All Content

Digital Dilemma


This spring, before Sentara Norfolk General Hospital in Virginia went live with eCare, its electronic health record (EHR) system, hospitalist Ryan Van Gomple, MD, would admit patients using the same system physicians have used for decades: hastily scrawled patient history notes, paper orders, and phone dictation. But eCare’s introduction—and subsequent tweaking in the past few months—has brought a radical transition to the 543-bed tertiary-care facility. Dr. Van Gomple and other hospitalists at institutions on similar systems can enter and access a patient’s data using desktop computers, handheld devices like Blackberrys or iPhones—even their personal laptops at home.

“One of the advantages is we can go back … not only with notes from the hospital stay; a lot of people are doing outpatient notes in the system, so you can start to piece together a total picture of a person’s medical care,” says Dr. Van Gomple, a hospitalist with Sentara Medical Group. “That’s one of the big goals of [EHR]—to have a streamlined system. One of the challenges is, How do you connect with different systems? That’s a great question.”

Dr. Van Gomple might not have the answer, but thanks to ambitious goals laid out by President Obama, the topic is in the national spotlight and already has nearly $20 billion in stimulus money scheduled for release in July 2010. Digitizing healthcare records to create a more efficient care delivery system—through improved record keeping, shortened patient length of stay (LOS), and increased ED throughput—isn’t a new idea. Hospitals have struggled for more than a decade with the EHR question, debating whether they should—not to mention how they would—create a computerized system to input patient records into a database that is accessible in real time to hospitalists, nurses, primary-care physicians, insurers, and so on. There have been long-stalled discussions on how to settle privacy concerns that arise from electronic records (see “EHR Upgrade Faces Privacy, Communication Obstacles,” p. 27). Still, a multi-billion-dollar federal pledge has created a moment in time to take EHR beyond the discussion phase.

Connected or Really Connected?

The federal government will spend the coming years defining and perfecting what qualifies as “meaningful use” of certified EHR systems. One widely quoted measurement is the eight-stage ladder created by HIMSS Analytics, a subsidiary of the Healthcare Information and Management Systems Society (HIMSS). The eight stages—and the percentage of hospitals in each stage—as of a March 2009 survey of more than 5,000 hospitals:

Connected or Really Connected? Source: HIMSS Analyticsclick for large version

Source: HIMSS Analyticsclick for large version

The Office of the National Coordinator of Health Information Technology (ONCHIT) is empowered to shepherd this process. David Blumenthal, MD, MPP, the director of the Institute for Health Policy, a joint effort of Massachusetts General Hospital and Partners Healthcare System, has been named as ONCHIT’s head. Money to entice hospitals to invest in EHR is part of the American Recovery and Reinvestment Act of 2009. And with Congress hammering out the details of healthcare reform legislation, a sharper focus has been placed on the potential efficiencies EHR can offer.

Money and attention aren’t the only keys to this puzzle, however. IT advocates, medical information officers, and HM group leaders say the government spotlight is a wonderful springboard, but they also say physician involvement in implementing the EHR technology is a must and will spur more hospitals to adopt the systems. Less than 8% of U.S. hospitals have EHR in at least one unit, the New England Journal of Medicine reported earlier this year.1 Just 1.5% of hospitals have a comprehensive system in all of their units.

“There are so many barriers getting to where our country really needs to get,” says Dirk Stanley, MD, MPH, a hospitalist and chief medical informatics officer at Cooley Dickinson Hospital in Northampton, Mass. “One of the big issues is the meaningful use, and how do you actually set criteria for your using electronic health records the right way? If you look at the big picture, you’re talking about so many clinical practices. … How do you write criteria that are meaningful to all those different settings? The government has an enormous challenge.”

Efficiency: HM Cornerstone

David Yu, MD, FHM, works at a hospital with paperless capability and sees on a daily basis how streamlined health records have a practical effect on a hospitalist’s workload and efficiency. Dr. Yu, medical director of hospitalist services at 372-bed Decatur Memorial Hospital in Decatur, Ill., and clinical assistant professor of family and community medicine at Southern Illinois University School of Medicine in Carbondale, is one of EHR’s most passionate advocates.

Decatur Memorial uses GE Healthcare’s Centricity system, which allows hospitalists to “download automatically into our physical history with the click of a button,” says Dr. Yu, a member of Team Hospitalist. “As you’re downloading, you’re accessing the information. It’s literally the same as you driving to the patient’s primary-care physician’s office, pulling the chart, and looking at it.”

Dr. Yu and those who support EHR say it streamlines intakes, discharges, and handoffs, which in turn reduce throughput and length of stay—statistics often cited to prove HM’s value to the hospital administration. The rush for implementation takes on added urgency considering that less than half of 0.5% of hospitals are fully paperless, meaning they have interdepartmental systems that can communicate with each other, according to HIMMS Analytics.

Obama and other healthcare reform advocates envision a day not far in the future when all of America’s hospitals will be connected through a national health records system. Databases in hospitals and physician offices and other healthcare providers will communicate with each other. It will make such health records as X-rays and lab test results a portable commodity, which, in theory, will provide faster and more accurate information for both patients and their providers.

One of the economic stimulus plan’s most important features is its “clarity of purpose,” Dr. Blumenthal wrote in the New England Journal of Medicine earlier this year. “Congress apparently sees [health IT]—computers, software, Internet connection, telemedicine—not as an end in itself, but as a means of improving the quality of healthcare, the health of populations, and the efficiency of healthcare systems.”2

Don’t Get Left Behind

It’s often said that hospitalists are on the front line of the hospital. So when it comes to designing and implementing EHR systems, HM leaders are in a unique position to influence how these systems take root at their institutions. Here are a few tips from industry representatives:

  • Attend meetings. Bureaucratic sessions might seem technical and mundane, but they afford attendees a chance to network with the hospital leaders and IT staff who will be the main players in choosing, buying, and installing the new system. “The conversion is 80% politics and management, and 20% IT,” says Dr. Stanley, chief medical informatics officer at Cooley Dickinson in Northampton, Mass.
  • Speak up. Hospitalists must voice their concerns; you can be sure the other specialists will speak up with theirs. If you fail to speak when given the chance, administrators likely will tune out after-the-fact complaints.
  • Participate in design forums, testing, and feedback sessions. Often hospitalists say they don’t have enough time to carve out for these interactive opportunities. “But HM group leaders should look at this as their investment in the future of their practice,” says Ehab Hanna, MD, MBBch, FHM, assistant chief medical information officer at Eastern Maine Medical Center in Bangor.
  • Plan ahead. EHR implementation will come with a steep learning curve. Consider staffing a service to reduce patient encounters ahead of time, to allow physicians a chance to learn the systems with less stress and time pressure. “If you have busy hospitalists seeing 15 to 18 patients every day, and you throw in this new CPOE, it’s not going to work,” says Dr. Yu of Decatur Memorial Hospital.—RQ

Proactive Approach

Obama has pushed EHR implementation as one of many solutions to the skyrocketing costs of healthcare, saying earlier this year that he is committed to “the immediate investments necessary to ensure that within five years, all of America’s medical records are computerized.” Even so, the EHR upgrade remains only a grand outline, one missing the details that will determine the future. There is time, of course. The first funding through the stimulus bill won’t be available until next summer.

Dr. Blumenthal’s office is crafting an interoperability plan in combination with a pair of still-forming advisory boards: a health information policy committee and a health standards committee. The stimulus bill also promises increased federal reimbursement payments for hospitals with meaningful use of certified EHR. First, the government has to define what is meaningful and, as Dr. Stanley points out, the definition will have different meanings to different sectors of the $2.2 trillion-per-year healthcare industry.

Once those definitions are set, there is a timetable for additional reimbursement and a one-time bonus of $2 million for institutions that implement “meaningful use.” There also will be escalating Medicare penalties for institutions that fail to show the kind of technological progress federal officials are looking for.

But even if those standards are set, it doesn’t guarantee hospitals will buy the technology that vendors are selling. Many in the HM field argue that the next step is the most important one.

“Physician adoption of electronic health records is the central, critical issue this industry is facing over the next few years,” says Todd Johnson, president of Salar Inc., a Baltimore-based firm that develops software applications for clinical documentation. “There are a lot of really bright people working on criteria that make electronic health records good tools. However, there doesn’t seem to be an organized body focused on the EHR adoption issues. Anybody can buy all these tools, but if you ultimately can’t get the right people to use them at the right time, the investment doesn’t yield much, right?”

Johnson, who thinks the federal focus on EHR technology is a main driver behind his firm’s 25% sales growth spurt in the first six months of 2009, says physicians have to be a driving force in the EMR implementation process or the system will fail. Take the industry’s classic cautionary tale: Cedars-Sinai Medical Center in Los Angeles. The oft-innovative institution made national headlines in 2002 when it scrapped a three-month-old, $34 million computerized physician order entry (CPOE) system after more than 400 doctors demanded it be shelved.

“The right thing to do is really steer the discussion to physician adoption,” Johnson says. “Make sure that physicians have a choice. Every hospital—and rightly so—wants to see the benefit of their investment in electronic medical records. If physicians don’t have a voice in what will or won’t work, purchasing decisions will be made without them. And that’s not a great thing. Hospital leadership needs to be cognizant of that.”

Dr. Stanley thinks hospitalists should take a proactive approach to EHR implementation at their hospitals. Many potential issues could be solved if hospitalists take an active role earlier in the process.

“As tedious as those early meetings are,” Dr. Stanley says, “that’s where the big planning and decisions get made. The problem is most people think of it as tedious and boring because they don’t appreciate the technology.”

By the Numbers

Highlights of President Obama’s push to goad more hospitals toward comprehensive EHR systems, as summed up in an outline in the May issue of Archives of Internal Medicine by David Liebovitz, MD, chief medical information officer, Northwestern Medical Faculty Foundation, and medical director of clinical information systems, Northwestern Memorial Hospital in Chicago:3

Office of the National Coordinator of Health Information Technology

  • Expanded by statute, awaiting input from two committees that are still forming (Health Information Policy and Healthy Information Standards);
  • $2 billion for supporting development of EHR through grants and loans to states, students, and hospitals. Workforce training money set aside and grants available for regional technology centers to help with EMR installation.

$17 billion for doctors and hospitals to adopt and use EHR

  • From 2011-2016, physicians are eligible for up to $44,000 in extra Medicare and Medicaid payments for “meaningful use” of certified EHR.
  • From 2011-2016, $2 million bonus payment to hospitals if meaningful-use standard met by 2011.
  • DRG add-ons phase out after four years.

Penalties for lack of meaningful use

  • Starting in 2015, physicians will receive a 1% reduction in their Medicare reimbursement. In 2016, the reduction will increase to 2%, and in 2017, the reduction will be 3%.
  • Also starting in 2015, hospitals will incur reductions to annual DRG updates.

What’s Ahead

Technology integration is the next step. A handful of companies offer complete EHR platforms, including industry leaders Epic, Meditech, Cerner Corp., GE Healthcare, and McKesson Corp. Specialty firms, such as Johnson’s Salar, offer ancillary and support software and hardware.

Kendall Rogers, MD, assistant professor at the University of New Mexico School of Medicine and chair of SHM’s IT Task Force, says the stimulus funding dedicated to technology will be better served if it focuses on incentives beyond hospitals. Dr. Rogers and others want to see guidelines to create incentives for IT vendors to offer user-friendly systems designed to further medical efficiency goals.

“If this needed technology was developed and proven, the needs for carrots and sticks for adoption would be far less,” Dr. Rogers and several of his peers wrote in an unpublished letter to the NEJM. “Rather than focusing primarily on adoption of systems that have serious limitations … a bill that requires improvements in existing technologies would have much more impact in improving the quality of healthcare.”

Even before that happens, full-scale implementation of these systems will be a costly project that requires a long-term relationship with a vendor. Dr. Van Gomple’s hospital system, Sentara Healthcare, has budgeted $235 million over 10 years for its EHR implementation, according to Bert Reese, senior vice president and chief information officer. His accountants tell him to expect roughly $50 million to be subsidized by the stimulus package. The money is helpful, but not enough for a hospital or system that still needs to find another $185 million.

“The stimulus is nice to get things going,” Reese says. “But if you as an organization think that will cover the cost, you’ll never get going.”

Reese says Sentara’s return on investment at full implementation—roughly five years from now—will be about $35 million per year in savings. He suggests organizations view the investment through a long-term profit goal in order to show the value over an extended timeframe. Otherwise, some C-suites will be scared off by the initial outlay, failing to see the value of efficiency, cost savings, and improved patient care.

“It’s not an IT project,” Reese says. “It’s a clinical project.” TH

Richard Quinn is a freelance writer based in New Jersey.


  1. Hamel MB, Drazen JM, Epstein AM. The growth of hospitalists and the changing face of primary care. N Engl J Med. 2009;360(11):1141-1143.
  2. Blumenthal D. Stimulating the adoption of health information technology. N Engl J Med. 2009;360(15):1477-1479.
  3. Liebovitz, D. Health care information technology: a cloud around the silver lining? Arch Intern Med. 2009;169(10):924-926.


EHR Upgrade Faces Privacy, Communication Obstacles

Not surprisingly, money is often the hurdle mentioned first by hospitalists and hospital administrators when the topic turns to electronic health record (EHR) implementation. But as President Obama presses his vision of a more technologically efficient U.S. healthcare system, obstacles abound: security concerns, privacy guarantees spelled out in the Health Insurance Portability and Accountability Act, and interoperability issues when disparate systems from different vendors attempt to interact.

“Security and privacy are critical issues,” says Todd Johnson, president of Salar Inc. “[They] sit at the center of the debate on how you structure the entire national health record infrastructure.”

Johnson says vendors will ensure the integrity of information by falling in line with the Office of the National Coordinator of Health Information Technology (ONCHIT), which is tasked with creating standardized safety rules to allow broad, secure EHR access. David Blumenthal, MD, MPP, director of ONCHIT, says new rules extend privacy regulations to “health information vendors not previously covered by the law, including businesses such as Google and Microsoft, when they partner with healthcare providers to create personal health records for patients. It requires healthcare organizations to promptly notify patients when personal health data have been compromised, and it limits the commercial use of such information.”2

Most hospitalists and technology administrators agree that the interoperability problems—one hospital EHR system’s ability to communicate with all other EHR systems—could stymie EHR growth. Most industry leaders argue the hurdles are surmountable.

“We use the same security standards as banks, though it is a lot more profitable to steal money than to steal medical records,” says Ehab Hanna, MD, MBBch, FHM, assistant chief medical information officer at Eastern Maine Medical Center in Bangor. “[EHR] are more secure than the paper records, because there was never an effective way to prevent or monitor any unauthorized access or copying of the paper record. We can do that in the electronic world.”—RQ

Recommended Reading

Role Refinement
The Hospitalist
Only Fools Rush In
The Hospitalist
What Are They Doing (to Me) in D.C.?
The Hospitalist
Psych Solutions
The Hospitalist
How do I keep my elderly patients from falling?
The Hospitalist
Job Hunter’s Checklist
The Hospitalist
Facility Transfers
The Hospitalist
Billion-Dollar Questions
The Hospitalist
The Downtime Dilemma
The Hospitalist
Simulation Sensation
The Hospitalist
   Comments ()