerous subspecialties—neurosurgeons, trauma surgeons, urologists, cardiologists. They’re all lining up, picking teams.
At the moment we’re starting to build a real data warehouse. We’ve been talking about it and dabbled in it for a few years now. Our current interface capabilities run about 45 days to do an interface, with a target this year to knock it down to 35 days.
In my view, Epic is the giant black sucking hole that will vacuum all the money out of the health system, and I have deep concerns. The opening tab is $145 million and I think that’s just a down payment.