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An HIT Moment with … Jim Tate

January 31, 2009 News 3 Comments

An HIT Moment with ... is a quick interview with someone we find interesting. Jim Tate is president and eHealth consultant at EMR Advocate, LLC.

What’s the best way to use federal dollars to get physicians to use EMRs in ways that benefit patients?

The current Federal incentive program for e-prescribing that began January 1, 2009 is a good model to also encourage providers to document patient care in an electronic record. I would suggest that starting July 1, 2009 providers would be given a bonus (5%?) for every Medicare/Medicaid charge that was documented in a CCHIT-certified EMR. Reduce that bonus every year by 2% until it becomes a penalty (-5%).

The process would play out over five years and the requirement that the EHRs are CCHIT-certified would guarantee that interoperability would be a part of the adoption wave.

What tips can you offer physician practices for selecting and contracting for EMRs?

  • Take your time.
  • Designate one physician to become the EHR Champion and assume ownership of the process.
  • Talk to peers and ask them which EHR systems they use and what has been their experience.
  • Go online and see what other physicians are saying about the systems they are using.
  • Consider only systems that are CCHIT certified.
  • Narrow your list of vendors down to three or four before calling the companies for a demo.
  • If you are not comfortable with your level of expertise, locate a consultant to help with the due diligence and contract negotiation.
  • Make sure your expectations are clearly understood by the potential vendor.
  • When you ask for a quote, make sure it is for a complete and inclusive system. I have seen physicians sign a contract and then be told three months later that if they want an interface to their in-house lab it will cost $20,000.
  • If you are not really sure what should be in the contract find someone who can help you.
  • Do not assume anything.
  • Everything is negotiable until you sign the contract.
  • If you have a timeline for your implementation, make that part of the contract.
  • If you want the trainers to have at least one year of experience, make that part of the contract.

You really need to protect yourself and stay in the driver’s seat and do the things that will lead to a smoother implementation that will occur on your terms.

Assuming physicians buy systems that are CCHIT-certified and therefore theoretically interoperable, how will they actually interoperate for patient benefit?

jimtateInteroperability can occur to benefit patients in ways that could never have been possible with paper records. The ability to generate, receive, and display CCD (Continuity of Care Document) type files is part of CCHIT’s 2008 Ambulatory criteria. This ability to generate and receive a file composed of a patient’s demographic and clinical information is a good first step to ensure that information can be shared between physicians and different EHR systems.

Another standard of CCHIT certified systems is the requirement that the EHR must be able to receive laboratory results in a discrete format directly into the patient’s electronic medical record. The provider is notified of the presence of the lab result by the system, not by the nurse. The results can be compared, graphed and then messaged to the nurse for appropriate resolution. This leads to fewer steps in the workflow, fewer lost labs and increased efficiency in the process. 

Debate continues on whether today’s EMRs are good enough to be worth massive federal investment. Where do they fall short and what should vendors be doing?

It is apparent that Obama is preparing a massive federal program to accelerate the adoption of health information technology. Currently we are only at the early stages of interoperability and the subsequent ability to exchange and gather data. The capability to exchange and congregate this discrete data must be aggressively expanded to bring added clinical value. Also, the user interfaces of many EHRs are cluttered due to the high level of functionality. Design work needs to be done to make these systems easier for the users. 

What technologies are available today that can help physician practices, but are less expensive and easier to implement than full-blown EMRs and practice management systems?

As a project manager for numerous EMR implementations in both the US and China, I saw the great risk of trying to immediately adopt all possible functionalities in an EHR. We called it the “Big Bang”. It was good for the vendor, usually not so good for the providers.

In many clinics, the workflow has been created over years, sometime decades. To change everything at once is incredibly stressful and can lead to the failure of the EHR being embraced by the users. To implement in a modular fashion has the benefit of reducing stress and also minimizing the loss of productivity that usually takes place with the “Big Bang”.

Messaging, e-prescribing, e-faxing and receiving discrete lab results are all good examples of “first steps” that can get the provider into the electronic arena.

Comments 3
  • Jim,
    Can you please point out where exactly in the CMS guideline does it say that physicians must purchase CCHIT certified EMR system to received bonuses or otherwise will incure penalty?

    I went on CMS web site and found no such information pertaining to your above statement.

    Please clearify as to where you have found this information..
    Thank you,

  • I find disheartening that our current president and now software consultants have the guts to advocate how and what physicians in private practice earn. Who the hell is Mr. Tate to advocate a 5% penalty for docs that refuse to use the very c-EHR systems that he advocates for? This is tantamount to having a career envious used car salesman suggesting to the current administration how to hurt physicians. This must be what Obama considers “change” (for the worse that is). How low can we go?

    The reasons that 96% of physicians despise certified electronic health records (c-EHR) systems and thus are not purchasing c-EHR are that:

    1) Across-the-board do not offer a ROI. c-EHR systems are expensive, increase overall costs, and destroy an office’s work flow.
    2) c-EHR systems have not been shown to decrease errors, and on the contrary, have been shown to INCREASE them, introducing 22 new errors in one study.
    3) Purchasing a CCHIT-certified EHR is associated with a 20-40% installation failure and with an 8% deinstallation rate thereafter.
    4) CCHIT-certified EHR systems are not yet interoperable and in general do not allow data input like how physicians are used to- dictation, typing, inking.
    5) c-EHR systems have not been demonstrated to increase quality in large, non-vendor associated prospective randomized studies.
    6) Doctors generally consider most CCHIT features “bloat”.
    7) Doctors hate e-prescribing and CPOE.

    Let’s say that a physician who sees $100000.00/year worth of Medicare billings gets punished 5% for seeing Medicare patients without a c-EHR, and compare his situation over 5 years to a foolish physician who has capitulated to this atrocity. Let’s do the math:

    — The non-complying physician will lose $5000 a year x 5 years for a total loss of $25000.00
    — The foolish complying physician will lose 10% a year for maintenance fees and other “consultant” fees to keep his system running, AND he’ll lose another 15% to workflow losses and another 15% to the costs of entering in the data as well as reporting P4P for a total 40% loss per year, or (5 x $40000) + $44000 = $156000.00 total losses.

    Note: The above figures are **conservative** and could be higher. Also, they don’t take into consideration the fact that the complying physician could be told that he didn’t use the c-EHR significantly thus voiding his earmark. It also doesn’t take into account losses associated with installation failures or deinstallations.

    So the physicians without c-EHR systems will come out ahead after 5 years by a factor of 6!

    What will really happen is that Medicare will end up failing faster than planned when physicians end up running for the exit door and either opt out completely or become nonparticipating providers. This will turn Medicare into an empty shell where there simply won’t be enough physicians to care for the massive and still growing population of the elderly.


  • I need to change my calculations section a bit. I was being way too conservative:

    — “10% a year for maintenance fees and other “consultant” fees to keep his system running” should be “24% a year for purchase plus maintenance fee costs over 5 years…”, due to information that I just obtained from reading the article, “Finding a Cure: The Case for Regulation And Oversight of Electronic Health Records Systems”, Harvard Journal of Law & Technology 2008 vol. 22, No. 1, by Hoffman and Podgurski, discussed at http://blog.case.edu/case-news/2008/10/30/ehrregulation (and these authors are **for** regulation!)
    — the phrase “(5 x $40000) + $44000 = $156000.00” should have read “(5 x $40000) – $44000 = $156000.00”. Taking the above average purchase plus maintenance fee costs, I amend it now to read “(5 x $54000) – $44000 from stimulus bill = $226,000.00 to keep a more realistic conservative calculation of the true costs of certified electronic health records over 5 years.
    — I would like to add to the last conclusionary paragraph a quote about the underpayment of doctors in the Medicare program, taken from a 3/6/2009 WSJ editorial on page A15. It should now read:

    “What will really happen is that Medicare, which currently pays doctors 20% below what is paid by private insurance companies will begin to pay even less as it punishes them for not using c-EHR systems. This will force physicians to leave the program at a faster rate, creating a crisis when there won’t be enough physicians to care for the massive and still growing population of the elderly.”


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