E-Health Ambitions to Confront Human, Financial Realities

It was five years ago in a Geisinger Health System hospital room. A nurse — in the midst of doing a procedure — paused before placing a plastic “sump” tube in a patient. She held up the tube and asked a nearby electronic medical record trainer how to document its use in the brand new system. For a moment, there was confusion. The word “sump” hadn’t yet come up in his hospital lingo education. He couldn’t answer.

But then Andy Schmid wandered into the conversation. Schmid, a registered nurse who at that time had 23 years of experience at the Danville, Pa., hospital system, was detailed to ease the awkward transition to the new record system. He immediately recognized the plastic hose as naso-gastric tubing, and bridged the language gap between the clinical and technologic.

Geisinger has a reputation for being far ahead of the curve on health information technology, but getting there wasn’t easy, Schmid recalls. “You don’t just put [the electronic health record] in and it goes. That was hard, not insurmountable, but something to be cautious about.”

As much as $36 billion in federal stimulus (PDF) money, which was provided in the American Recovery and Reinvestment Act, is to be used to help physicians and hospitals go digital by 2015. But this cash incentive alone won’t boot up the powerful new software. The early dilemma Schmid described highlights one of many obstacles – involving both human and financial capital — physicians and administrators must confront in order to reap the long-term benefits.

Health workers need to be trained. Smaller offices may struggle to come up with down payments only partially covered by the stimulus money. And, once the electronic records are up and running, physicians familiar with the technology say their greatest value is their ability to identify areas for improvement by measuring outcomes. But these improvement efforts cost time and money, too.

Balancing those concerns with the imperative to deploy the technology quickly – beginning in 2011 – falls in the purview of two federal advisory committees created by the stimulus legislation and “staffed” by representatives of the health care industry, patients and other groups who stand to win or lose.

The committees must help define “meaningful use” and other requirements for providers seeking Medicare and Medicaid bonuses for adopting e-health in time for federal officials to meet a December deadline for setting their policy. Some physicians are concerned those standards will place the technology out of reach for their practices, though committee members are aware of that fear.

“Health IT rage [is] the product of getting too far ahead of the physician learning curve,” said Wes Garner, an executive at the health care research firm, Gartner, Inc., at the May 15 meeting of the Health IT Standards Committee.

Another member, Dr. Jim Walker, Geisinger’s chief information officer, agreed: “Health IT is extremely complicated,” despite his own company’s success. Aside from “physician comfort,” he added, patient safety is at stake.

For smaller practices, bank accounts could be at stake, too. Geisinger’s early start and considerable resources – the 2-million-patient system has used e-health in outpatient settings for more than a decade – are advantages that few smaller providers enjoy. Only 17 percent of doctor’s offices, according to a 2008 study in the New England Journal of Medicine, use electronic records. The shortfall between the stimulus incentives and booting up new systems can be imposing.

A recent PricewaterhouseCoopers report, “Rock and a Hard Place,” found that the average three-physician practice could spend as much as $300,000 to buy e-health software, cover training costs, and pay for upgrades over two years. The stimulus incentives can subsidize, at most, $44,000 per doctor. The amount is less if doctors haven’t adopted e-health by the end of 2012.

“This money is going to, in good faith, get most physicians on their way there,” said Dr. Ted Epperly, the president of the American Academy of Family Physicians. But, “margins are thin” for family physicians, he noted, who earn less than doctors in other specialties. Those who don’t shell out for e-health upgrades soon will risk penalties to Medicare payments down the road.

Even when practices succeed with the technology, the success can lead to more expenditures. Though Epperly’s medical association has complained to Congress that isn’t always affordable for small practices, he has no problem seeing their value from the exam room of his Idaho practice. “[Health IT] is a revealer of outcomes, in a good way,” he said, explaining that his electronic records showed him his practice could do a better job with immunizations and diabetes tracking.

But, “They’re useless unless you act on them, so the down payments seem to reveal more costs,” he said. Rejiggering the practice to improve immunizations costs time and money, too, and there’s always more room to improve.

Dr. Steve Davidson, the chairman of the emergency department at Maimonides Medical Center in Brooklyn and an e-health enthusiast who at one point warned readers who don’t share that interest away from his Twitter profile, nevertheless points out that the vast potential of the technology often lies locked behind the barriers of staff capabilities and financial resources.

In one example, Davidson said he suspects the rate of patients in his emergency room “is changing in the direction of them arriving more frequently, quicker.” He would like to set a goal for the time between patients’ arrivals and when they see a physician, and use his electronic system to track it. If the department doesn’t meet the goal, he’d consider adding an extra nurse to triage patients. But, Davidson says he is short one “army of programmers or data analysts or doctors who can do both.”

“Unless you custom engineer it, there’s not an electronic medical record system for the emergency department that will give you that information, even though the information that drives it will help you do a better job,” he said. And without it, it is more difficult to justify the additional investment of upping staff.

“Over the last 16 months, resources have become even more constrained,” he added.

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