Hospital-driven EHR Mandates: Boosting Physician Use, But at What Cost?

There are numerous benefits to replacing paper charts with electronic health records (EHR) including, but not limited to, provider integration, record legibility, and other clinical benefits. Some argue these benefits are defeated by EHR detriments, which include the high cost of transitioning to EHR from paper records, the inefficiency of many EHR systems, and the fact that such systems can sometimes be hard to use and difficult to maintain. Given these various pros and cons of EHRs, it’s no surprise that while many physicians have welcomed the change, a substantial number have not.

Although the government has offered incentives to encourage physicians to switch to EHRs, and various EHR systems are being heavily pushed by hospitals, there are still physicians who have yet to buy into the value of EHRs, who cannot find the EHR that is perfect for their practice or who, even with the available incentives, are unable to fund the transition.

Hospitals appear to be growing frustrated with physicians on their medical staff who refuse to get on board with EHR. Recently, at least one health system of which I am aware sent a letter to physicians participating in its physician-hospital organization (PHO) stating that the PHO’s board of directors had decided to mandate the use of EHR for independent primary-care physicians.

The Board approved an action requiring implementation of the PHO’s selected EHR system for primary-care physicians who did not yet have a signed contract with an EHR vendor by February 6, 2012. Such physicians, as well as those using an EHR not certified for the Stage 1 requirements of CMS' meaningful use, would be required to implement the selected EHR by December 31, 2013. It should be noted that there is an exception for EHR systems in place prior to February 6, 2012, if that EHR is able to meet the Stage 2 requirements on the effective date of Stage 2 implementation (January 1, 2014).

The approach being used in this case is an aggressive step towards bringing independent physicians into the PHO’s (and the Hospital’s) fold. However, it’s unclear what the repercussions of this mandate will be:

1. How will physicians who are on staff at multiple hospitals feel about this mandate? What if multiple hospitals (through their PHOs/IPAs) demand certain EHRs be adopted?

2. What about physicians negotiating an EHR package that did not have one signed by February 6, 2012?

3. Why must it be the PHO’s/hospital’s selected EHR that needs to be obtained?

4. How will physicians who cannot afford the EHR (even with support) be able to comply with this requirement?

5. What will be the repercussion for failing to comply? Is a physician’s medical staff or PHO/IPA participation being threatened?

6. Is the proposed EHR system the most appropriate EHR for primary care physicians? What if physicians legitimately believe that the EHR does not best suit their practice or their patients?

One cannot help but wonder if there are driving forces, other than a desire for integration, at work here. Does the PHO (or hospital) stand to gain financially when more physicians are signed with a certain vendor? Is there a concern about anti-competitive behavior? Once a switch to the new EHR is made, will the physicians be required to use a certain billing company? I am aware of at least one case where a hospital allowed full access to the EHR for billing purposes only to its hospital-owned billing company, forcing physicians to terminate long-standing billing relationships.

From the perspective of a physician practice trying to survive financially, this mandate is clearly unwelcome, but may leave the practice no option but to comply if the PHO contracts are needed. Additionally, in this case not only has the PHO taken away freedom of choice in whether the practice even wants to obtain EHR, but it has also removed any ability of the practice to select its preferred EHR.

Although some might applaud this bold move by the PHO as motivating physicians to finally accept EHR, the physicians on the receiving end of such a mandate should evaluate their options before making any decision. I further recommend a discussion of concerns, and alternatives, with legal counsel.

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