Wednesday, September 10, 2008

Can IT Help Hospitals Improve Their Relationships With Community Physicians?

In boardrooms across the country, health system chief executives are searching for any tactic that might better align hospital and physician interests. Downward pressure on physician incomes has placed unprecedented strain on hospital-physician relations. At a minimum, doctors are increasing their productivity by reducing the time they spend on hospital initiatives. On the other of end of the spectrum, some physicians are competing directly with local hospitals through physician-owned outpatient centers. 

From a hospital perspective, this growing disconnect could not come at a more inopportune time. From reining in supply costs by standardizing preference items to enhancing quality on reported metrics by complying with evidence-based guidelines, physicians hold the power to make or break hospitals' most critical priorities. Health system executives have responded by experimenting with a wide variety of strategies to exert greater influence over physicians. 

So what does this have to do with IT? Until the spring of 2007, not a whole lot. That's when HHS and IRS ruled that hospitals and other key stakeholders could subsidize up to 85% of the costs of electronic health records for physician offices. A new hospital-physician alignment strategy was born. Prior to the changes, the Stark Act and federal anti-kickback rules were interpreted to bar hospitals from donating technology or making other gifts to doctors or independent physician practices. 

Hospital leaders theorize that subsidizing EHRs can generate significant goodwill with physicians. They envision a world in which the seamless transfer of information between the physician office and the hospital would encourage doctors to admit patients to that hospital. In its Annual Survey of Executive Opinions on Key Information Technology Issues, 
Modern Healthcare reported that more than 70% of hospitals already extend IT benefits to physicians through the waiver program or plan to do so in the next two years.

Challenges of Physician Office EHR Implementation

While their peer executives celebrated the Stark ruling, hospital CIOs cringed. During recent Advisory Board research on physician office EHR implementation, one hospital IT executive commented, "I used to view Stark as my friend. I could tell independent physicians, 'I would love to help, but Stark won't let me.' ... Philosophically, it's not too hard to argue that the physician office [electronic health record] would be wonderful, but the fact of the matter is that I'm faced with an unlimited list of capital requests just from my own facilities, never mind trying to take on all the needs of physician offices." 

The challenges of implementing EHRs in independent community physician offices are numerous. They include: 

  • Allocating the necessary resources within an already overburdened hospital IT department;
  • Educating physicians on the hardware and infrastructure investment they must make without the hospital's support;
  • Integrating physician office data with information from inpatient systems (which might not be integrated themselves);
  • Accelerating change management within independent community physician offices where the hospital has little or no authority; and
  • Protecting physician productivity (and income) following implementation.

For hospitals subsidizing physician office EHRs, the stakes are high and failure is not uncommon. 

While serving as the National Coordinator for Health IT, David Brailer wrote, "Clinicians who purchase an EHR and who attempt to change their clinical practices and office operations face a variety of risks that make this decision unduly challenging. Implementation failure and partial use of EHRs are commonplace."

Effects on the Hospital-Physician Relationship

To be sure, offering physician office EHRs to community physicians will change the hospital-physician relationship, but not necessarily for the better. Hospital IT departments will effectively become vendors for their community physicians, providing services to doctors for a fee, albeit a heavily discounted fee. 

Because most physicians expect the same level of service and flexibility offered by vendors, many hospitals have turned to a vendor-hosted application service provider model. While outsourcing affords a number of benefits, it limits the hospital's opportunity to build close relationships with physicians and potentially restricts access to patient information. Furthermore, early adopters have found that even when implementation is outsourced, many physicians still hold the hospital accountable for successful deployment.

Beyond any hoped-for improvements in physician-hospital relations, there is genuine value in collecting and communicating information between care settings. Wiring community physician offices with an interoperable office-based EHR holds the potential to elevate care quality by breaking down information silos across sites of care. 

With poor information transfer causing 20% of adverse drug events, there is a clear opportunity to reduce these events and the associated costs through office-based EHR adoption. In order to achieve these community-wide gains, however, a critical mass of physicians must adopt the office-based EHR, and the systems must be interoperable with inpatient systems. 

Unfortunately, securing interoperability is fraught with roadblocks, including the multitude of vendor products, uncertainty over data ownership and physician concerns with patient privacy. As a result, only about a third of family practice physicians with an office EHR have an interface with the hospital, according to a survey conducted by 
Family Practice Management.

Hospital executives viewing EHR subsidies as a powerful strategy for aligning interests with their community physicians should consider that the negative ramifications to hospital-physician relations of a failed implementation might very well outweigh any potential goodwill generated from a successful deployment. Hospitals and health systems hoping to strengthen their relationships with community physicians through EHR subsidies might be better off considering alternative strategies.

Source : Matt Cinque (iHealthbeat)

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