Despite incentives, doctors are wary about switching to electronic health records By Lena H. Sun Wednesday, March 16, 2011; 10:54 AM With funding and technical support from his employer, Washington internist Brad Moore made a swift transition to electronic records seven years ago. He now pulls up a patient's chart with a few clicks of his mouse. Lab tests show the man, a diabetic, has his blood sugar under control. A surgeon's note describes progress after a shoulder operation. Before heading to the exam room, Moore, 47, clicks on a yellow "FYI" button, the electronic equivalent of a sticky note. It reminds him to ask how his patient is doing after his wife's recent death. About 20 miles away in suburban Maryland, internist Jonathan Plotsky hunts for the same kind of information in charts, some of them six inches thick, others taking up three volumes. He is well aware of the benefits of electronic records, but like most U.S. doctors, Plotsky, 56, is hesitant to switch. At up to $50,000 per clinician, the systems cost too much for him and the part-time doctor with whom he practices, he says. He doesn't know what to buy, how to install it or how he would transition to paperless. "I'm waiting to see what will work for people," he says. The cost is prohibitive. It won't be any more revenue, and it will change the way I do things. This spring, the federal government will ramp up cash incentives to encourage doctors such as Plotsky to take the step Moore barely thought about in 2004 when George Washington University Medical Faculty Associates introduced its practice-wide electronic system. Under an ambitious plan to modernize health care in much the same way paperless technologies have revolutionized banking and retail, federal officials plan to provide up to $27 billion over 10 years to encourage doctors and hospitals to go electronic. More than 500,000 doctors, dentists and nurse practitioners could qualify for the federal incentives, which are part of the 2009 economic stimulus program. But at least two deficit-reduction bills have been introduced in the House that target the payments as part of unspent stimulus funds. Those efforts are unlikely to succeed, said health-care IT analysts, because Democrats control the Senate and President Obama is almost certain to veto any move to strip money from the project. All this leaves doctors such as Plotsky confused about the federal government's carrots and sticks. Many are aware that beginning this year, health-care professionals who effectively use electronic records can each receive up to $44,000 over five years through Medicare or up to $63,750 over six years through Medicaid. But to qualify, doctors must meet a host of strict criteria, including regularly using computerized records to log diagnoses and visits, ordering prescriptions and monitoring for drug interactions. And starting in 2015, those who aren't digital risk having their Medicare reimbursements cut. Nonethless, Jay Bernstein, a Rockville pediatrician, remains more adamant than Plotsky. Going digital should not be a mandate with penalties, he believes. And the benefits, such as more accurate documentation, are outweighed by costs - both in dollars and in the changes that making the switch would bring to his work. "These ivory-tower types try to boil down the art and practice of medicine into something that can't be boiled down," said Bernstein. Practical barriers About 20 percent of U.S. hospitals and and 30 percent of office-based primary-care doctors - about 46,000 practitioners - had adopted a basic electronic record in 2010, according to government statistics. But most doctors would need to upgrade those systems to qualify for federal incentives. Recent surveys show that more than 45,000 doctors and hospitals have sought information or registration assistance from the federally funded help centers set up around the country to give free hands-on support; an additional 21,000 have begun signing up for the payments. Advocates say the benefits of computerized systems are numerous. When a doctor or nurse is about to decide on a prescription or lab test or whether to hospitalize a patient, "there is nothing as powerful as giving them information that is relevant to them just at that point," said David Blumenthal, the government's national coordinator for health information technology. In addition to gathering each patient's medical history in a single database, the systems use reminders and alerts that register allergies and unsafe interactions when a new drug is prescribed. They also allow doctors to check for previous labs and X-rays to prevent duplicative tests. Blumenthal, who recently announced his return to his Harvard University teaching position, said he benefited from such an alert when he ordered a CT scan of a patient's kidney. An electronic reminder told him a previous CT scan had imaged the patient's kidney. He canceled the order. "If every doctor had that kind of experience once a month, think of all the money and incovenience to the patients that could be saved," he said. Critics worry about privacy concerns and medical errors. Doctors seeking cash incentives for going digital must use systems capable of being encrypted. But no federal regulations clearly require that doctors turn the data encryption on or prevent those who don't do so from getting paid, said Deven McGraw, director of the health privacy project at the Center for Democracy & Technology, an advocacy group. "This is a point of frustration," said McGraw, who sits on an advisory group that sought unsuccessfully to prevent those who violate privacy regulations of the federal Health Insurance Portability and Accountability Act, or HIPAA, from getting incentive money. Joseph Kuchler, a spokesman for the Centers for Medicare and Medicaid Services, acknowledged that providers can operate an electronic system with its encryption turned off. But any that do so are violating HIPAA and face stiff penalties, he said. As a condition of receiving payments, providers are also required, generally, to protect health information privacy. Those potential penalties "will serve as strong incentives to ensure that the encryption technology is not permanently turned off," Kuchler said. As a practical matter, doctors say, they keep encryption functions turned on to comply with HIPAA patient privacy rules. Some studies have also highlighted computer errors and design flaws that can affect prescriptions; others have questioned whether electronic records result in better outcomes. However, a study in the March issue of the journal Health Affairs surveyed the recent literature on electronic health records and found that 92 percent reached positive conclusions. Still, new systems "will give rise to other problems we may not be able to anticipate," Blumenthal said. To address those issues, his office gave a grant last December to the Institute of Medicine for a year-long study on ways to improve the safety of electronic health records. Convenience for patients Many doctors point out that they bear the biggest costs, while patients and insurance companies benefit most. Nafeesa Owens, 34, a Springfield mother of twins, loves the convenience. She fills out forms and sends questions to doctors and nurses at her pediatrician's special online patient portal. I'm a big fan. Everything is at your fingertips," she said, juggling 9-month-old Austin and Zavier during a recent checkup at the Lorton office of All-Pediatrics, a Northern Virginia practice that went digital two years ago. Tom Sullivan, 72, said all six pediatricians in his practice use laptops perched on tables that they wheel from exam room to office. He calls them "cows," computers on wheels. During a recent weekday, he is checking 3-year-old Marin Blaya, who has yet another ear infection. Her exasperated grandmother, Cynthia Blaya, thinks it's time for ear tubes. Not yet, Sullivan replies, after checking the girl's medical history. He prescribes amoxycillin, an antibiotic. Immediately, a notification alerts him to Marin's asthma and eczema - conditions that may increase the likelihood of allergic reactions. He acknowledges the reminder, then finishes filling the prescription. It says you go to the CVS on Franconia Road. Is that still the one you want?" he asks, turning to the grandmother. She nods. He taps with his stylus. The order is instantly sent. Doctors say the biggest benefit for patients is having their entire medical record in one place. "In the old paper days, the chart frequently wasn't with me when the patient called, and even if it was, perhaps the lab results were in there, but I would have to wade through and find it," said Moore, the GWU doctor. All 550 physicians in Moore's practice, the area's largest independent physician group, use the same system. Executives won't say how much it cost, but annual hardware and software maintenance alone runs about $2.5 million, and salary for dedicated IT staff is an additional $3.2 million. Biggest obstacle: money Eugene Sussman, who works with 11 other pediatricians in Montgomery County, is on the fence. He figures it would cost his practice at least $250,000 to go paperless. To help defray the cost, Sussman is considering affiliating with Children's National Medical Center. Children's and Rockville-based Adventist Healthcare offer subsidies to doctors if they affiliate with the hospital and use designated vendors. Even so, Sussman figures that subsidy would cover only about 15 percent of the total cost. The new Medicaid incentives could pay the practice more than $500,000. But there's a catch: To qualify, 20 percent of a pediatrician's patients must be Medicaid beneficiaries. At the moment, only 16 percent of the patients in Sussman's practice are in that category. The costs "are the biggest holdback nationwide," said Sussman, 64. Doctors who are my age, in their early 60s, maybe will retire out. They may think, 'I don't need this bother; it's going to cost more money and cost more time.'