So you have this idea to create a set of educational materials to help patients who have been asking you about the latest alarming disease of the day. But when you sit down to put your thoughts together, you realize you’ve never done this before. The questions mount: What should the document look like? How specific do I make it? Do I include studies? At what reading level should it be written? Should I make it poster-size and hang it up in the lobby? What about a guidebook? What exactly are the characteristics of a useful patient education resource? The tips and recommendations in this article are designed to answer these and other questions and help you work through the process of bringing your ideas for patient education materials to life.  

 on medical documentation and malpractice, said that medical documentation is supposed to “legibly communicate pertinent information” but that physicians often “approach documentation with the goal of communicating effectively with themselves.” 

His sentiments were quantified by researchers at Emory University School of Medicine (

http://dx.doi.org/10.1016/j.jamcollsurg.2008.06.184

www.medicalnewstoday.com/articles/125340.php

) who confirmed that doctors not only frequently approach medical documentation incorrectly, but also do the same when it comes to communicating with patients, frequently overestimating the literacy of their patient population. In one study of a 300-patient cohort whose members averaged a fourth-grade reading level, only 16% could comprehend all seven questions from the 

. Furthermore, there’s no guarantee that relatively literate patients will possess a similar level of proficiency when it comes to understanding math and numbers. A second study using the three-question Woloshin-Schwartz numeracy quiz found that only 31% of a 266-patient cohort was numerate and that “numeracy was shown to be an independent predictor of misunderstanding.” Frustratingly, researchers also reported that carefully designed pictures did not improve patient understanding, either. 

Being aware of your patients' potential literacy limitations should affect the type and complexity of the information you offer to your patients. 

When gathering information, think not only of simplification—patients in the second Emory study had difficulty discerning between the quantities 33% and one-in-four, and with answering the question, “During the last month or so, how often have you had to push or strain to urinate?”&mdash;but of ambiguity. Patients with limited English proficiency interviewed by the Mayor’s Health Literacy Fellowship Program revealed that they found certain words and phrases, such as “Don’t skip a step,” to have double meanings, enabling the 

New York City Health and Hospitals Corporation

 to eliminate ambiguous words and symbols from its patient education materials. 

Limit the scope of your work. Before you begin your research, decide on a main objective. Will this resource serve as background information for a discussion during an office visit? Should it serve as an at-home reference? Will it be a comprehensive guide that covers pathogenesis, patient risks, prevention, and treatment methods for a particular disease? 

Answering such questions at the outset of the document creation process will help establish an appropriate framework for the eventual finished product, allowing you to allocate your research time more efficiently and effectively. This will help you stick within the project parameters and avoid gathering too much (or overly detailed) information. 

Then, stick to your plan. If you find yourself drifting into areas outside the scope of the piece, set that information aside and use it to create another resource at a later date. 

The choice of format comes down to two key factors: 

Personal preference: Do you loathe brochures but love booklets? There’s not much sense in working in a medium that you can’t stand. Select the format that you think is most effective. 

Method of distribution: However, keep in mind that different formats may be more appropriate than others, depending on where the material is being distributed. If you want patients to grab the material from a waiting room, a small, colorful trifold in a holder might work best to attract their attention. If you’ll physically be handing the resource to someone and explaining the information to them, bulleted, block text on a sheet of paper will keep the information right in front of them for perusing as you talk. 

No matter the format you use to present information to your patients, keep in mind that this information and the way in which it is presented must not be a burden to the reader, or they won’t use the resources you give them. Again, consider what purpose you wish the piece to serve. What do you want the patient to do with the information on their own? How much do you want them to rely on you as a resource? Format will dictate how you are able to leverage information in order to meet these goals. 

Whether you’re building a new piece from scratch or you’re updating a pamphlet or brochure you’ve been using for years, the best place to start your search is the public domain. The depth and breadth of healthcare information presented on the websites of the 

, makes it perfect source material for patient handouts—it’s already been extensively vetted and designed with the patient in mind. These resources offer a wealth of condition- and disease-specific information online, including disease histories, geographic and demographic data, risk factors, prevention, diagnosis, treatment, side effects, complications, and new research. 

However, if your requirements call for more specialized content, you can turn to the professional literature and medical journals for more in-depth information (just remember that you will have to do quite a bit of work to interpret and contextualize this information for most patients). Physician-authored blogs are also an increasingly popular resource for assessing current opinion on new developments in a particular field and sharing anecdotal information. 

Depending on your practice setting, you may have to submit your materials to a review process before you are allowed to give them to patients. Even if that is not the case, it’s never a bad idea to consult with colleagues and other experts before you finish work on your project. Their insights, suggestions, and perspectives will allow you to see your subject from new angles and help improve the quality and educational value of the resource. 

Don’t be afraid to run long in your first draft. Now is not the time for brevity! You’ll be trimming and editing the piece regardless of how succinct you believe yourself to be. Besides, starting with too much information is a good way to separate wheat from chaff while ensuring you cover all the bases. (Mixed metaphor alert!) 

Although editing for space is essential, remember that “concise” is not always synonymous with “effective.” Though a patient’s attention span and ability to process information might be shorter and poorer than you’d like, use that to your advantage. Strike a balance between a Twitter post and the Encyclopedia Britannica and make every word count. 

Many physicians view the creation of patient education materials as part of their duties as healthcare professionals and therefore would not seek the aid of a freelancer for such a project. Others might not want to cede control over the creative process. For others, the issue may be as simple as money—why pay someone to do something that you can do yourself? 

But time is also money, and not everyone is interested in adding “writer” and “artist” to their job description. In that case, why not simply take advantage of all that information available online and find some ready-made patient education materials for use in your practice? While there are many excellent tools and resources for patients available online, many physicians report that one size definitely does not fit all, and that materials customized to the unique needs of their patients can often make a big difference in whether and how the patients use that information. 

More food for thought: The one successful method tested by Emory researchers to improve patient understanding was a computer-based program through which a figure spoke to patients and asked the same questions that were on the International Prostate Symptoms Score questionnaire. The program improved understanding for all patients at all educational levels. If you are interested in learning more about creating multimedia patient education resources, the 

UNC-Chapel Hill Health Sciences Library’s Media Design Studios

 offers step-by-step guides on creating animations, websites, posters, presentations, brochures, and digital images. These additional skills can help you better communicate with patients who may not respond to traditional means of information delivery. 

Don’t let all your hard work go to waste because you lost the latest version of your project due to a computer crash, or because you saved it “somewhere” and now can’t find it on your hard drive. Good filing and data backup practices are a must. Collecting all versions of your files in folders organized by topic type gathers all related items in one place. Subfolders or a standardized file naming practice will compartmentalize raw data and source material, working, and finished documents, as well as format types and older versions of since-updated materials. 

In an environment where numerous people have access to the same materials, a well-managed filing system will prevent one person’s modifications from altering the preferred aspects of a document for someone else. Additionally, well-kept records allow you to assimilate multiple projects into more complicated efforts, and also make it easy to refer to previous work when modifying and updating your materials. 

Further, keeping hard copy records in a similar filing system keeps extra materials handy and can serve as a physical backup if any electronic snafus occur. 

Well-planned and executed patient education materials are an important component of the physician-patient communication process. Although there are many useful resources available online from trusted sources that you can use in your practice, you may find that it is more than worth it to take the time to create customized materials with the unique educational needs of your patient population in mind. 

 editor and a freelance healthcare writer. His article “

Where Do We Go from Here? A Health 2.0 Progress Report

” appeared in the January 2009 issue of 

Articles

Feature Articles

So you have this idea to create a set of educational materials to help patients who have been asking you about the latest alarming disease of the day.

A Beginner's Guide to Creating Patient Handouts

Many of your current patients and patient candidates have grown up online and interact with the Internet differently than when the Web was new. Having only a basic website for your practice isn’t enough anymore; unless your site helps your patients find you, you could be missing out on potential revenue.   

If you’re going to connect with the Web generation, your practice must reach out to them in a way in which they are likely to respond. Even if your website provides valuable information about yourself, your practice, the procedures in which you specialize, news, and more, you may still not reach many prospective patients. One of the primary reasons for this is because your website is competing with medical directories like WebMD, BoardCertified.com, Healthgrades, and others. These sites have a huge database of physicians within their digital infrastructure, with hundreds of thousands of pages of content. How can you compete with such sites? The answer: you don’t. Instead, you should utilize these online resources to drive traffic to your site. 

Board-certified plastic surgeon and BoardCertified.com advisory board member Benjamin Schlechter, MD, FACS, experienced firsthand varying degrees of success with online marketing. “What I have come to understand about Internet marketing is that even though my website is very detailed and is referred to in search engine terms as ‘optimized,’ I am primarily reaching patients who are looking for me by name,” he said. Schlechter began exploring alternative means to promote himself online. “Ironically, the cost for me to maintain a membership in an online directory such as BoardCertified.com is fractional compared to the investment I made in my own website. Yet, the returns are greater.” 

To effectively reach Web-savvy patients, you must use more than just static Web pages. One of the most effective ways of attracting and keeping a captive online audience is through online video. Using video to market your practice lets you build a foundation of trust with patients before they ever walk through your office door. They can learn about your personality, your approach to treatment, and your quality of care. Three factors make online video so powerful: 

Study after study shows that most Web users do not read large blocks of text, preferring to skim text and graphics. They demand a deeper connection—a faster, more direct way to absorb information. Video provides a solution. From Hulu to YouTube, online video is exploding, and you should make every effort to include this on any website on which you promote your practice. Embedding customized video programming provides the chance to make a personal and emotional connection with potential patients. 

 It’s often difficult to communicate complex medical information to patients. Details of surgical procedures, the anatomy and function of the body’s organs, the effects of treatments—all can be sources of confusion and frustration for doctors and patients. Video communication helps cut through the confusion; one short animated segment showing a patient exactly what his or her treatment will entail is worth a thousand words of clumsy text explanation. 

Let’s face it: surgery can be scary. Not to mention, the clinical environment most people experience—a world of harsh glare, beeping machinery, strange noises, and intrusive strangers&mdash;isn’t exactly comforting. Online video can help minimize patients’ anxiety prior to surgery by showing them exactly what’s going to happen to them while they’re in your care, from admissions to the surgery itself to the recovery room. 

The unique BoardCertified.com network provides member physicians with an increased and more credible online presence, offering the ability to enhance their profile and practice information. The multi-tier membership offers a broad range of benefits to doctors, hospitals, and associations, including microsite profile pages, comprehensive physician profile pages, and even website design and hosting. The user-friendly BoardCertified.com platform also empowers patients with not only the ability to locate doctors in their area of medical interest, but also with knowledge and information about procedures and treatments. Patients can utilize the search functions on an unlimited and cost-free basis. 

The medical industry has changed exponentially over the past several years. You can no longer sit back and wait for patients to come to you. Patients are demanding quality care, timely service, and most importantly, customer satisfaction. They are also utilizing evolving means to research procedures and physicians, including online medical directories and other websites. In planning for the future of your practice, you must remember it is better to be proactive, not reactive. 

Mr. Fox is the president of BoardCertified.com. 

Tech Sectors


Having only a basic website for your practice isn’t enough anymore; unless your site helps your patients find you, you could be missing out on potential revenue.

Your Patients Are Online: Has Your Practice Gone Digital?

Preparing for the American Board of Internal Medicine Maintenance of Certification 

The following questions can assist candidates prepare for the Maintenance of Certification Exam in Cardiovascular Disease. Feedback regarding these questions is welcomed and can be sent to 

These questions were prepared by Pranab Das, MD. 

1. A 25-year-old black woman with a history of smoking, uncontrolled diabetes, hypertension, and morbid obesity presents to the emergency department with severe retrosternal chest pain that started 12 hours earlier. An electrocardiogram shows anterior ST-segment elevation myocardial infarction. She is emergently taken to the cardiac catheterization laboratory. Following percutaneous coronary intervention of her culprit artery, she is monitored in the critical care unit. She is continued on abciximab for 12 hours, given enoxaparin for deep vein thrombosis prophylaxis, and also starts taking aspirin and clopidogrel. A transthoracic echocardiogram is of limited value due to her morbid obesity. Two days later, as the patient is being transferred to telemetry, she develops sudden slurring of speech and left hemiparesis. A computed tomography scan of her head reveals no intracranial bleeding. She is immediately evaluated by neurology, and intravenous alteplase is administered. The patient has only minimal residual neurological deficit. What is the likely source of her neurological events? 

b) Carotid artery dissection during cardiac catheterization 

2. A 46-year-old white man presents to the emergency department with severe retrosternal chest pain and diaphoresis. He has multiple coronary risk factors, including smoking, hypertension, diabetes, and hyperlipidemia. The initial electrocardiogram shows 4-mm ST-segment elevation in leads II, III, and aVF, and a large R wave in lead V1. He has an elevated jugular venous pressure and a blood pressure of 84/40mm Hg. A bedside echocardiogram shows no evidence of pericardial effusion. While he is being rushed to the cardiac catheterization laboratory, he becomes extremely hypoxic. A 100% nonrebreather mask is placed, but the patient’s oxygen saturation continues to be in the low 80s. The most likely etiology of the patient’s hypoxia is: 

c) Patent foramen ovale with right-to-left shunting 

3. A 72-year-old white man with a longstanding history of a heart murmur recently received a diagnosis of metastatic carcinoma of the prostate. On physical examination, his murmur is best heard at the second intercostal space on the right side during expiration while he is leaning forward, and is holodiastolic in nature. A transthoracic echocardiogram shows severe aortic regurgitation. The patient is deemed not to be a surgical candidate for correction of the aortic regurgitation. The best course of medical therapy for this patient’s chronic valvular regurgitation is: 

c) Nondihydropyridine calcium channel blockers 

4. For patients with coronary heart disease (CHD) or CHD risk equivalents, the Adult Treatment Panel III guidelines recommend a goal low-density lipoprotein (LDL) cholesterol level of less than 100mg/dL, and an optional goal LDL of less than 70mg/dL for very high-risk patients, especially those with acute coronary syndromes. All of the following conditions are considered to be CHD risk equivalents, except: 

5. A 65-year-old white diabetic man presents to the emergency department at 8 am with acute coronary syndrome. An elevated troponin of 4.3 is found and an electrocardiogram shows dynamic changes suggestive of ischemia. The patient is given a chewable aspirin of 325mg and intravenous unfractionated heparin. He is taken to the catheterization laboratory later that day, where he is found to have a significant right coronary artery lesion. He is treated with percutaneous coronary intervention, and a sirolimus-eluting stent is placed in the right coronary artery. The patient receives eptifibatide during and following the procedure. He is also given 600mg of clopidogrel at the end of the procedure. His recovery is uneventful, and he is discharged to home on hospital day 2 on a regimen of aspirin 325mg daily and clopidogrel 75mg daily. During his follow-up visit 6 weeks later, he reports having some dark stools over the last 2 weeks with no associated epigastric pain or hematemesis. His hemoglobin has remained unchanged. In addition to starting a proton-pump inhibitor and referring him to a gastroenterologist, the following measure will likely reduce his risk of gastrointestinal bleeding without putting him at risk of stent thrombosis: 

c) Decreasing the dose of asprin to 81 mg daily and continuing the same dose of clopidogrel 

d) Continuing the same dose of aspirin and changing clopidogrel to every other day 

e) Stopping both the aspirin and clopidogrel as he has completed the recommended duration of dual antiplatelet therapy following drug-eluting stent placement

Pulse

The questions asked in this article can assist candidates prepare for the Maintenance of Certification Exam in Cardiovascular Disease.

Maintenance of Certification in Cardiology

Installing an EMR in your practice is a long, difficult, painstaking process that requires extensive research and due diligence, total commitment from staff, intensive training, and full support from a dedicated vendor. Given all that, plus the severe disruption to a practice’s workflow and productivity that is a hallmark of the installation process, it’s no wonder that EMR installations have a high rate of failure; in fact, the outcome can be so disappointing that more than one in 10 practices decide to reverse course on going digital and return to paper files.

 by the Medical Records Institute—itself no longer in business&mdash;suggested that 19% of physician practices had uprooted an EMR or were in the process of doing so. About 14% of 

 surveyed at a conference focused on EMRs had gone or were considering going back to paper. David J. Brailer, MD, PhD, former head of the 

Office of the National Coordinator for Health Information Technology

, once estimated that 30-50% of all inpatient, ambulatory, and ancillary 

 fail. As befitting the complex nature of EMRs, the reasons for failure are myriad and varied—practice mergers, vendor bankruptcies, cost, or simply user incompatibility. 

 in Davis, CA, which has just three physicians and a physician assistant at two locations, spent $50,000 on EMR software and maintenance over a four-year period beginning in 2004. Administrator Chris Taylor estimates that the practice used maybe 5% of the capabilities of Charting Plus EMR, a product now called MediNotes e, from 

. “We kind of went into it blindly. We didn’t fully understand the workflow,” Taylor says. “We were using a full-blown EMR as a document management system.” The doctors had made a decision to eliminate paper, but didn’t otherwise change many of their ways. “They still wanted to dictate,” according to Taylor, “but they didn’t want to chase charts.” 

The practice took a week off for training when it first installed the EMR, then came back to a full slate of patients. “We should have started back with schedules that were half full,” Taylor says in retrospect. It took until late 2007 for Valley Oak to realize something was wrong. “Almost two years ago, the docs decided they needed to change something,” Taylor explains. They made the choice to abandon Charting Plus at the end of last year in favor of a “hybrid” EMR from 

, for which Valley Oak pays a monthly subscription rather than hefty up-front licensing fees. Montvale, NJ-based SRSsoft defines a hybrid EMR as one that, like a hybrid car, reduces inefficiencies. In this case, customers select only those modules they need, such as remote access, e-prescribing, order management, or outcomes tracking and reporting. 

SRSsoft CEO Evan Steele puts the EMR failure rate at about 50%, based on the number of replacements the company has done. “But in high-performance practices, it’s up to like 80%,” he says, referring to practices with high-volume specialties that produce big charges for each patient visit. “Even the slightest decrease in productivity is magnified,” he says. 

That is true at Valley Oak Orthopaedics, where each surgeon might see dozens of patients a day when they’re in the office. “They couldn’t do that with a point-and-click EMR,” Taylor says. They perform surgeries at multiple hospitals and ambulatory surgery centers, and dictate notes at the surgical facilities. The new system gives the doctors remote access to their patient records from any of those locations, something they did not have with the old EMR system. “It’s got to make the doctor more efficient,” Steele says. 

Getting an EMR project right will only become more important now that the American Recovery and Reinvestment Act (ARRA) has allocated billions in subsidies for health IT. “Our clients want that money,” Steele says, voicing a sentiment felt across the EMR industry. 

Because the SRSsoft EMR does not have many of the features as some of the costlier systems on the market, the company so far has not sought recognition from the 

Certification Commission for Healthcare Information Technology

 (CCHIT). SRSsoft even makes a point in noting in press releases when new customers decide to turn off certified EMRs and switch to its product. That strategy may or may not work in the future. The 

Centers for Medicare and Medicaid Services

 (CMS) has required CCHIT-certified products for several demonstration programs, but it’s still unclear how federal officials will define the “meaningful use” of a “certified EMR” that will qualify healthcare providers for ARRA funding starting in 2011. 

The stimulus removes the cost barrier to EMR adoption, but that may be cold comfort to practices that already have shelled out big dollars on information technology. The Endocrine and Psychiatry Center in Houston ditched a Misys Healthcare Systems EMR two-and-a-half years ago after spending about $100,000 over five years on software, hardware, training, and maintenance. “I couldn’t afford it,” says one of the partners, endocrinologist Rikesh Patel, DO. 

, charged a license fee per user, and the practice, which now has eight physicians, was growing. Also, Patel says, the product did not offer the kinds of online services he wanted, including a portal for patients to view their medical records and test results, request appointments, refill prescriptions, pay bills, or have online visits with their doctors, for which the practice charges a fee. The practice switched to a little known, free, integrated EMR and practice management system called 

 that relies on advertising. When patients sign up to use the portal, they must consent to have advertising presented on the page, Patel says. He says 600 to 700 patients a month go to the site. 

With the online bill paying and, to a lesser extent, the e-visits, Patel says he is capturing $1,500 to $2,000 a month in revenue that otherwise would be written off as delinquent accounts. For this reason, Patel is not so much worried about losing Medicare reimbursements if the product does not turn out to meet the “meaningful use” standard. “Overall, it’s been fantastic for what I want to do,” Patel says. “I have been happy for the past two years and have not spent a dime, so all this talk about how it costs too much to implement an EMR or change over is ridiculous.” 

For the transition, Patel didn’t need to buy any new equipment, and the biggest investment was the time for staff training. Even that, though, was not so bad. “It was a lot easier to learn than the old system,” Patel says. 

Having already been through training on a previous system can make an EMR replacement much easier to manage than an original implementation. At Valley Oak Orthopaedics, Taylor actually has few regrets about spending tens of thousands of dollars on a system thatultimately didn’t work out, particularly in a region dominated by 

. “It was pretty inexpensive compared to some of our big-system competitors,” Taylor says. “We got value out of it and we learned a lot about EMRs.” 

Though it was a challenge for a small, busy primary care practice like Millennium Medical Services in Brooklyn, NY to change both its practice management and EMR software in a period of three months, Chief Financial Officer Loretta Vento says it was helpful that the three physicians and 11 full-time-equivalent staff members already had computer skills. “My docs were trained,” Vento says. They were comfortable with tablet PCs and had a wireless infrastructure in place. “When we went from Amicore to Sage, we were ready.” 

The practice went live with an Intergy product from 

 in December 2007. For the first two weeks, everyone learned the practice management and billing pieces of the new software. The third week, the practice turned on the EMR. “Within a couple of weeks, the physicians were comfortable with the software. Within a month, they were very comfortable,” Vento reports. 

Given the circumstances, the transition was remarkably smooth, since the impetus was a failed vendor, Amicore, a much-hyped venture between tech heavyweights 

. “We really thought that with that kind of backing, Amicore wouldn’t go anywhere,” Vento says. They were wrong. 

Back in 2004, Amicore was trying an approach that was relatively new at the time, giving customers an in-house server but hosting the data at its facilities. “Because of the instability of the product in the beginning, it was torturous,” Vento says, and the practice wound up with what she calls a “disastrous” installation. “It was a whirlwind. We were riding a roller coaster for about three years.” The founding partners sold the Amicore Penchart product to Misys in late 2006, but Misys later decided not to support the system anymore, leaving customers high and dry. “We could not go back to paper,” Vento says.

 Complicating the situation, Millennium Medical had wanted an integrated practice management system and EMR. While Amicore purported to offer one, the complete product with the PM piece included was just about to come to market when the company was sold. In a crunch, the practice turned to Sage, which had recently purchased the Intergy line from former 

, and the practice actually was a beta site for Sage. “We got a lot of attention from them in the beginning,” Vento says. There was a short-term productivity drop of 10-15% during the transition, which actually is less than experienced by many practices, and Vento believes the whole experience has been worth the time and effort. 

Still, no EMR project, replacement or otherwise, is without headaches. Millennium Medical wanted to find a way to migrate the Penchart data to the new system, or at least preserve existing records for viewing in Intergy. They could not, so users have to flip between systems to see older records. Similarly, Valley Oak Orthopaedics has left its Charting Plus software on its computers to pull up older records. 

, a physician-owned, multispecialty group with more than 200 providers in and around Albany, NY, two of the 35 practices in the organization had a “legacy” 

 EMR from before they joined the group in 2000-01. They also were the only two practices with an EMR prior to 2005, when the parent organization chose Allscripts TouchWorks—now called Allscripts Enterprise&mdash;as the EMR for the other locations. 

The first Allscripts go-live was in July 2005, and the installation was complete by October 2006. But the legacy NextGen EMR remained in place until March 2009. “We ran two platforms for quite a while,” says CMO Barbara Morris, MD. The cost of running two systems was too high, particularly because the NextGen EMR ran on 

, while the Allscripts product is delivered via a Web interface. This year, the last two practices switched to Allscripts. 

For a large practice, Morris says there was a “huge EMR implementation and support system within the company.” Within a month, the “good users” were using advanced features such as data mining and quality reporting. The IT group within Community Care worked withallscripts to extract discrete data from NextGen and translate it to the Allscripts database, a difficult proposition. Morris says the physicians who had used NextGen for so many years had to overcome various psychological barriers more than any technological issues during the transition. “I think it was difficult, but not logistically,” she says. 

Really, it all comes down to usability and physician satisfaction. “It still frustrates me how doctors who don’t know technology spent a fortune on their EMR and didn’t get anything out of it,” says Patel, who has found success in his second time around. “I have had so many happy patients; they tell their friends and family about the new EMR system I use, and my practice has grown three-fold.”

Neil Versel is a freelance writer and proprietor of Neil Versel’s Healthcare IT Blog (

Cover Story

Installing an EMR in your practice is a long, difficult, painstaking process that requires extensive research and due diligence, total commitment from staff, intensive training, and full support from a dedicated vendor.

Will Your EMR Installation End Up a Sweet Success, or Will Your Plans Go Sour?

The recently enacted American Recovery & Reinvestment Act (ARRA), commonly referred to as the “stimulus plan,” includes more than $19 billion in incentives for physicians to adopt electronic health record (EHR) technology. This part of the ARRA legislation is known as the Health Information Technology for Economic and Clinical Health Act (HITECH). In essence, HITECH calls for physicians to earn up to $44,000 over five years if they use an EHR in such a way as to comply with yet-to-be-finalized criteria. So, if you are one of the 83% of doctors who have not yet implemented an EHR system, now may seem like the perfect time to do so. But not so fast… 

Now, I’m probably the last person you’d expect to be saying this, but as I investigated the actual details of this law, I came to a startling realization: none of the details have been worked out, and running out to get an expensive EHR system in hopes of recouping the cost through the incentive programs is nowhere near a sure thing. 

Let’s start with what is known. Beginning in 2011, physicians can receive extra Medicare payments for the “meaningful use” of a certified EHR. These payments can total as much as $18,000 in the first year for practitioners who adopt in 2011 or 2012, with slightly lower amounts for those who do so in 2013 and 2014; incentives are gradually reduced and then end in 2016. For physicians with high volumes of Medicaid patients (30% or higher), the law provides subsidies through the Medicaid program as well. Doctors must choose whether to participate in the Medicaid or Medicare bonus program; they cannot receive bonus payments from both. 

Thus, eligible professionals demonstrating meaningful use of a certified EHR starting in 2011 could collect $44,000 over five years. Waiting until 2013 would result in a maximum bonus of $27,000 over three years. HITECH also imposes financial penalties to spur adoption. Physicians who are not using EHRs meaningfully by 2015 will lose 1% of their Medicare fees, then 2% in 2016, and 3% in 2017. The bottom line is that 2011 is still 18 months away, so there is plenty of time to wait to make a decision about your EHR, even if you want to collect the maximum $44,000 benefit. 

What qualifies as meaningful use of a certified EHR? 

The law states that only “eligible professionals” who “meaningfully use” a “certified” EHR will able to collect the stimulus money. Yet none of these terms have been authoritatively or legally defined. There is much analysis and information about this legislation from various sources floating around the Internet, but none of it has the official seal of government approval. Like most new laws, it will probably take years of regulation, test cases, and interpretations by lawyers and courts before we have definitive answers to many of our questions. We can, however, make some logical assumptions based on the goals of the government. 

The biggest issue is America’s high level of healthcare expenditures (compared to the rest of the world). Thus, we can assume that meaningful EHR use will promote the functions that can reduce this cost, such as prescribing generics, sharing lab and radiology findings among physicians rather than reordering tests when the results aren’t readily available, and ensuring that standards of care for community health are followed. 

Using e-prescribing, computerized ordering/reviewing of tests, and health information exchange networks all seem to be part of what would be defined as meaningful use; unfortunately, it seems unlikely that tort reform will make it into this discussion to any significant degree, and thus we will continue to practice defensive (and expensive) medicine, ordering questionable tests, procedures, and consults just to reduce our risk of lawsuits. 

In terms of a “certified” EHR, it seems reasonable—and it is assumed by many observers&mdash;that CCHIT (Certification Commission for Health Information Technology) certification will suffice in lieu of a formal government certifying body. So, even though CCHIT charges tens of thousands of dollars to apply&mdash;and requires not only the “meaningful” features above, but also hundreds of other “bell and whistle” features that make EHRs less usable&mdash;it looks like that is the future of our EHR choices (Amazing Charts is currently going through the onerous process of getting CCHIT-certified, so watch for a future article describing this experience). 

The most important question for physicians is how to get the promised money (before future budget cuts remove it). I reviewed the HITECH legislation and couldn’t find any real details on how the money was to be distributed. I went to the Healthcare Information and Management Systems Society (HIMSS) conference, where everyone was buzzing about the HITECH legislation. I had two basic questions, assuming I used a certified EHR in a meaningful way by 2011: 

• Who is an “eligible professional?” An eligible professional appears to be a physician, but does a nurse practitioner or physician assistant count? What if this mid-level practitioner owns his or her own practice? 

• How does a physician actually get the money? It appears that you are allowed up to 75% of Medicare payments per physician, but will the payments come in a lump sum, or over time, or piecemeal with each Medicare payment? 

Amazingly, nobody I spoke with—including a number of EHR vendors who were advertising the $44,000 stimulus funds to entice folks to purchase their overpriced systems&mdash;knew the answers. Eventually, I found a booth for the agency tasked with overseeing HITECH, the Office of the National Coordinator for Health Information Technology (ONCHIT). There, I spoke with two representatives (who requested not to be identified). One said they just didn’t know; the other said she “couldn’t answer.” When asked if she couldn’t because she didn’t know, or wouldn’t because she wasn’t allowed, she replied, “A little of both.” 

Frankly, I have no idea what that means. It certainly sounds cryptic, but the fact that even an ONCHIT representative couldn’t (or wouldn’t) provide the answers to simple questions is astounding, especially given the way in which this money is being advertised by vendors and agencies with an interest in accelerating EHR adoption. 

While it is disappointing that there is, as of yet, no clear interpretation of several fundamental parts of the HITECH legislation, it is unconscionable that vendors and other groups are hyping this money knowing that the details have yet to be defined. I suspect we’ll find, as we did with the promise of P4P, that the actual money delivered is far less than what was implied. A further risk is that the next administration or congress may choose to cut funding for this incentive program due to fiscal constraints. In the end, it is the underpaid and overworked primary care physicians who will be cajoled, enticed, and ultimately forced into spending tens of thousands of dollars for unproven technology. 

I will continue to closely follow and report on how these critical issues play out over the coming months. Until then, slow down and try to ignore all the background noise from vendors and other groups with their various agendas, pushing you into an EHR solution before you’re ready. 

Dr. Bertman is Physician Editor-in-Chief of 

. He is a Clinical Assistant Professor of Family Medicine at Brown University and president of AmazingCharts.com, a leading developer of EHR software. He is also the founder and president of AfraidToAsk.com, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI. 

Columns

The recently enacted American Recovery & Reinvestment Act, commonly referred to as the "stimulus plan," includes more than $19 billion in incentives for physicians to adopt EHR technology.

I’ll get $44,000 to Use an EHR? Where do I Sign Up?

It’s been three months since the passage of the American Recovery and Reinvestment Act of 2009 (ARRA), which incorporated the Health Information Technology for Economic and Clinical Health (HITECH) Act and its provision for billions of dollars in incentives to promote the use of interoperable, certified health information technologies. Although much is already known about the details surrounding this initiative—potential reimbursement timetables have been published, along with eligibility criteria for the Medicare and Medicaid portions of the programs&mdash;there is still much uncertainty over what qualifies as a “certified” EHR and how “meaningful use” of this technology will be defined. But, progress is being made every day. 

Consensus seems to be forming around several factors that will define meaningful use: physicians will have to use EHRs to e-prescribe, coordinate care with other providers by exchanging patients’ clinical summaries and other data, and electronically document and report on quality metrics. ARRA established an HIT Standards Committee tasked with providing recommendations regarding certification criteria, implementations standards, and other issues. The committee has just begun the process of deliberation, testimony, and comment that will inform its decisions. John Halamka, MD, Chief Information Officer and Dean for Technology at Harvard Medical School, is also vice chair of the HIT Standards Committee. He published a recap of the first committee meeting at his website (

http://geekdoctor.blogspot.com/2009/05/first-meeting-of-hit-standards.html

). In addition to outlining what he refers to as the committee’s eight “guiding principles,” he also outlined several major themes that emerged during the meeting that will shape the debate going forward, and explained the standards adoption processes (the full implementation and operating plan is posted at 

www.hhs.gov/recovery/reports/plans/onc_hit.pdf

I agree with Dr. Halamka that this document does a good job summarizing, as he puts it, “the magnitude of the work ahead” for the Office of the National Coordinator for Health Information Technology. He also states that “with each passing day, more and more details of the new plan are published at a remarkable pace.” That pace may not be fast enough, however, for physicians who are anxious to get started with the EHR selection and implementation process (which can take upwards of a year) but who are also worried that, in the absence of clear cut definitions for “certified EHR” and “meaningful use,” the system they purchase now may not meet the final eligibility requirements. With so many vendors claiming that they “know” what the meaningful use criteria will be, this anxiety is understandable. So I put it to our readers: Is there enough information currently available to make prospective EHR users reasonably certain that they can implement an HER secure in the belief that they will be eligible for the CMS incentive payments? Or is it wiser to take a wait-and-see approach, at least until the initial criteria are announced in December? Or, should the financial incentives not factor into this decision at all?

Editor's Note

It's been three months since the passage of the American Recovery and Reinvestment Act of 2009, which incorporated the Health Information Technology for Economic and Clinical Health Act and its provision for billions of dollars in incentives to promote the use of interoperable, certified health information technologies.

May 2009

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I’ll get $44,000 to Use an EHR? Where do I Sign Up?

Hurry Up and Wait