Juggling patient loads, staffing headaches and insurance claims, doctors in small practices aren't likely to squeeze in time to map out a new office computer system--unless they think something big is on the line.
"The future of medicine is at stake for these physicians," says David Kibbe, M.D., director of the American Academy of Family Physicians' Center for Health Information Technology and the administrator of Doctors' Quality Information Technology, or DOQ-IT, a new program to match doctors in small practices with electronic health-record systems.
Despite the prospect of extra work, Kibbe is finding it surprisingly easy to convince doctors their offices need to have a comprehensive health information technology system. They are painfully aware that crossing the digital divide would help provide feedback on patient care, standardize treatment, help with billing and make it easier to catch potential errors, Kibbe says.
"They are very aware that paper-based records are hazardous to their patients' health. It's not something we need to sell them on," he says.
The problem has always been finding ways to get systems into small practices with a minimum of havoc and at an affordable cost, Kibbe says.
DOQ-IT is supposed to come up with ways to help. The special project is funded by the CMS; Lumetra, the California Quality Improvement Organization for Medicare, was awarded the initial project last year. They are already lining up 250 to 300 California doctors, all from practices with six or fewer physicians. By 2005, Lumetra's contract includes setting up DOQ-IT training programs in two other states. The AAFP's Center for Health Information Technology has been contracted to help implement the program, says Tony Linares, M.D., medical director for quality improvement at Lumetra.
"In a busy practice there is a feeling that I just don't need anything else on my plate," Linares says.
The idea behind DOQ-IT is to experiment with ways to make it easier for small practices to adopt electronic healthcare-record systems. DOQ-IT will select vendors and prepare offices for the start of their new system, then help train the doctors and staff. It follows up with ongoing support to make sure the new systems stay up and running.
"Readiness is everything. If the practice has been prepared and the doctor is computer-literate--and most are these days--and the staff is engaged, the training can be done online and doesn't require sitting in a classroom for two, three days," Kibbe says.
This year, DOQ-IT will hold three main training sessions for the doctors, divided between Northern and Southern California. The vendors will provide training sessions in the doctors' offices for physicians and staff. After that, the plan is to have training online with ongoing technical support available by telephone.
"If you've got a good phone connection and access to e-mail, it works pretty well. Having a vendor fly in and set up training in your office doesn't cut it anyway. That kind of blitz training is never enough to get you over the hump," says John Sattenspiel, M.D.
His office in Salem, Ore., has recently begun using an electronic health-record system. He was part of a small AAFP pilot program, which is testing many of the same techniques being tried in DOQ-IT.
Sattenspiel's office has two physicians and two physician assistants. Doctors currently have to carry a paper chart into the room with an electronic notepad. The cost of converting paper records to electronic data files is too much for most physicians, he says.
There is little hard data on just how many small practices have adopted the technology. An AAFP survey suggested 23% of its members have some form of electronic health-record system in place. From working in the field, Kibbe estimates the number is closer to 20% but may be as low as 15% of practices using electronic health-record systems to manage patient care.
Finding time is one problem, but the biggest barrier is cost. Depending on the vendor and the complexity of the system, an electronic health-record system can cost a small practice from $10,000 to upward of $30,000--per doctor, per year, Kibbe says.
The CMS is expected to include some seed money for physicians in DOQ-IT to bring down the cost of installing the systems, but the amount is not expected to be released until sometime in the fall. The CMS would provide the money to demonstrate how reimbursement helps improve the adoption of IT in chronic disease management, Linares says.
The federal government has recognized that physicians are the missing link in what is otherwise a technically sophisticated healthcare system. A great deal has been invested in upgrading hospitals and laboratories, but the AAFP estimates that two-thirds of care is provided by small family practices--most of which have not followed the trend, Kibbe says.
As part of the grant, the doctors in the program will have to agree to send quality-of-care measurements to the CMS on their treatment of coronary artery disease, diabetes, heart failure, osteoarthritis, depression, hypertension and preventive patient care. Doctors will receive feedback on their care, including clinical guidelines and preventive service reminders.
"Most doctors can't tell you how many diabetics they saw last week. With electronic healthcare records, that data will get back to the practice. It will allow the doctor to make improvements," Kibbe says.
The CMS has not said what will happen to the data being collected and whether it may be published. Until that is determined, some physicians may be reluctant to participate in DOQ-IT, but in general doctors have been hungry for feedback, Kibbe says.
The possibilities are tantalizing. Calculating a patient's risk for breast cancer, sending prescriptions electronically, speeding up billing time--it's all waiting there for family practices on the other side of the digital divide.
The AAFP is stressing the need for its members to adopt the technology, knowing it is one of the routes their doctors will have to use to survive in the increasingly competitive healthcare market.
"It's much more than putting paper records on computers," AAFP President Michael Fleming, M.D., says. His private practice bought an electronic health-record system late last year. "We're talking about a 10-physician practice, soon to be 11, and the biggest room in the office was the file room," he says. The bonuses included helping the doctors code correctly, which speeds insurance billing. The doctors also have easy access to the data for practice-based research, though at the moment they are still getting used to the new system, Fleming says. "There are a lot of alligators in the swamp, but it's going about as well as we expected," he says.
The CMS expects DOQ-IT to include a range of small- and medium-sized practices in rural and urban areas, with doctors of various technical backgrounds. The program will release the list of California participants by the end of summer. Massachusetts and Utah are on the list for getting the second round of DOQ-IT programs, Linares says.
The contract includes setting up the program in California and at least two other states, but as many as five states could be included. The agency has given DOQ-IT a budget of $2.5 million per state. It is expected to run through 2007.
The special project is being run under the Medicare Prescription Drug, Improvement and Modernization Act of 2003, which emphasized upgrading information technology as a way to combat public-health threats, he says.
With the Bush administration appointing David Brailer, M.D., as the country's first national health information technology czar in May, DOQ-IT organizers expect that their program may have some retooling before the contract is over. With the greater emphasis on IT heralded by Brailer's appointment, DOQ-IT is likely to fit well with the government's overall mission to spread electronic health records throughout the healthcare system, Kibbe says.
"The need for better health IT is the one thing Democrats and Republicans in Washington seem to agree upon right now," Kibbe says.
Steve Walsh is a freelance writer based in Valparaiso, Ind. He can be reached at [email protected].
DOQ-IT fact boxWhat it is: Doctors' Office Quality Information Technology (DOQ-IT) helps physicians in small to medium offices adopt electronic health-record systems, while helping the collection of data for federal programs.
The partners: California's Quality Improvement Organization was awarded the special program last year. The American Academy of Family Physicians' Center for Health Information Technology will run the program.
The budget: Budgeted to run through 2007 at a cost of $2.5 million per state for three states in the original grant, beginning with California.