ACP Pushes Quality as Key Role for EHRs

TORONTO — For electronic health records to have real value, physicians need to use them to improve quality, and not just to improve documentation and coding.

That's the message the American College of Physicians is sending to doctors, policy makers, and the health information technology industry with the release of a position paper on EHR-based quality measurement and reporting. Released in April during the ACP's annual meeting, the paper outlines several objectives to maximize the use of EHRs for reporting quality measures. For example, EHR-based quality reporting should use only those measures that are clinically relevant and that help improve outcomes.

The ACP also advised that any EHR-based measurement should use information that is routinely collected during a visit, including data provided by patients. This will likely require EHR systems to include new functionalities that are not part of today's standard systems, such as practice-based registries that allow reporting on a population of patients, as well as connections to patient portals.

It's critical that the collection of information does not create another administrative burden for physicians, said Dr. Michael S. Barr, the ACP's vice president for practice advocacy and improvement. “If we layer additional processes onto the daily workload of doctors, especially without taking away other responsibilities, we won't get the potential of EHRs because physicians will not implement them the way we're talking about,” he said.

The paper also emphasizes the need for EHRs to provide real-time clinical decision support systems that are linked to quality reporting. This type of functionality would allow physicians to get patient-specific recommendations after entering routine clinical information into the system.

This kind of real-time feedback has been lacking in current quality reporting programs such as Medicare's Physician Quality Reporting Initiative (PQRI), said Dr. Joseph W. Stubbs, ACP president. Dr. Stubbs said there is often a long lag time between when physicians report on measures and when they receive reports on their performance under PQRI. For example, he submitted his final 2008 quality measures in December 2008 and did not receive feedback until October 2009.

Most current EHR systems can't provide the level of functionality described in the ACP's policy paper. But technology is not the major obstacle, Dr. Barr said. A bigger barrier is the cultural change required of each member of the clinical team in rethinking the office workflow as part of EHR implementation, he said.

The other hurdle for implementing widespread use of EHRs for quality reporting is the physician payment system. The current volume-based payment system doesn't allow physicians to be paid for actually improving quality, Dr. Stubbs said. “Without the business model for practicing better quality of care, it's an extraordinarily expensive prospect for physicians, particularly in small groups, to think about putting in an electronic health record,” he said.

Despite these obstacles, the ACP is encouraging its members to adopt EHRs, and is launching new resources for evaluating the technology. At the annual meeting, the ACP demonstrated its new AmericanEHR Partners program (www.americanehr.com

The focus on using EHRs for quality comes as the federal government is finalizing regulations on what constitutes “meaningful use” of EHRs, the standard for qualifying for Medicare and Medicaid incentive payments under the Health Information Technology for Economic and Clinical Health Act. Physicians who demonstrate meaningful use of certified EHR technology can earn up to $44,000 in bonus payments under Medicare starting in 2011. A similar program under Medicaid allows eligible physicians to earn nearly $64,000 in incentive payments.

Dr. Stubbs said the federal incentives could be a big boost for physicians looking to purchase EHR systems. But the success of the program depends on whether the meaningful use criteria can actually be achieved. The worst thing would be for physicians to invest money up front to purchase EHRs, but find out later that they fell short of meaningful use by one measure and thus won't get any incentive dollars. “That would do more to destroy the effort than anything,” Dr. Stubbs said.

As written, the proposed rule on meaningful use is not achievable, said Dr. Peter Basch, medical director for ambulatory, EHR, and health IT policy at MedStar Health in the Baltimore-Washington area. But Dr. Basch, who also is a member of the ACP's Medical Informatics Subcommittee, said he is hopeful that the Centers for Medicare and Medicaid Services will modify the requirements so that the average physician can achieve meaningful use in 2011 or 2012. “These are dollars they do want to pay out,” he said. “They do want to make this reasonable for doctors to do.”