As founding president and CEO of the Massachusetts eHealth Collaborative (MAeHC), Micky Tripathi brings an authoritative viewpoint to any dialogue about EHR adoption and implementation – both at the federal policy level and at the hands-on community level where physician practices put evolving technology to work.
Prior to leading MAeHC, Tripathi (pictured) was the founding president and CEO of the Indiana Health Information Exchange, where he led the design and launch of one of the largest and most successful statewide laboratory results-delivery businesses in the country.
He currently serves on a number of boards and steering committees, including the Information Exchange Workgroup of the HIT Policy Committee, the eHealth Initiative, and the New England Health Exchange Network.
PhysBizTech recently caught up with him for a discussion about the current state of EHR adoption in physician practices, an example of innovation in the field and a preview of where things are headed for small practices.
Q: How would you describe the progress of small physician practices in adopting EHR technology at this moment in time?
A: By any reasonable objective measure, the progress that's been made since the passage of HITECH has been extraordinary. The most recent numbers I saw were that well over 50 percent of physicians are on EHRs. Even in the small-practice groups, the numbers are pretty high, especially in primary care. That's an incredible shift from where we were just before HITECH was passed. It would be hard to find an example in the U.S. of that much technology being adopted by that broad a base of users in such a short period of time.
That doesn't mean there aren't issues. There certainly are. But overall it has been quite an amazing process -- and it's been comprehensive when you look at large practices all the way down to small practices adopting.
Q: Among the practices that have not adopted, what may be holding them back?
A: I would put this question of adoption in two categories. One is the group of people who have met the letter of meaningful use, so they are live on a system and they have checked off all the boxes they need to get their meaningful use dollars…but they haven't done a whole lot more. In some ways, they haven't truly adopted. They've made some progress, and they're doing some things that have been shown to improve the quality, safety and efficiency of care, which is great, but they may not have fully embraced the technology and may not be using the technology for all of the things that it could be used for: fully using alerts and reminders, using the registry function to start to move toward population management, for example. They're not yet using it for patient engagement, creating patient summaries and those types of things.
Some physicians in that category find it difficult to do some of those things, and perhaps are a little too focused on just getting the dollars, but they're also trying to keep as many of their old processes in place as they can.
The second group is made up of physicians who just aren't adopting at all, but I think that's an increasingly small group. In some cases, the EHR systems aren't as well defined for certain specialty kinds of practices. A lot of the criticism you hear with EHRs is that they're very well designed, but they're focused on primary care. They don't quite meet the needs of all specialties. Particularly specialties like ophthalmology, which has complex diagnostic equipment, and if it's not integrated with their EHR, it starts to really hurt the physician's workflow.
Q: So we'll always have some sectors in which the technology doesn't work. Are there other factors that could be in play?
A: There may be a whole cohort for whom it's age-related. And there's probably a whole cohort who wanted to do it a little bit on the cheap, so perhaps they purchased a less robust EHR system or a new unproven system.
One of the things you find with some of those systems is that the technology is not the issue, it's the support. You need to have good trainers and a good support bench from your vendor. If you're not well enough trained to begin with, or something breaks and they don't have good support, the tendency is instead of working hard to try and fix it, you end up not using it. You may stop using it altogether because the lab interface stops working, for instance, and you just go back to paper or fax lab results.
Among the small practices, you probably have some of those issues. In general they don't have the support staff in their practices to help them get over some of the regular problems that arise with technology. And if you don't fix some of those small things, they end up becoming big and lasting problems.
Q: Do you worry that small practices may not be able to keep up with the staged requirements for meaningful use?
A: As you start to raise the bar on some of these measures like increasing the percentage of prescriptions that have to be e-prescribed, or you increase the percentage of labs that have to be structured labs, you then start to see some of the rocks get uncovered just below the surface of the national infrastructure. I think that particularly hit the small practices.
For example, as you go into more rural areas, that's where you have lots of one- or two-doctor practices, and broadband may not be widely available, or the local pharmacies may not be participating in SureScripts, or maybe the hospital isn't yet delivering lab results electronically. That's where they may not be able to meet the measure requirements simply because they happen to be in an isolated area that is sort of a dead spot with respect to some of the transaction infrastructure that needs to be in place. That's a general concern.
But I think for the most part – and the proof will be in the pudding once people try to attest against the requirements – CMS has tried to provide enough exceptions and waivers for some of the obvious issues that might arise. Let's say you're in an area that doesn't have broadband; there's actually a list of the ZIP codes that would allow you to qualify for a waiver. Hopefully we’ve addressed enough of those issues through the waiver and exception process so that most of it will get taken care of.
The issues that I hear most about are related to interoperability and patient engagement. In particular with the patient engagement part, meaningful use Stage 2 has requirements that patients do certain things in order for the physician to get credit for meeting the objective. Again, you could be in certain rural areas where that's just not a part of the culture. The requirement that 5 percent of your patients view, download or transmit their records may seem like a low bar, but for a typical primary care physician that could translate into 100-150 unique patients, and for a specialist it could easily be double that, which doesn’t sound so easy anymore. That may actually be a challenge in part because it's not part of the way medical culture practices today. Also, the practices themselves may not be as savvy in the use of technologies to allow them to meet those requirements. Of course, the purpose of the objective is to motivate these types of changes in culture and use of technology, but change is hard.
With the bread-and-butter requirements -- things like basic documentation and recording vitals that were menu-set in Stage 1 and may get to be core in Stage 2 -- I think most people are fairly comfortable and have a reasonable technology in place to be able to do those things, small practices included.
However, some of the things that require a little bit more management attention -- like patient engagement and interoperability -- that's where small practices are going to have the hardest problem. They don't have the extra staff who can spend time keeping their eye on that ball.
Q: And then what about Stage 3?
A: Right now we don't know what Stage 3 is going to be. The request for comments is out there, so we'll see where that ends up. Part of the reason for soliciting public comments is to get industry feedback before we start to make the requirements more solid. One concern that I have as I look at some of the ideas that are out there for comment is that they start to impose requirements that may be more affected by the ways that people practice medicine and the culture of medicine in particular areas than the use of technology.
Stage 3 would have requirements that imply that there would be care plans and care teams across settings. If you're a small practice out in a rural area where you're operating on basically fee-for-service type of reimbursement -- and you're probably going to be operating that way for a long time to come -- who are the members of the care team? Well, if I'm the doctor, am I supposed to figure out who the patient's cardiologist is, or who his dermatologist is? If I'm way out in the hinterlands, and I just deal with the patient's primary care on a fee-for-service basis, I don't have all those other pieces of information. Am I going to be required to collect it and maintain it? It's just not how medicine is practiced out there, for better or worse. So I start to get concerned in Stage 3 about those kinds of things. Hopefully the feedback CMS receives in its request for comments will help address some of those kinds of issues.