How do we actually increase Electronic Health Record Adoption?

In past recent writings I spoke of the top 10 ways to prevent EHR adoption. I wanted to start there because very good people with very good intentions are in the process of creating rules, regulations and standards that are preventing the adoption of the EHR’s. These well meaning individuals and governmental entities see the possibility of correcting many medical related problems using information technology. However, they seem to miss a very fundamental issue -- Who purchases EHR’s and why? Currently, the Physician or Provider of health care is expected to purchase the EHR. The next question is why would they purchase an EHR? I have been in the business of selling EHR systems to Cardiology Physicians for 10 years now. There are two reasons that Cardiology groups have purchased EHR’s: 1) To make them more efficient (efficiency is defined as doing the same amount of work in less time or making more money with the same resources); 2) To give themselves a competitive advantage over their competition by offering higher quality care and or providing them protection against government regulations. When we first started selling systems, most groups purchased the system for the second reason. They wanted to be better than their competitor and protect themselves against regulations. Currently, more and more physicians see that if they do not purchase these systems they cannot take advantage of the incentives available and will make less money over time when they will ultimately have to purchase a system.

Psychological Barrier to Adoption

There is still a major barrier to overcome if EHR adoption is to improve significantly. This is a psychological barrier that I will try to explain but it is not necessarily easy to put into words. I will call it the “Perception of Fairness.” All through our lives this concept comes up. If you are a parent, you might have heard it framed this way “Mom, it isn’t fair that I have to go to bed at 9:00 PM. Tommy’s parents let him stay up until 10:00 PM.” I was involved in preventive health programs in the early 80’s and I remember sitting in front of an insurance company executive who was adamant that he would not pay for a health prevention program (stop smoking program) . The insurance company should not have to pay their customers to live healthy—it isn’t fair for us to have to pay for their good behavior.

My company hired an independent marketing firm to evaluate three of our customers at random to find out how they made the decision to purchase an EHR, what led them to pick our product, and the most important question was did they get a positive return on their investment. The firm finalized three case studies. The findings were so startling that they called me up to discuss them before I read the report. The two findings they could not seem to understand were the following. Each of the three groups they picked made significant return on investment -- like in the neighborhood of for every dollar they spent on information technology they made 5-10 dollars back. The analyst indicated that if he had seen the data in a published report he would not have believed it even though he got to visit the groups and see it with his own eyes. Yet each group indicated that the dollar they spent to earn 5-10 dollars back was too expensive. In other words, I should lower the price of the EHR because it was too expensive. Normally, if you can spend a dollar and make 5 or 10 dollars back you would be more than happy. I know I would. By the way, this return didn’t take 5 years it took 2 years to get back (just in case you are wondering). So, why did they think it was too expensive? It is because in most cases physicians are purchasing these systems to make sure they are meeting Federal, State and commercial vendors’ regulations. They are afraid they will be audited and if they have incomplete records they will be accused of fraud. They purchase them so they can “fire” staff to reduce their expenses (they almost never can fire staff. In most cases they are understaffed); however, in 40% or more of the sales we have made one of the first questions we get is how many FTE’s can I get rid of? They seem to view the EHR as a punitive thing. They feel forced to purchase one. They feel that everyone else--the federal government, the state, the commercial payers and the patients--benefits more from the provider having an EHR then the provider does. It is hard to get excited by a $44,000 increase in fees over five years for using EHR technology when there is at least a 10% or more cut in Medicare fees coming to them in the near future. For a cardiologist, that represents a $50,000 reduction in fees in one year (not five years). You see the math doesn’t compute well for physicians. One might ask where the $50,000 cut came from. Here is the math. I estimated that a Cardiologist will bill Medicare approximately $1 million in fees per year. (This is based on a Cardiologist that does about 60% of his billing with high end medical procedures like Stent or EP studies.) Medicare on the other hand will only pay around 50 cents on a dollar so the Cardiologist will only be allowed to earn $500,000 (before you get too excited, the Cardiologist’s overhead and support costs will be somewhere between 45 and 60%). However, if Medicare cuts the fees 10% this results in a reduction of $50,000 to the cardiologist.

The quickest way to increase EHR adoption

The quickest way to increase the EHR adoption for private practitioners is to somehow reduce the burden of the cost. The simplest way is to offer an immediate tax deferment. A one time dollar for dollar up to $45,000 per cardiologist for EHR software and infrastructure would go a long way in accomplishing this goal. It is immediate and allows the Cardiologist to recover the fees the same year he purchases it. The second thing I would do is to allow $8,100 per year in additional incentives per cardiologist for meaningful use of the EHR. This additional money will allow them to keep the EHR up to date (18% of the original fee is a reasonable rate for support fees for this type of technology). I can think of several additional methods for increasing adoption rate. This one, however, is by far the simplest to administer and implement and would result in a large scale adoption movement. This program should be available to the Providers who already purchased systems as well as those who are looking to purchase systems. It will allow those who already invested to recoup some of their investment while also allowing them to update their older systems.