There's been a push in recent years for medical providers to move toward an electronic health record (EHR) – and away from piles and piles (and piles) of paperwork.
The health care industry is one of the few that remains reliant on paper records, which complicates an already complex line of work. While other fields depend upon email, e-conferencing and server storage to make their organizations go, medical providers are still using handwritten notes and fax machines.
"Essentially for years and years and years, we've all gone to see the doctors and they've written into a paper chart," said Nina Vaccaro, the executive director of the Southside Coalition of Community Health Clinics.
But that's becoming less and less practical – not to mention more and more costly – so the eight member clinics all decided to make the conversion to an EHR.
Why make the switch?
An EHR is what it sounds like – an electronic record of all of the health charts, forms and documents that currently reside in physical files. Before providers begin inputting information electronically, though, they've got to convert the information they already have, which is the culmination of decades' worth of care.
"The challenge is moving years and years of paper record into the EHR and making sure that we're not losing any patient information along the way," said Vaccaro.
The challenge is so Herculean, in fact, that it begs the question: How is it that medical providers have relied on paper records for so long, so many years into the digital age?
"That's a great question," laughed Dr. Elaine Batchlor, the chief medical officer for L.A. Care, a nonprofit that provides health care to the county's most vulnerable populations. "One reason is that physicians have operated sort of a like a cottage industry with a lot of very small physician officers and practices. These are not large organizations, so they haven't had the capacity to really lead this kind of transformation."
Batchlor said capturing medical information is "much more complicated" than capturing, say, financial information.
"It's taken longer for the industry to develop standard formats and standard language to do that, and it's still evolving," she said. "It's just a much more complicated process and undertaking."
And then there are the finances: Federal and private incentives to convert to an EHR have only popped up in recent years, and those make it much easier to implement the system. St. John's Well Child and Family Center, a member clinic of the Southside Coalition, began implementing an EHR system in April 2011 and had finished by December 2011. The approximate cost of implementation was $1.5 million, but the clinic received slightly less than $1 million in funding for the implementation.
Batchlor said costs generally range from $5,000 to $15,000 per provider, which includes a one-time implementation fee, hardware, software and connectivity – there are also ongoing maintenance costs. (Those costs, though, can go much higher.) On top of that, providers who have implemented an EHR can expect about a 25-percent drop in productivity while their medical staffs learn how to use it. Once a provider finds its footing, though, productivity usually goes up.
So does the quality of care.
"One of the main impetuses for implementing these systems is to improve quality and efficiency," said Batchlor. For Vaccaro, it's a "great way to collect data about patients and community health and practices," as well as a "great tool of accountability."
"Monitoring the quality of care that's being provided by the agency is a really important component of EHR," she said. "There's also information that says once you have a doctor that's up to speed on the EHR, they're actually more efficient in the care they provide."
Jim Mangia, president and CEO of St. John's, agreed.
"The challenge is it reduces your productivity substantially, because providers have to get familiar with it," he said. "You can't see as many patients. And it's very expensive. But once you get over that hump, you can then increase your productivity. You can standardize your care so that everybody's providing the same level of care to everyone."
It also lends more options in terms of compiling public health data, he said.
"Before, we used to randomly pull 70 charts to get a sense of what our standard of care is," said Mangia. "Now we just press a button and print a report of every patient that shows us what the trends have been. It's much, much easier to collect data, and that really allows you to impact population health in a much more substantial way."
Vaccaro added that it's also a big part of a clinic becoming a patient's "medical home": It more easily provides patients with medical information (sometimes via online patient portals) and helps providers keep better track of when patients are due for procedures.
Challenges and moving forward
Cost – financial and productivity-wise – isn't the only hurdle, though. As with any electronic storage method, the risk of information loss or security breaches is considerable, so those implementing the systems have to create backups, both on- and off-site. (Clinics in California, said Vaccaro, have to look to non-earthquake prone states for servers on which to store their backup records.)
On top of that, the process of researching, choosing, implementing and maintaining an EHR can be overwhelming, which is part of the reason the federal government established regional extension centers in every geographic region, said Batchlor. These centers are "charged with reaching out to small practices and community clinics" to provide "federally-subsidized technical assistance for the whole EHR implementation process." L.A. Care operates the regional extension center for the county.
"They really provide on-site hand-holding for the providers through that process," she explained.
That hand-holding is important because providers have a deadline. President Barack Obama's 2009 stimulus package allocated $20 billion to the development of a health information technology infrastructure. Early adopters receive a pretty significant sum in incentive money, but Medicare-eligible providers who haven't adopted an EHR by 2015 will start to get penalized by way of reductions in their Medicare funding.
Batchlor says not all providers will be on EHR by that deadline.
"That's an ideal that will not be 100 percent realized," she said. "What the federal government is trying to do is strongly encourage providers to move in that direction by providing incentives first, then switching over to penalties. By the time the deadline arrives, if the carrot hasn't worked, then they take out the stick."
But the carrot ought to work, because it's to providers' advantage to use an EHR. Several provisions of the recently-upheld Affordable Care Act (ACA), she said, "will push providers to be using EHRs," including payment process changes and innovation programs.
"EHR and health information technology are tools to redesigning health care delivery to make it more affordable, more efficient and consistently better quality," said Batchlor. There are programs in the ACA to that end, she continued, "and to the extent that providers participate in those things, they will have to use EHR technology to get there."