It's hard to think of any major portion of President Obama's health policy that hasn't engendered intense argument. But one at least comes close: the provision of the 2009 federal stimulus law that pushes medical practices to update their record-keeping for the 21st century. The aim is to ensure that all of the nation's medical records are computerized by 2014. There seems to be a broad consensus that increased use of electronic data will improve the quality of health care in the country and ultimately lower costs.
And here's why. In roughly three out of four doctors' offices in the country, patient charts are still updated by hand and stored in vast, color-coded filing cabinets. If a patient changes doctors, the file has to be mailed or faxed and the new doctor often has trouble reading the previous doctor's hen scratching. Patients walk out of a medical office with one or more tiny pieces of paper to get prescription drugs filled. When they come back for a follow-up, they have to bring a bag full of drugs so the doctor will know what the patient is taking.
Given such cumbersome procedures, few would argue that computerization isn't needed. But the federal program did lead to complaints in the beginning. Critics warned that doctors who serve mostly low-income patients would lack the time or inclination to make the painstaking switch to electronic records. They worried that the nationwide push would widen the so-called "digital divide" that already exists between doctors in affluent parts of the country and those in underserved urban and rural areas.
So far, that hasn't happened.
The $19 billion medical records law — which pays doctors to switch to an electronic system or upgrade one they're already using — is having an impact on the entire health care industry. And small primary care practices that treat Medicaid patients are no exception.
As of last week, the U.S. Department of Health and Human Services reported, more than 100,000 primary care doctors across the country had taken advantage of federal incentives to adopt a certified electronic medical record system. Half of the doctors were members of small practices that serve Medicaid and Medicare patients, and the rest worked in community health centers, public hospitals, rural health clinics and other public settings.
A national campaign
State-by-state breakdown of basic electronic record keeping
Lower than U.S. average:
Near the U.S. average:
state % w/basic system Maryland 13% Connecticut 15% Kentucky 16% New Jersey 16% New York 17%
Higher than U.S. Average:
state % w/basic system District of Columbia 18% Illinois 18% Missouri 19% Texas 21% West Virginia 21% Rhode Island 21% Louisiana 21% Delaware 21% Florida 22% Georgia 22% California 22% South Carolina 22% Tennessee 22% Alabama 22% Oklahoma 22% Wyoming 23% North Carolina 23% Indiana 24% Michigan 25% USA average 25% Arizona 25% Idaho 25% Arkansas 25% New Mexico 26% Pennsylvania 26% South Dakota 27% Colorado 27% Kansas 27% Ohio 27% Nebraska 28% Alaska 29% Maine 29% Montana 30% Vermont 31% Mississippi 33% Virginia 33%
state % w/basic system Hawaii 35% Iowa 38% New Hampshire 42% Massachusetts 42% Washington 44% North Dakota 48% Wisconsin 49% Oregon 49% Minnesota 49% Utah 52%
In addition to cash for doctors — $65,000 for every Medicaid physician and $44,000 for Medicare practitioners — states have been given millions of dollars to set up education programs aimed at helping the medical profession qualify. These advisory groups, called regional extension centers, have the job of translating some 700 pages of complex federal rules on so-called "meaningful use" of electronic health records. Some 22 states have set up regional centers, and several states have exceeded federally set goals for the number of doctors they enroll. Alabama is one of them.
When it opened its doors in April of 2010, the Alabama Regional Extension Center began calling, emailing and visiting 1,300 primary care doctors in the state in an effort to enroll them in the meaningful use program. A small staff of clinically trained experts offered free assistance in choosing a technology vendor and creating a plan for converting paper records into electronic format. They helped doctors and their staffs develop daily routines that included data entry and retrieval, as well as exchange of electronic information with pharmacies, hospitals and other doctors.
"It is not simple," says Mike Bice, one of Alabama's regional supervisors. "But it's a much better way to care for patients and a much better way to do business…The biggest thing we do is help them avoid strategic errors. There are so many ways to make mistakes."
As of last month, 1,100 Alabama doctors had registered for the program and of those, 640 were already using federally certified health records systems. In total, Alabama doctors have received $44 million in federal payments. That compares to $33 million in Georgia, which has more than twice the population. Other relatively poor southern states are raking in even larger incentive payments. Louisiana has helped doctors qualify for $84 million; Kentucky doctors have qualified for $65 million.
For Medicaid doctors — those with 30 percent or more of their patients covered by the federal-state program — qualifying for the first $21,000 federal installment is relatively easy. They simply have to adopt or upgrade a certified electronic records system.
For Medicare doctors, who are paid higher rates, the first step is steeper. They must qualify under the meaningful use rules immediately. For example, physicians' practices must maintain an up-to-date computerized list of medications and allergies for each patient, provide patients with summaries of every office visit, and transmit prescriptions electronically.
Ultimately, Medicaid doctors will have to adhere to the same set of rules in order to get subsequent installments of their $66,000 total incentive payment. But they have quite a while to do that. Medicare doctors must be certified by 2012 in order to receive their full incentive. After that, they have until 2014 to qualify for a smaller incentive of $24,000. Medicaid doctors have until 2021 to fully qualify.
In the meantime, states are developing what is known as a health information exchange that will allow doctors who convert to electronic systems to access patient records within the state through secure portals, and ultimately transfer records across the country.
In general, states are setting their own schedules for developing in-state networks and going national. South Carolina, for example, is already connecting doctors to a national health exchange, though its statewide network is not fully implemented.
In addition to primary care doctors, Alabama's regional extension team is helping independent pharmacies, small laboratories, and public clinics and hospitals get electronic health systems up and running. "Rural providers may not be ahead of the curve," says Dr. Daniel Roach III, Alabama's state health information coordinator. "But they won't be left behind."