While iPad-specific EHRs continue to emerge, and every EHR vendor is trying to find a way to get to the “sweet spot” of customer expectations of having EHR on a tablet, the iPad for EHR  isn’t ready for prime time.  Some might turn that around, stating that EHR isn’s ready for iPad, which is probably equally true, but in the end the point is that doctors should not be thinking that iPad is their savior when adopting EHR.

Anyone who has ever tried to type an email on an iPad must continue to understand that the flatscreen keyboard is not an ideal text entry tool, especially when it occupies half of the screen when it pops up.  Plus, there are many EHR actions that require specific data entry that is blended with some typing, and that doesn’t lend itself well to an iPad (or any other tablet for that matter).

I made this point in a blog post last April, and now we have some proof.  Read this article.

Per the CTO of Seattle Children’s Hospital:  “Every one of the clinicians returned the iPad, saying that it wasn’t going to work for day-to-day clinical work,” says CTO Wes Wright. “The EMR (electronic medical record) apps are unwieldy on the iPad.”

This is not to say that it will never be an option to put an EHR (or a part of the EHR’s data) on an iPad… but doctors need to reduce their expectations that there will be a natural movement to tablets because they want the familiarity of carrying a record into the exam room with them.  It’s just not that easy.

When doctors are asked about their reluctance to adopt EHR, they tend to have a lot of reasons to avoid it.  Rates of adoption vary from 20-50% depending on the provider type and also on the degree of EHR use.  It is especially interesting to see reports that total EHR use for all clinical actions and documentation has been estimated to be as low as 10%, meaning that the overwhelming majority of doctors are still in the process of getting their EHR use patterns established.

A distinct psychology of EHR acceptance is well understood by those who have already implemented an EHR technology in their daily practice.  Doctors have contemplated the challenge of properly working with the patient while also having to turn to a computer to do data entry, and it makes them uncomfortable.  An online publication listed the concerns that doctors have about EHR adoption, in order of most to least significant:

• Hardware/Software Costs (66%)
• Finding Time for Staff Training
• Workflow Readjustment
• HIPAA/Privacy Compliance
• Downtime and Loss of Revenue
• Internal Management of IT
• Reliance on Vendors in an Emergency
• Loss of Patient Care Quality
• Deployment Logistics (15%)

The essence of this list is that there are a lot of reasons that a doctor can find for avoiding EHR.  But the most likely barrier is the doctor’s mindset.   A blog from Margalit Gur-Arie at http://thehealthcareblog.com/blog/2011/04/25/the-kubler-ross-model-of-ehr-adoption/ should help you see that even EHR adoption can be characterized in the “five stages of grieving” model.  I found it to be a most enjoyable read.

I view the EHR world as providing health care providers with improved, efficient patient care.  When those new to EHR think about their move from paper records, they worry about where their data resides because they tend to dislike the concept of having their patient data in electrons on media like DVDs or tapes.

When they think about web-based EHR, they worry more about having their data.  In my view, it’s a control issue.  With paper records, they had control of the data entirely – it resided in the little dark room in the stacks of cabinets where they were all alphabetized.  With a server, they had the DVD or tape backup in their briefcase.

With web-based software, the data is “in the cloud.”  That virtuality can give a feeling of lack of control.  Yet, the most careful controls that can be enacted exist with web-based software.  Real-time shadow backups can be done with web-based software, as well as ongoing backups and moving those backups offsite from the hosting center to protect the data against natural disaster.

Reading the Yahoo news description of how people in Tuscaloosa, AL, were dealing with the devastation from the tornado outbreak last week reminded me of how worrisome it is to have paper records or electronic records in the practice.  These unfortunate circumstances can happen anytime, and can take a practice and its patients to a position of zero data in a matter of minutes.  To read the Yahoo story, visit:  http://news.yahoo.com/s/ap/20110502/ap_on_re_us/us_severe_weather

With web-based software, your worries of losing your data can be put to zero.  That’s comforting and for me, as a user of RevolutionEHR, gives me a sense of maximum control.

The government’s EHR Incentive Program has resulted from the American Recovery & Reinvestment Act (ARRA), referred to as the “federal bailout bill” to stimulate the economy, that was passed by Congress in February 2009.  It has been written about many times, and by now you should know that the government is funneling $17 billion to America’s health care providers and hospitals to help encourage them to buy, implement, and utilize EHR technology.

The famous maximum bonus payment grid that has been reprinted in most optometry publications shows that an optometrist is in line for up to $44,000 for meaningful use of a government certified EHR technology (the total is $64,000 if at least 30% of your patients are covered by Medicaid, which is very uncommon.)  The bonus funds for the Medicare version of the EHR Incentive Program are paid over five years, and if you qualify in 2011 or 2012 you can receive up to $18,000 of that $44,000 in the first year.

You must understand that your bonus check will be calculated at 75% of one year’s Medicare allowable charges — yes, you will get your payment for seeing Medicare patients, and then another 75% on top of that!

This system feels backward to me.  The bonus payments should be increased as this process get harder.  Yet, you get 41% of the total bonus payment in the first year of meaningful use, when you are given the easiest path to demonstrating meaningful use.  This is also at a time when doctors are struggling just with the decision of “which EHR to buy?”  This has created an uneasy race to EHR adoption because doctor’s want (and feel they deserve) the money and they need to buy now if they want to achieve the maximum dollars.

Most concerning is the fact that this program has not been scrutinized to identify the potentially high number of doctors who do not have enough Medicare allowable charges to obtain the maximum bonus incentive payments.  Many optometrists do not see enough Medicare patients to add up to $24,000 in allowable charges for a year, which then calculated at a 75% bonus payment would put them in line for the first-year maximum bonus of $18,000.  Are you a “have” or a “have not”?

How do you know what your Medicare allowable charges are for a given year?  It’s not easy to calculate.  You must add together the payments received for Medicare patient claims for services, excluding non-covered services like refractions.  This means the payments from Medicare, plus the payments from the secondary insurances or the patients who pick up the copays and deductibles.

For a long time, I held the belief that this was no big deal for optometrists.  But a survey of 21 doctors in different practice settings showed a startling concern.  While the average Medicare allowable charges was $30,000, removing the 4 doctors who each had over $50,000 of allowable charges caused the average to drop to $14,500.  This means that the overwhelming majority of optometrists surveyed will miss out on some of the government’s first year maximum.  In 8 cases the doctors would miss out on over $10,000 of the first year’s $18,000 maximum.

For those health care providers who have a hefty Medicare practice, the Incentive Program will work out very well.  For those who have not had the time or demographics to build a Medicare practice, they will incur the same costs for adopting EHR as the heavy Medicare practices, but the government is essentially telling them that they don’t deserve the same funds to offset those costs.  That’s just not fair.

ODs tell me that they are worried about the EHR Meaningful Use Objective related to collecting vitals on patients.  “Expert” ODs and EHR vendors’ representatives are debating this point in various forums, and I have remained convinced that the necessity that is delivered in the CMS Final Rule on Meaningful Use is clear.  The rule clearly states that 50% of unique patients age 2 and over seen by the doctors must have height, weight, and blood pressure documented within the EHR reporting period.  That’s right — all three need to be documented (deep in the official rule, it says that weight can be patient self-reported.)

An exception can be claimed by any provider who believes that “all three vital signs of height, weight, and blood pressure of their patients have no relevance to their scope of practice” – wording taken directly from the CMS Meaningful Use document published on November 7, 2010.  The exceptions will be hard to come by for most health care providers.  I’m sure some ODs are attempting to perform their 2011 Meaningful Use with an EHR that is certified right now are preparing to tell CMS “I claim an exclusion”, but until CMS renders an opinion or verdict on such, we are left to be unsure if ODs can make such claims.

If we were to argue that vitals do not pertain to optometry, we would be ignoring the epidemic of obesity and diabetes in the US and their impact on a number of retina conditions.  Diabetic retinopathy is a serious problem, and it could be argued that more specialists like optometrists taking height and weight would help Americans become more aware of the risks from the underlying diabetes condition.

I also received a note from an OD who is involved in the Ocular Nutrition Society, who stated that he is aware of over 60 studies that link obesity to chronic eye diseases.  He succinctly noted that there are plenty of pieces of evidence that the government can use to say that we as specialists should be held to the standard of collecting vitals.   Consumers of American health care need to come to expect all doctors to take a more whole-body approach to their care, even when those doctors are optometrists.

As far as I’m concerned, it would have been helpful if CMS would have allowed for documentation of “patient declined weight measurement” or some sort of self-reporting in order to meet the measure, but those allowances don’t exist.  Furthermore, the self-reporting of height makes it harder to find a convincing reason for patients to step on a scale.

I remain convinced that those providers who are running out in front of official CMS determination of the exclusions are setting themselves up for failure.  If they get the exclusions counted, they will be vocal with their “I told you so” attitude, but I’d sure like to see CMS make some pre-emptive statement about their intent of this Objective on specialists.