The American Health Information Community on Tuesday sent back for revision a list of recommendations by its work group on electronic health records aimed at boosting EHR adoption, including a controversial incentive proposal that would reward doctors who have EHRs and penalize those who do not.
David Brailer, co-chairman of the AHIC, a public-private policy healthcare information technology policy advisory panel created by HHS Secretary Mike Leavitt in 2005, asked fellow AHIC member and EHR work group co-leader Lillee Smith Gelinas to take the recommendations and tweak their language and have them checked by lawyers.
Finally, Brailer advised Gelinas, vice president of clinical performance at group purchasing organization VHA, that the EHR work group should “have some forum with an open hearing so we can have more debate” on the proposals.
The six proposals were:
- Leverage federal purchasing power by having the government, through its contracts with health plans and other payers, support widespread adoption of IT standards and "foster the use of pay-for-performance programs for physicians that include structural measures to incent the adoption and effective utilization of certified EHRs."
- The pay-for-performance schemes should use "reliable, standardized and validated tools which are currently available to assess structural measures as defined by the Medicare Payment Advisory Commission, such as the NCQA’s Physician Practice Connections or the CMS’ publicly available Office System Survey."
- HHS should continue to support the physician IT training programs now under way called Doctor's Office Quality-Information Technology University, or DOQ-IT U.
- HHS should work with the federally funded Certification Commission for Healthcare Information Technology, which tests and certifies EHR systems, "to obtain medico-legal counsel to assure that its functional criteria include documentation, security and other approaches that will mitigate malpractice risk."
- "Similarly, HHS should meet with medical malpractice insurers "to encourage premium reductions for those physicians who have adopted certified EHRs."
- "HHS should develop a schedule for implementing differential reimbursement to Medicare physicians for use or nonuse of EHRs. While we would defer to departmental expertise, we note that this might be achieved by paying full Medicare rates and marketbasket updates (and possibly an EHR premium) to physicians using certified EHRs, while physicians using paper-based records are paid at discounted rates achieved by nonqualification for full marketbasket updates or other measures."
Gelinas noted that market surveys show physician adoption of fully implemented EHRs remains in the 10% range. "What other industry would tolerate this?" she said.
But the proposals drew criticism from several AHIC members on several points.
Chip Kahn, president of the Federation of American Hospitals, said any measures used for pay-for-performance rewards should be approved by the National Quality Forum, the AQA (formerly the Ambulatory Quality Alliance) and the Hospital Quality Alliance, not MedPAC.
"I can't be against pay-for-performance; it's the fad of the moment," Kahn said. But he said he opposed a "budget-neutral" approach in which Medicare would take money from one group without EHRs to pay for the bonuses given to another that adopts EHRs.
"To imply that someone should be penalized and another one who is to be rewarded is problematic," Kahn said. "It's great to have an incentive program, but when you say budget-neutral, that means you’re going to penalize one and reward another."
AHIC member Douglas Henley, executive vice president of the American Academy of Family Physicians, joined Kahn in supporting the NQF and the AQA and HQA over MedPAC as better organizations to provide pay-for-performance measures.
Henley said the proposals were finally suggesting using cash to help physicians adopt EHRs, but Henley called for modifying the pay-for-performance provision to be more explicit as a pay-for-use scheme for EHRs.
"Within a health plan, the docs are getting paid to a fee schedule," Henley said, noting there should be "an additional pool of dollars for pay-for-performance." If a physician adopts an EHR, there will be additional payments, he said.
In an interview after the meeting, Kahn said one of the problems with offering incentives to providers for IT adoption is that buying a system doesn't guarantee it will be used effectively.
"There are no police out there looking over everybody's shoulder all the time," Kahn said. "So you don't know. Leapfrog wants everyone to put in CPOE (computerized physician order entry), but can you get all your doctors and nurses to use it? There were a lot of failures with CPOE.
"They don't have the recommendations worded just right," Kahn said. "I think they needed more work to be done. Making this a part of physician payment, I think it's important to provide incentives. If we have different types of pay-for-performance and pay for use, but if they're done where there are winners and losers, that's a problem from the get-go. Lillee admitted it takes years to get these into the work flow and use them so that patients will benefit.
"But from a public policy standpoint, to help serve the patient better, we're going to need to spend some money on IT," Kahn said. "And there is no financial incentive in IT for physicians. We're going to need to help them, whether it's through tax dollars or other means, we need to look at it."
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