The RAND Corporation published research regarding health information system implementation in 2005 entitled, "The State and Pattern of HEALTH Information Technology Adoption". RAND started the study in 2003 to attempt to understand and predict the factors that would influence the adoption of electronic medical records in healthcare. The research covered a number of different areas; however, I will focus on the factors that influence health information technology adoption. Specifically, this summary will try to address why ASCs appear to be lagging behind the already slow adoption of EMR when compared to hospitals.
EMR financial implications
Health information technology (HIT) has been at the center of attention in many organizations due to the passage of the American Recovery and Reinvestment Act of 2009 and the Health Information Technology for Economic and Clinical Health Act. The HITECH Act was embedded within ARRA and created incentives for healthcare organizations to implement EMR by decreasing Medicare funding to those organizations or providers which failed to implement EMR by 2015. This would be accomplished through a reduction in Medicare payments by one percent for the first year, followed by two and three percent reductions in subsequent years. There are also monetary incentives for early installations of EMR and those monies decrease with each year EMR is not in place. To qualify for the $44,000 payment, physicians must implement and use a certified EMR and meet the criteria for meaningful usefulness before January 1, 2011. If they qualify, payments will arrive over five years. The first-year payment is $18,000, followed by $12,000, $8,000, $4,000, and finally $2,000 (Bick, 2009). If providers choose not to adopt EMR until after 2011, the funding decreases.
In addition to the ARRA, the passage of the Healthcare Reform Bill put additional pressures on healthcare providers to increase their efficiency. By 2014, all Americans will be required to have healthcare insurance, adding over 32 million people into the system. Combine this with the tremendous shift in demographics with the 79 million aging baby boomers accessing more healthcare services and one has the making of a perfect storm (Rowe, 2010). The demand to have information flow seamlessly throughout the healthcare network will be instrumental to the overall success of healthcare reform.
Number of physicians impact adoption rate
Given these pressures to implement EMR, it is interesting to explore the factors that are influencing the rate of adoption. According to the RAND study, the adoption rate in 2003 for ASCs was approximately 13 percent, compared to 23 percent in the hospital setting. Some more recent marketing data posted on "Medicine and Technology" (www.medicineandtechnology.com) shows that 36.1 percent of physicians are using EMR in their practices. The number dramatically increases to over 70 percent if there are over 26 physicians in the practice (Kim, 2010). This tie between the numbers of physicians in a practice to EMR adoption rate was also evident in the RAND study where it was estimated that practices with over 30 physicians would have an adoption rate of 38 percent, three times higher than a single practitioner (RAND, 2005).
In another study conducted by the U.S. Department of Health and Human Services, the adoption rate in 2006 by physicians within the ambulatory setting showed a similar correlation between the number of practitioners and rate of adoption. This study indicated that practices with greater than 11 physicians had an adoption rate of 46.5 percent versus a solo practitioner at 24 percent (Hing, Hall, Ashman, 2010). All of these studies support a significant correlation between the number of physicians and the rate of EMR adoption. Therefore, given these statistics, the fact that ASCs have fewer physicians practicing within their structures may be a contributing factor to ASCs' slower adoption rate than hospitals.
Hospital affiliation a significant influence
Another factor influencing adoption within the ASC setting is whether or not it is affiliated with a hospital system or is freestanding. According to the Department of Health and Human Services study, the rate of adoption for a freestanding ASC was 22.3 percent versus a hospital-based ASC with a 62.4 percent adoption rate. The researchers then asked participants about their future intentions for EMR installations. Specifically, the ASC providers were asked about their plans to install EMR in the next three years. The freestanding ASCs responded that there was a 63.6 percent likelihood of having EMR installed by 2009, while the hospital-based ASCs reported a 87.7 percent projected installation by 2009 (Hing, Hall, Ashman, 2010).
The reason affiliation with a hospital system appears to be another factor influencing the adoption of EMR at the ASC level could be tied to the previous factor involving the numbers of practitioners, as hospital-based systems tend to be larger. It also could be related to the availability of capital funds. Smaller freestanding ASCs would typically not create the revenue to support expensive EMR installations. From my personal experience in managing HIT across 17 ASCs of various sizes, it is very difficult for the smaller one-room centers to fund these implementations. As such, we are considering less expensive electronic document management systems rather than complete EMR at these smaller locations.
High costs serve as big deterrent
According to a study conducted by Harvard School of Public Health and posted on "Harvard Science" (www.harvardscience.harvard.edu), 'inadequate capital for purchase' was the number one reason most commonly cited as the barrier (73 percent) to implementation of EMR. The second highest cited barrier to implementation was 'concerns about maintenance costs' at 44 percent (Datz, 2010). Again, from my experience, maintenance of these systems at remote locations is a challenge. Standalone ASCs would not have HIT staff available to them in-house as do the hospital-based ASCs. What appears to be lacking in these studies is the influence of an outside management company in the rate of adoption of EMR. There are a number of very large ASC management groups, with some managing hundreds of centers across the country. I would think that the rate of EMR adoption would be higher in these groups as they look to standardize practices and increase efficiencies. They would also be able to build an IT infrastructure or data center and have HIT professionals available for support.
Lack of federal funding hindering investments
Another factor that may be influencing ASC's adoption rate is that ASCs currently do not qualify for any of the federal stimulus monies. Although the individual physician's practices qualify for this funding, the centers in which they often do their procedures do not. In addition, there are few EMR vendor solutions that would qualify a center for this funding, as many ASC EMR vendors are not certified by the Certification Commission for Healthcare Information Technology (CCHIT). Only a handful of the current vendors have this certification and some center HIT administrators may be waiting to see "what vendors qualify and if there will be funding." According to David Blumenthal, MD, national coordinator for Health Information Technology, "The HITECH Act calls for the development of a nationwide health information technology infrastructure that allows for electronic use and exchange of information that promotes a more effective marketplace, greater competition, and increased consumer choice among other goals." (http://healthhit.hhs.gov) If this is the goal, the funding and certification process should extend to ASCs, as a large population of patients chooses to have their procedures done in an outpatient setting. The interoperability of systems needs to include EMR within ASCs.
Vendors catering to ASCs' needs
According to several studies, ASCs have lagged behind hospitals in EMR adoption due to a number of factors: their smaller size, having fewer practitioners and less available capital. Additional factors could be the lack of on-site HIT professionals, lack of stimulus funding and clarification regarding CCHIT certification of EMR vendors. A factor that was not considered in the referenced studies was the rate of adoption by ASCs managed by a larger management group. Presumably, this group would have a higher rate of EMR adoption as they could afford more HIT infrastructure and staffing. Although ASCs are currently lagging a bit behind their hospital counterparts in adoption rate, some very innovative solutions from vendors are starting to reach the market, which could change this statistic. Many of the newer systems are turning toward web-based, hosted platforms or 'software as a service' (SaaS) models. This model decreases the high capital investment and lowers maintenance costs, thus making EMR more affordable and attractive to ASCs. As more vendors offer SaaS or other hosted solutions, I wouldn't be surprised to see the adoption rate in ASCs quickly increase as these systems gain more popularity.
Learn more about Surgery Center Partners at www.surgerycenterpartners.com.
EMR financial implications
Health information technology (HIT) has been at the center of attention in many organizations due to the passage of the American Recovery and Reinvestment Act of 2009 and the Health Information Technology for Economic and Clinical Health Act. The HITECH Act was embedded within ARRA and created incentives for healthcare organizations to implement EMR by decreasing Medicare funding to those organizations or providers which failed to implement EMR by 2015. This would be accomplished through a reduction in Medicare payments by one percent for the first year, followed by two and three percent reductions in subsequent years. There are also monetary incentives for early installations of EMR and those monies decrease with each year EMR is not in place. To qualify for the $44,000 payment, physicians must implement and use a certified EMR and meet the criteria for meaningful usefulness before January 1, 2011. If they qualify, payments will arrive over five years. The first-year payment is $18,000, followed by $12,000, $8,000, $4,000, and finally $2,000 (Bick, 2009). If providers choose not to adopt EMR until after 2011, the funding decreases.
In addition to the ARRA, the passage of the Healthcare Reform Bill put additional pressures on healthcare providers to increase their efficiency. By 2014, all Americans will be required to have healthcare insurance, adding over 32 million people into the system. Combine this with the tremendous shift in demographics with the 79 million aging baby boomers accessing more healthcare services and one has the making of a perfect storm (Rowe, 2010). The demand to have information flow seamlessly throughout the healthcare network will be instrumental to the overall success of healthcare reform.
Number of physicians impact adoption rate
Given these pressures to implement EMR, it is interesting to explore the factors that are influencing the rate of adoption. According to the RAND study, the adoption rate in 2003 for ASCs was approximately 13 percent, compared to 23 percent in the hospital setting. Some more recent marketing data posted on "Medicine and Technology" (www.medicineandtechnology.com) shows that 36.1 percent of physicians are using EMR in their practices. The number dramatically increases to over 70 percent if there are over 26 physicians in the practice (Kim, 2010). This tie between the numbers of physicians in a practice to EMR adoption rate was also evident in the RAND study where it was estimated that practices with over 30 physicians would have an adoption rate of 38 percent, three times higher than a single practitioner (RAND, 2005).
In another study conducted by the U.S. Department of Health and Human Services, the adoption rate in 2006 by physicians within the ambulatory setting showed a similar correlation between the number of practitioners and rate of adoption. This study indicated that practices with greater than 11 physicians had an adoption rate of 46.5 percent versus a solo practitioner at 24 percent (Hing, Hall, Ashman, 2010). All of these studies support a significant correlation between the number of physicians and the rate of EMR adoption. Therefore, given these statistics, the fact that ASCs have fewer physicians practicing within their structures may be a contributing factor to ASCs' slower adoption rate than hospitals.
Hospital affiliation a significant influence
Another factor influencing adoption within the ASC setting is whether or not it is affiliated with a hospital system or is freestanding. According to the Department of Health and Human Services study, the rate of adoption for a freestanding ASC was 22.3 percent versus a hospital-based ASC with a 62.4 percent adoption rate. The researchers then asked participants about their future intentions for EMR installations. Specifically, the ASC providers were asked about their plans to install EMR in the next three years. The freestanding ASCs responded that there was a 63.6 percent likelihood of having EMR installed by 2009, while the hospital-based ASCs reported a 87.7 percent projected installation by 2009 (Hing, Hall, Ashman, 2010).
The reason affiliation with a hospital system appears to be another factor influencing the adoption of EMR at the ASC level could be tied to the previous factor involving the numbers of practitioners, as hospital-based systems tend to be larger. It also could be related to the availability of capital funds. Smaller freestanding ASCs would typically not create the revenue to support expensive EMR installations. From my personal experience in managing HIT across 17 ASCs of various sizes, it is very difficult for the smaller one-room centers to fund these implementations. As such, we are considering less expensive electronic document management systems rather than complete EMR at these smaller locations.
High costs serve as big deterrent
According to a study conducted by Harvard School of Public Health and posted on "Harvard Science" (www.harvardscience.harvard.edu), 'inadequate capital for purchase' was the number one reason most commonly cited as the barrier (73 percent) to implementation of EMR. The second highest cited barrier to implementation was 'concerns about maintenance costs' at 44 percent (Datz, 2010). Again, from my experience, maintenance of these systems at remote locations is a challenge. Standalone ASCs would not have HIT staff available to them in-house as do the hospital-based ASCs. What appears to be lacking in these studies is the influence of an outside management company in the rate of adoption of EMR. There are a number of very large ASC management groups, with some managing hundreds of centers across the country. I would think that the rate of EMR adoption would be higher in these groups as they look to standardize practices and increase efficiencies. They would also be able to build an IT infrastructure or data center and have HIT professionals available for support.
Lack of federal funding hindering investments
Another factor that may be influencing ASC's adoption rate is that ASCs currently do not qualify for any of the federal stimulus monies. Although the individual physician's practices qualify for this funding, the centers in which they often do their procedures do not. In addition, there are few EMR vendor solutions that would qualify a center for this funding, as many ASC EMR vendors are not certified by the Certification Commission for Healthcare Information Technology (CCHIT). Only a handful of the current vendors have this certification and some center HIT administrators may be waiting to see "what vendors qualify and if there will be funding." According to David Blumenthal, MD, national coordinator for Health Information Technology, "The HITECH Act calls for the development of a nationwide health information technology infrastructure that allows for electronic use and exchange of information that promotes a more effective marketplace, greater competition, and increased consumer choice among other goals." (http://healthhit.hhs.gov) If this is the goal, the funding and certification process should extend to ASCs, as a large population of patients chooses to have their procedures done in an outpatient setting. The interoperability of systems needs to include EMR within ASCs.
Vendors catering to ASCs' needs
According to several studies, ASCs have lagged behind hospitals in EMR adoption due to a number of factors: their smaller size, having fewer practitioners and less available capital. Additional factors could be the lack of on-site HIT professionals, lack of stimulus funding and clarification regarding CCHIT certification of EMR vendors. A factor that was not considered in the referenced studies was the rate of adoption by ASCs managed by a larger management group. Presumably, this group would have a higher rate of EMR adoption as they could afford more HIT infrastructure and staffing. Although ASCs are currently lagging a bit behind their hospital counterparts in adoption rate, some very innovative solutions from vendors are starting to reach the market, which could change this statistic. Many of the newer systems are turning toward web-based, hosted platforms or 'software as a service' (SaaS) models. This model decreases the high capital investment and lowers maintenance costs, thus making EMR more affordable and attractive to ASCs. As more vendors offer SaaS or other hosted solutions, I wouldn't be surprised to see the adoption rate in ASCs quickly increase as these systems gain more popularity.
Learn more about Surgery Center Partners at www.surgerycenterpartners.com.