When it comes to e-prescribing, apparently it’s fashionable to fall into the gap.
The difference between the potential benefits of electronic-prescribing tools and physicians’ actual use of commercial e-prescribing products is staggering, according to a report published last month online by Health Affairs
. (See May 7 “Recapping the News.”) This is at least partly because of products lacking advanced features or physicians not using them because of external implementation hurdles or a perception that these features didn’t have value, the report stated.
That finding is supported by a second report released last month that concluded that steps by the federal government to make it easier for hospitals to pay for physicians’ information technology has not boosted physician IT use, though industry officials at the time were anticipating help on the matter from the Internal Revenue Service.
That help came earlier this month, when the IRS issued a "memorandum"
that says not-for-profit hospitals may provide financial assistance to physicians to acquire and implement electronic health records without jeopardizing the hospitals’ tax-exempt status.
“There’s sort of a disconnect between efforts to get everyone onboard and what an individual physician is experiencing,” says Joy Grossman, lead author of the first study and a senior health researcher at the Center for Studying Health System Change, the Washington-based nonpartisan research organization that conducted the study.
The study concluded that most physicians who had switched to e-prescribing would not go back to paper. The report, Physicians’ Experiences Using Commercial E-Prescribing Systems
, is based on interviews with doctors at 21 different practices: four with between five and 10 physicians; five with between 11 and 20; six with between 51 and 100; and six with more than 100. “We talked to very different folks, but we got very strikingly similar results,” Grossman says. “There hasn’t been a lot of research ... on the nitty-gritty of what it takes to get these systems up and running.”
In exploring how physicians use e-prescribing and what created barriers and made the process easier, one constant that researchers found was that rollouts were difficult and required substantial human and financial resources. As a result, Grossman says, the researchers found no examples of “relatively simple ‘plug-and-play’ applications.”
While noting that electronic medical-record vendors may enhance their products’ functionality, security and interoperability to earn the Certification Commission for Healthcare Information Technology’s stamp of approval, the report stated that CCHIT doesn’t evaluate or compare the “usability” of different products and there is a need for such a process. Since CCHIT doesn’t do this, “Certification is unlikely to directly address many of the design and implementation barriers noted in this study,” the report says.
Rod Piechowski, vice president of technology leadership for the Chicago-based IT booster group the National Alliance for Health Information Technology, says evaluating usability is not a role for CCHIT or a government organization, and he compared the state of health IT with the early days of personal computers and how several companies emerged that published books and magazines that were helpful in guiding consumer choices.
“Maybe it’s something that will just naturally spring up again,” Piechowski says, suggesting that perhaps bloggers are filling that niche today. “As the need arises, someone will fill that need.”
And while CCHIT is expanding its interoperability standards, the report stated that physicians continue to rely on their patients as the main source of information when compiling medication lists because of difficulties obtaining a comprehensive list of medications prescribed by physicians outside of their own practice.
Although most physicians in the study had access to clinical decision-support tools, the use of these applications was limited and “there was general agreement that the pop-up alerts were triggered too easily, even when set to the most severe threshold,” the report stated. “As a result, physicians typically overrode them.”
The study was funded by the Agency for Healthcare Research and Quality, and Grossman says the agency was particularly interested in learning more about physicians’ experiences with e-prescribing. She says the general finding was that it was an oversimplification to say that financial concerns and physician unwillingness to change were the only barriers to IT adoption.
External barriers include system features that don’t work as advertised or unreliable information supplied by third parties. One particular source of frustration was inaccessible or out-of-date health plan formulary data. Even when physicians could access formulary information, the data were often old or incomplete, leading physicians to question their reliability, the report stated.
“That was one of the things I was surprised about,” Grossman says, adding that one practice participating in the study reported that a health plan provided it with its e-prescribing system—but then failed to supply the e-prescribing vendor with its formulary data.
Piechowski says that anecdote illustrates how, as IT transforms healthcare, “other organizations have new responsibilities to the system as a whole.” But he did not doubt the finding. “Another rock has been picked up and something else has been discovered.”
Grossman says the benefits from e-prescribing that physicians reported were usually “related to basic functions,” including improved legibility, better documentation and record-keeping.
Meanwhile, nearly two out of three chief information officers in the second survey indicated that federal actions taken last year giving hospitals a safe harbor from the federal anti-kickback law and exceptions to the Stark laws barring remuneration for referrals have not prompted hospitals to fund or extend their healthcare IT systems to physicians.
Last August, HHS’ inspector general’s office released a long-awaited safe harbor from anti-kickback statutes for IT investments. Simultaneously, the CMS published similar Stark exceptions.
But in a February Web survey of members of the College of Healthcare Information Management Executives, 62% of the 117 who participated indicated they “have no plans to take advantage of the new Stark exception and anti-kickback safe harbor laws,” according to a CHIME news release. The other 38% indicated they do plan to avail themselves of the leeway granted by the rule changes.
The relaxation of the rules was taken in hopes that it would boost clinical IT adoption by office-based physicians, where the adoption of full-function electronic medical-records systems remains in the 10% to 20% range, according to several surveys.
In a section on the CHIME survey reserved for written comments, respondents indicated one concern was with the change of party control in Congress and whether the exceptions might be altered or reversed, according to Anne Wizauer, spokeswoman for the group.
In addition, “A major concern is the IRS possibly questioning 501(c)(3) status,” Wizauer says, referring to the section of the tax code that gives many hospitals tax-exempt status. The IRS requires donations from tax-exempt hospitals to primarily serve a public benefit, not a private interest.
Wizauer’s fears were quelled earlier this month when the IRS gave hospitals the all-clear.
The IRS decision came in the form of a memorandum from Lois Lerner, director of the exempt organizations division of the IRS, to the directors of the rulings and agreements and of the examinations sections of the division.
In the memo, Lerner noted the decisions by HHS and the CMS that “some hospitals believe that their medical staff physicians need a financial incentive to acquire and implement EHR software that would allow the physicians to connect to the hospitals’ EHR systems."
IRS spokeswoman Nancy Mathis says the memo was a "field directive," an internal document directing officials within the IRS how to carry out agency business. When it comes to the IT issue, "I think it is our final answer," Mathis says.
Tom Hyatt, a healthcare attorney with the Washington law firm of Ober, Kaler, Grimes & Shriver, says the ruling will be good news for some hospital leaders. "I've got several systems that have contacted me periodically saying, has the IRS said anything yet? They've really been waiting for this to come down," Hyatt says.
"I think it is a very good thing.
"I think many systems have been developing electronic health records, but the key is getting the physicians into the loop. Many systems I'm familiar with have been on hold waiting, (wondering) whether there is going to be a private inurement problem. This is going to be a green light."
Lawrence Hughes, regulatory counsel for the American Hospital Association, agrees with Hyatt that the IRS ruling was clear enough that it should assuage hospital officials' legal worries about IT assistance.
"I think that the IRS statement is a good signal to hospitals that they can move forward with their IT arrangements with physicians and we are pleased that IRS moved so quickly," he says. "We brought the issue to the IRS very specifically in the fall."
Scott Wallace, president and chief executive officer of the NAHIT, was upbeat about the impact the ruling would have on hospital IT sharing programs, saying without the IRS clarification, "The Stark revisions were kind of hollow.
"It was a huge issue and getting such a broad statement of support was important," Wallace says. "I think this is big. The providers want to connect physicians. They have a solid business rationale for doing this."