The front lines of healthcare are small- and medium-sized medical practices that deliver 70% of America’s healthcare. Initiatives by health information technology czar David J. Brailer, MD, PhD, Health and Human Services, and the proposed bills of Sens. Hillary Rodham Clinton and William H. Frist, MD, and others have put the spotlight on technology. Yes, these are positive catalysts for information technology (IT) adoption. Standards and interoperability will accelerate the process 25% faster than would otherwise happen.

However, adoption can move even more quickly if additional steps are taken:

1. Incenting small- and medium-sized physician groups to adopt electronic medical records (EMRs). For parallels, consider the financial services industry and the adoption of credit cards. Government, insurers, and providers must work together to devise an equation that benefits all. One possible approach: Medicare fee schedules with EMR discounts.

The challenge in creating a national integrated health information system is that the healthcare industry has been historically fragmented. Small doctor’s offices, which on average have approximately 2.5 physicians on staff, will not move as quickly without help as compared with large hospitals. But even in the hospital sector, nearly 80% are nonprofit, single-site facilities. Therefore, only 20% of the hospital capacity in the United States is actually in a position to retain earnings that can be reinvested in any form of healthcare process improvements or technology.

2. More pay for performance. Following closely on incentives is pay for performance. Health plans are already taking tentative steps in this area, but a standardized and broader system for pay for performance will be possible through widespread EMR adoption.

To counteract spiraling expenditures and ensure better quality, pay-for-performance programs—where doctors get financial incentives to meet certain quality standards—are proliferating. For physicians, it is no longer a question of whether they will be asked to participate in such programs, but when and how many. EMRs are a technical necessity for pay-for-performance programs to be economically viable.

Pay-for-performance measures are being established nationally and regionally by industry partnerships. For example, there is the National Quality Forum, a nonprofit public-private partnership charged by a presidential advisory commission to develop consensus-based national healthcare quality measurement standards. Another example is the Ambulatory Care Quality Alliance, which has been assigned to design evidence-based guidelines vetted by leading medical organizations, quality groups, purchasers, and health plans for the many incentive programs already planned or in operation.

Already, large private-sector programs have been launched around the country. For example, a pay-for-performance plan coordinated by California’s Integrated Healthcare Association, a nonprofit consortium of medical groups, health plans and health systems, distributed $50 million in bonuses last year.

In the pay-for-performance arena, hospitals have an advantage over small practices. A hospital’s data is not fragmented by payor; it can be analyzed deeply and ad hoc, plus hospitals’ more sophisticated computer systems capture more data more often. Small practices do not have these advantages unless they implement EMRs.

Small practice groups without EMRs get their data and reports from health plans, often in separate reports covering subsets of the overall practice. Variations exist, reporting frequency is too infrequent at once per year, and the whole picture suffers. Dependency on payor data to drive quality is flawed. Practices need their own EMR systems.

EMR makes tracking pay-for-performance measures possible. Among the common measure outcomes that would require data from patient charts are structural measures that would assess an office’s capacity to deliver promised care, efficiency measures to gauge a physician’s ability to deliver quality at the best cost, and patient experience measures relying on patient survey results. A small practice reporting on these measures without EMRs would find its administrative resources prohibitively expensive. Indeed, many HMOs that have launched pay-for-performance programs are giving medical groups incentives to invest in EMRs.

3. Develop one common standard, not many. Physician practices are the nodes of delivery for the healthcare infrastructure. As different standards are proposed by public and private interests, consider that interoperability without the nodes is like a highway without cars. Government is forging the vision, and private industry can collaborate to make sure the small- and medium-sized physician offices make their way onto the highway.

One of the key impediments to physician adoption of EMR is the reluctance to invest in a software that could become outdated if industry standards change. Small practices do not have the resources to evaluate and implement technology compared with larger groups.

Implementation of industry standards is the key foundation to the software platform that small practices need for reassurance.

One common standard can help drive EMR adoption among small practices. Consider, for example, the Continuity of Care Record (CCR) standard being developed by the American Society for Testing and Materials, HIMSS, the American Academy of Family Physicians, and the Massachusetts Medical Society. The CCR standard goal is to ensure that a patient’s medical record can be easily updated and shared among every provider in the patient care delivery chain. Clinical information and drug data, as well as insurance information, will be seamlessly transmitted from one provider to another regardless of institution.

One common standard will provide better quality and reduce medical errors and costs for patient care. One standard will make EMRs even more of a must-have technology and drive adoption at all levels.

4. EMR technology should pay for itself. As evidenced by low adoption rates, for small practices, this often isn’t the case. Streamlined workflow, increased doctor efficiency, clinical data collection, and decision support are all one side of the coin. The other side: While improving workflow and reducing costs is helpful, a truly valuable EMR addresses coding, reimbursement management, and payor interactions to help drive practice profitability. If your EMR system pays for itself with increased collections, the practice will be highly motivated to completely adopt the system.

To see the impact EMR can make on small practices, consider the example of MedPeds, a six-physician pediatrics and adult medicine practice in Laurel, Md. Last year, MedPeds made the transition from a practice operating with paper-based charts to one utilizing EMR technology from eClinicalWorks.

Many physicians are reluctant to adopt EMR if it does not mirror workflow. An intuitive, easy-to-use system is key to adoption. MedPed’s head nurse had never used a computer prior to implementation. When MedPeds moved to electronic tablet PCs, the nurse considered retiring because the process overwhelmed her.

Within two months, however, she became enamored with what she could now do for the patients in her role as a triage nurse. She’s now the EMR’s biggest advocate because of how easy her job became, how quickly she was able to pull information from a patient’s electronic record, and how easily her messages transferred from her desk to the physician’s desk and back again. A message from a triage nurse now goes to a physician and back, on average, one day faster.

Chart tacks have been eliminated and, as a result, employees no longer search throughout the office for patient information. Instead, all necessary employees enjoy instant access to all patient information, which is more accurate, in-depth, and available. Additionally, chart creation time has been reduced to a couple minutes, saving time and money. Also, the management of all phone calls and messages has greatly improved.

MedPeds found these “soft” benefits to be invaluable when considering the efficiency increases and flexibility EMRs have given doctors and nurses. For example, on-call physicians can view complete patient histories, past visits, current medications, allergies, labs, and charts from home. He or she can then speak to the patient and send a partner a message or a phone encounter right to his or her inbox so it is available Monday morning.

An EMR solution helps a practice with continuity of care. Medical reminders and alerts, lab tracking, and database management are also distinct advantages, as is the ability to run reports to see trends or quickly view previous patient visits.

Today, many consumers are clamoring for increased knowledge and empowerment. In this regard, an EMR solution with patient-doctor interaction should be strongly considered. MedPed is implementing a patient portal, an application that will make the patient experience more pleasant and customer-friendly.

The current paradigm is that information is physician- and telephone-centric. However, the patient portal is patient- and Web-centric with patients controlling their access to key information such as prescriptions, referrals, lab results, and appointments. The elegance of a patient-centric data flow is that it will save physicians money and enhance patient satisfaction. Information patients want to receive and send is so integrated within the EMR that staff will be able to avoid the hassle of playing telephone tag.

Streamlined workflow, increased doctor efficiency, clinical data collection, and decision support are just a few of the benefits. While reducing costs of transcription and staff is helpful, a truly valuable EMR addresses coding, reimbursement management, and payor interactions to help drive practice profitability. If your EMR and practice management system pays for itself with increased collections, the practice will be highly motivated to completely adopt the system.

At MedPeds, the EMR technology has reduced nonphysician support staff by 33%. The office overhead for the practice has decreased by approximately 15%, overdue accounts have decreased by 50%, and productivity by the providers has increased by 10% on average with some variation among providers dependent on individual adaptation to the new technology in charting.

Return on investment for the EMR is 100% in one year. However, most small practices are reluctant to embark in EMR technology without a clear path to increased reimbursements. Most small practices have not achieved this ROI due to technical and cultural differences in adaptation. A modest 10% bonus in pay for performance of EMR adoption would jump-start hesitant practices to make the cultural leap of faith.

Meanwhile, patient satisfaction has increased, according to managed care patient satisfaction surveys and in-office patient comments. Patients like the easy access to their records when they call for advice, the ease of communication with the specialist, prescriptions waiting at the pharmacy, and the ease of obtaining accurate information from the doctor on call.

Providers, payors, and the government together need to take responsibility for a much more sophisticated, involved shepherding of healthcare information. Most small practices are reluctant to initiate capital investment without a clear path. Policymakers and the private sector must work together to turn guiding tenets into practical realities.

— Seth Eaton, MD, is with MedPeds, a six-physician adult medicine and pediatrics practice in Maryland.