As written, the proposed rule on meaningful use is not achievable, said Dr. Peter Basch, medical director for ambulatory, EHR, and health IT policy at MedStar Health in the Baltimore-Washington area. The overall goals of meaningful use are reasonable, he said, but the details in the proposed rule raise concerns. Some of the metrics and thresholds in the rule contain "unintended trip wires" that even advanced users of EHRs probably can't overcome, he said.
But Dr. Basch, who also is a member of the ACP's Medical Informatics Subcommittee, said he is hopeful that the Centers for Medicare and Medicaid Services will modify the requirements in the final rule expected later this year, so that the average physician can achieve meaningful use in 2011 or 2012.
"These are dollars they do want to pay out," he said. "They do want to make this reasonable for doctors to do."
The return on investment that physicians can expect to see after implementing an electronic health record is likely to differ greatly based on the size of their practice, Dr. Basch said.
In large practices, physicians can anticipate significant cost reductions from elimination of chart pulls and improved intra-office communication. And such practices are likely to achieve savings from improvements in process throughput, coding, elimination of transcription, reductions in physician-to-staff ratios, and increased productivity, he said.
But the return on investment equation is quite different for small practices, Dr. Basch said. For example, small practices can't bank on saving much by reducing or eliminating chart pulls, because they typically keep charts right in the office and don't pay $8-$15 per chart pull the way large practices do. Small practices have the potential to reduce some staff following EHR adoption, but that won't happen immediately. Also, if the practice is already fairly lean there may not be much trimming of staff costs, he said.
The greatest potential for savings comes from better coding and the elimination of transcription. "Most of us tend to undercode, and EHRs can help us with coding," Dr. Basch said.
Small practices have additional obstacles when implementing an EHR, he noted. They generally don't have sufficient capital to invest in an expensive system, so they have to borrow money or take a reduction in income during the initial start-up period. Practices that aren't interested in taking out loans or reducing their income can consider an application service provider model, which essentially allows them to lease an EHR system. This isn't a good fit for every practice, Dr. Basch said, but it is attractive because it doesn't involve a large cash outlay upfront.
For practices considering the leasing approach, the monthly cost will be important. Those costs have typically ranged from $500 to $1,000 per month, but they appear to be coming down, Dr. Basch said. "As those monthly figures begin to move down because of market pressure, this could certainly make an EHR investment a lot more affordable for many, many people," he said.