In Canada, subsidies don't guarantee EHR adoption

Will the U.S. achieve its goal of providing most Americans access to an electronic health record by 2014?

Maybe not, if the experience of the country's neighbor to the north is any indication.

Seven of 13 Canadian provinces and territories offer subsidies to primary-care physicians for the purchase of EHR systems, according to a new report published in the Journal of Healthcare Information Management. But after nearly a decade of providing these subsidies, Canada still has not achieved majority adoption of EHR systems among its primary-care physicians, the report notes.

In 2004, President George W. Bush set the goal of making electronic medical records available to most Americans by 2014. Soon after taking office in 2009, President Barack Obama adopted the same goal for his administration.

One huge boost the Obama administration had that Bush chose not to pursue was a financial helping hand from Congress, which in 2009 included in the federal economic recovery legislation sufficient funding for a massive EHR subsidy program, estimated to range between $14 billion and $27 billion.

In the U.S.—unlike in Canada—provider access to the EHR subsidy money is contingent upon not only adoption of healthcare IT systems but also the demonstrated meaningful use of these systems.

Writing in the current issue of the JHIM, Canadian physician informaticists Mark Dermer and Matthew Morgan conclude that the U.S. is moving forward "in a sensible way" in tying EHR subsidy payments to something more than simply the purchase and installation of an EHR. The U.S. subsidy program, they said, “has the potential to be rapid, broad and a means to achieve greater benefits and a faster return on investment than has been achieved in Canada.”

"Subsidies don't guarantee meaningful use, but they are a prerequisite to meaningful use,” Morgan said in a recent interview. “We do believe in meaningful use. As a Canadian, I'm embarrassed that we never had a national dialogue on meaningful use.”

On the other hand, the authors said, the U.S. may be wasting time and precious resources overemphasizing testing and certification of EHR functionality while failing to measure, test and certify EHR systems on their usability, the physicians said.

Still, Morgan said, in the long run, the better way for both countries is to tie physician EHR payments to patient outcomes and to require physicians seeking board certification to demonstrate competency in EHR use.

Dermer is a family physician and the lead physician of the Central Ottawa (Ontario) Family Health Organization, a physicians' group practice. He is an assistant professor of family medicine at the University of Ottawa. He also serves as an independent management consultant.

Morgan is a staff physician at Toronto General Hospital and a partner in the Courtyard Group, a healthcare IT consulting firm. He is a former vice president of clinical informatics at Misys, an EHR systems vendor that is now part of Allscripts-Misys Healthcare Solutions. Morgan also is a former director of healthcare informatics at IT vendor Per-Se Technologies.

A key element of their seven-page article "Certification of Primary Care Electronic Medical Records: Lessons Learned from Canada" (subscription required) is a table tracking Canadian EHR penetration rates for primary-care physicians.

The table shows that if U.S. physicians are anything like their American counterparts—and Dermer and Morgan argue that they are—even with federal subsidies starting next year, U.S. physicians will have a long way to go before a majority of them will achieve EHR adoption and meaningful use.

According to preliminary survey data for 2009 available from the ONC, although 44% of office-based U.S. physicians self-report that they have some form of an EHR system, only 6% say they have a "fully functional" system, which would come closest to matching federal meaningful-use capabilities.

Morgan said U.S. and Canadian primary-care physicians confront many of the same barriers to implementing EHR systems.

"They both are very busy and have very high patient volumes," Morgan said. "The pressure continues to build among primary-care physicians in both countries in many, many ways."

Alberta, with 3.7 million people and about 4,000 primary care physicians, launched its first provincial government program to subsidize electronic health record systems in 2001. And yet its EHR penetration rate, highest of all Canadian provinces and territories, is 40%.

About 30% of healthcare services and treatments in Canada are funded by individuals and supplemental private insurance, the authors said, while "universal public insurance covers virtually all physician and hospital expenses and also covers most medications for persons 65 years and over and persons who require income assistance."

Meanwhile, "Canadian doctors receive nearly all of their clinical revenues from provincial and territorial insurance plans," they said. A majority of Canadian physicians are in private practice, and although primary-care physicians "have historically been paid by a fee-for-service system … increasing numbers participate in ‘blended' payment plans that combine capitation, fee-for-service, incentives for outcomes and support for continuing education."

Since its inception in 2001, Canada Health Infoway, a national health IT initiative similar to that coordinated by the ONC in the U.S., has received more than $1 billion in funding "to distribute as a strategic co-investor with provinces and territories for selected projects in the areas of drug, laboratory, diagnostic imaging, telehealth and client and provider registries," the authors said. But in addition, "each provincial and territorial government has its own ‘eHealth' infrastructure that is either within the ministry of health or under its authority," they said.

"These provincial and territorial entities work to build information systems capacity within their jurisdiction, particularly in the area of clinical data repositories and registries, often with the assistance of Infoway funding," Dermer and Morgan said. "The provinces and territories are also responsible for any existing EMR funding and certification programs that exist to advance the use of information systems by physicians, particularly primary-care doctors."

During the past year, several Canadian eHealth programs have been criticized by independent public audits for both lack of progress and poor organization of their initiatives, according to the report.

The variability in EHR testing and certification programs in Canada has been particularly problematic, according to the authors, who noted that systems tested and certified in one province have failed certification testing in another, a powerful argument in favor of the U.S. approach of a national testing and certification system.

Canadian adoption of EHRs appears to adhere to a recognized "adoption curve": The pioneers are first, followed by early adopters and then the early majority, the late majority "and finally the laggards," according to the report. "Nearly all Canadian jurisdictions are in the early adopter or early majority phase of overall EMR use, though advanced, meaningful use lags considerably behind."

In the U.S., however, while certification in the past has been standardized nationwide, the criteria have been inordinately complex, the authors suggest. Dermer said one failing with the certification programs in Canada and the U.S. has been that, so far, both have shunned EHR system usability as a test and certification criterion. Accordingly, Dermer argues, to continue to ignore whether EHR systems are easily usable by physicians is to court programmatic disaster.

"If the meaningful-use criteria are designed solely to measure functionality for output, then I think the initiative is going to fail, or at least it will certainly fail in getting to meaningful use," Dermer said. "I think that's a real potential trap that anybody can fall into, and we've certainly done that in Canada as well. Our subsidy and certification programs don't capture that part."

Dermer said another huge challenge all healthcare organizations are confronting is a limited health IT workforce.

“The biggest problem we face is going to be industry capacity to do that level of implementation in time,” Dermer warned.