Perspective: Costs, control, data access remain top EHR concerns

As physicians increasingly adapt and implement electronic health record systems, concerns remain about costs, control, and access to information. Jay Wolfson, DrPH, JD, project director and prinicipal investigator for the PaperFree Florida Collaborative Health Information Technology Regional Extension Center (REC), recently shared his thoughts on these issues with Medical Economics Editor-in-Chief Lois A. Bowers, MA.

PaperFree Florida is a federally funded, regional, public-private partnership designed to enable clinicians to implement and meaningfully use electronic health information systems. The REC was formed through a partnership between USF Health, the Greater Ocala Health Information Trust Inc., Watson Clinic LLP, and the Florida Academy of Family Physicians.

Wolfson also is the DIstinguished Service Professor of Public Health and Medicine and associate vice president for health law, policy, and safety at the University of South Florida. He was designated a member of the Medicare Competitive Pricing Review Committee; served as associate director of the National Patient Safety Center of Inquiry, Veterans Health Administratioan, VISN 8; and was a trustee, vice chairman of the board, and chairman of finance of Tampa General Hospital for 12 years.

Q: What was the genesis of PaperFree Florida?

A: About 8 years ago, we launched something called PaperFree Tampa Bay. We worked with physicians in this community to give them free access to electronic prescription capability.

During Hurricane Katrina, the entire Gulf Coast basically shut down for a period of time. At about that same time, the regional health information organization we had built made available to the pharmacies across the country access to prescription information for Medicaid beneficiaries since the company that ran that nationally happened to be based in Florida. And the power of sharing useful information, basic information, to people who need it, became so important at that time-so that the diabetic patients could get their medication, physicians could have access to information about their patients-that it became a natural opportunity for us to expand our interests in creating access to useful, vital information to physicians, patients, their families, and others when they need it, without compromising confidentiality.

The federal government initiated the [regional extension center] program that 62 grantees participate in through the Office of the National Coordinator for Health Information Technology, and PaperFree Florida is one of them. We cover 11 counties in central Florida, and our job is to facilitate the adoption and use of electronic health information systems among primary care physicians (PCPs) in the community. We rank between the third and the first in the country in performance, and part of the reason for our success is that we’re so used to working with PCPs.

Our concern is making things simple, easy, and useful. We have 1,000 physicians in the program, and we are working with lots of other physicians outside of our service area. Our goal has been and remains not just to assist in the adoption of electronic health record (EHR) systems but to use the information for purposes that the federal and state governments and private insurance are going to expect physicians to have available.

Q: What do you say to physicians who would prefer not to adopt EHRs?

A: Whether they like it or not, doctors are going to need to be able to demonstrate that they meet certain outcome measures, that they can address certain safety issues, and that they can demonstrate cost efficiencies for themselves as well as for those who are paying them, and that they are addressing access to care.

A colleague of mine said, “Look, I’m 55 years old. I’ve had enough of this. I’m just going to sell my practice.” And I said, “Do you know who you’re going to sell your practice to? You’re going to sell your practice to one of my residents. And my residents don’t use paper. We’re paper-free. We have been for a few years. So who are you going to sell it to?” And he said, “You’re right. I have to get something.” And I said, “I think you’re going to have to get something for a lot of reasons.”

Q: What would you say to a physician who is concerned about the expense of purchasing an EHR?

A: Doctors can go a long way by talking to their colleagues and working together. Even if they’re independent practitioners, they can work out deals where they can purchase things with a discount.

Q: Once physicians implement EHRs, do they recognize the benefits?

A: Internists have a great need and interest to have a viable system of interoperability because they’re the ones communicating with specialists, who have to get the data back and manage the care of patients.

The question is, are physicians going to take control of this, or are they going to let hospitals, insurance companies, or the government do it? Many hospitals and some insurance companies are now reaching out to physicians and saying, “Let us help you with your EHR. We can assist you in acquiring one and, of course, you’ll be part of our network.” That may reduce some of the liability, but it ties you to that particular network. And then they’ll have access to all your information, often on a real-time basis.

Q: How can physicians get more control?

A: Physicians have to come together at their community level and say, “What is the most important thing for us?” When it comes to EHRs, the question is, “What are my needs in practice, and how do those needs get translated into technology that is useful and economical for me? I don’t have to buy a Cadillac. Maybe I can buy a Toyota, as long as it works, as long as reporting needs are met, and as long as my internal operational needs are met. Let me talk to my friends and colleagues. Let me talk to my other internist friends. Let me talk to the professionals with whom I have the greatest referral relationships and find out how we can work best together.”

Q: Many physicians have told us that they’re concerned about the government having access to their data. What would you say to them?

A: My colleagues are most concerned about getting paid, but secondly, once they’re connected, they’re concerned about who will do what with their information.

I know a pilot who, every couple of years, has to get recertified. He has to have his vision checked, go to a simulator, and spend a day and a half or 2 days to make sure he knows how to fly a plane. Once you graduate from medical school, finish your residency, and take the boards, you may have to take some continuing medical education courses, but you never have to get into that cockpit again in front of someone making sure you can fly a plane. It’s incumbent upon physicians, whether they’re PCPs or specialists, to recognize that the system is going to start demanding that of them. When we have these information systems in place-and they will be put in place-it will be possible for insurers, hospitals, and the government to oversee and monitor all of the things physicians do to establish very specific measurable guidelines of performance-clinical performance, financial performance, utilization performance-and they will use those guidelines as a basis for paying physicians as well as for determining whether they can participate in these programs.

From a policy perspective, it’s not unreasonable, if you place yourself in the shoes of the federal government, to say, “Well, since we’re paying you with Medicare and Medicaid, and we’re a significant portion of your practice, we need to know as much about what you do as possible so that we can help you ensure that quality and outcomes meet reasonable standards. If you don’t, we will have to assist you in improving yourself somehow, or we’re not going to pay.”

Q: Where is interoperability already working well?

A: The Veterans Affairs (VA) system does it really well. I’ve worked with the VA for more than 20 years, and I have a son who is a Marine veteran. He can go to any VA clinic or hospital in the country, and they can access all of his medical records, all of his scans, all of his lab tests instantly with the single system.

The Mayo Clinic can do that, too, as can any entity that has complete dominion and control over its clinicians, its pharmacists, its nurses, and its hospitals. But that’s not reality in most of our communities.

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