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Central Iowa’s largest health-care systems are well positioned to tap into their share of $17 billion in federal stimulus funds that will soon become available to hospitals and clinics that are using electronic medical records, say administrators.

At the same time, those hospitals’ and clinics’ information technology staffs are working with the Iowa Department of Public Health to devise a plan for a statewide health information exchange system. Those efforts could bring Iowa a portion of $2 billion available to states to plan and build systems enabling health records to be shared, even between competing hospitals.

Health-care providers say patients are the biggest beneficiaries of these systems, which are geared toward eliminating easily misplaced paper charts, increasing efficiency and ensuring that critical patient information is readily available to caregivers. However, the high cost of such systems has made them largely unavailable to health-care providers with fewer resources, particularly smaller physician practices and rural hospitals.

Statewide, the Iowa Foundation for Medical Care (IFMC) has estimated that approximately 20 percent of health-care providers have implemented electronic medical records, which mirrors what most experts believe is the national adoption rate.

Carrots and sticks

Under the American Recovery and Reinvestment Act, which became law in February, doctors in health systems or practices that have implemented “meaningful” electronic medical records (EMR) systems will begin receiving bonus payments added to their Medicare and Medicaid reimbursements, beginning in 2011.

Over a five-year period, a practice or hospital could receive as much as $44,000 in additional funds per doctor as an incentive to have an EMR system in place sooner rather than later. Also, hospitals that have qualifying systems (under definitions that are now being finalized) will receive base payments of $2 million each, with payments adjusted upward or downward based on their number of patient discharges and how many Medicare and Medicaid patients they treat.

“We are very encouraged by the recent legislation that rewards organizations for doing the types of things we’ve been doing,” said Cristina Thomas, regional chief information officer for Catholic Health Initiatives, the parent organization of Mercy Medical Center – Des Moines. “We’ve been monitoring that legislation to ensure that we’ll meet the definitions (of a meaningful EMS system).” Generally, those definitions will require certain functions and capabilities, such as the ability for doctors to write and send prescriptions directly from the systems.

The stimulus bill also calls for health-care organizations that have not adopted EMR systems by 2015 to be penalized. They will lose 1 percent of the Medicare/Medicaid reimbursements they would otherwise receive. That penalty increases to 2 percent deducted in 2016 and 3 percent in 2017 and afterwards.

Thomas estimated that at its hospitals statewide, Mercy’s doctors and nurses are now using approximately 4,000 electronic devices to access their patients’ medical records. Some monitors are built onto carts that can be wheeled into patients’ rooms, while other laptop devices enable doctors to scroll through menus with a penlike stylus as they see patients. And using smart phone technology, doctors can now access patient records using their cellphones. “We’ve definitely been progressing, continuing to implement documentation at the bedside, automating more of the records so that there is real-time information access of orders and images for physicians as well as our nursing staff,” Thomas said. “They’re using a variety of mobile devices that didn’t exist three years ago. We’ve also implemented a physician portal, so that through any Web browser a physician can initiate or make changes to orders and monitor their patients remotely.”

Mercy is now working to add to the hospital system’s capabilities, such as enabling nurses to more completely document a patient’s medical information at the bedside, Thomas said. It is also in the process of rolling out a similar EMR system, which is now available at some of its outpatient clinics, at the remainder of the clinics.

Iowa Health – Des Moines officials also say they believe they’re in good shape to qualify for the federal incentives, though implementing a system is a challenging, ongoing process.

“It’s a journey when you’re working with an electronic health record,” said Roxie Menke, a clinical information specialist who oversees the inpatient EMR system for Iowa Health. She estimated that about 80 percent of patient care areas at Iowa Health’s three Des Moines hospitals are using electronic medical records.

“Getting the doctors used to using electronic forms, that’s probably a challenge,” she said, “but they’re finding it’s improving their care to patients. Another challenge is getting the documentation done at the bedside at the time of care, in real time. I think that’s probably one of our biggest barriers right now, because that’s a workflow culture change.”

On the outpatient side, all 45 of Iowa Health’s primary health-care clinics in Central Iowa are now using an EMR system, though it’s a separate system from that used by the hospitals, said Leslie Schneider, who oversees the clinics’ EMRs.

The biggest benefit for patients is that their primary care doctors and specialists can more easily access and share information, Schneider said. “Regardless of which (Iowa Health) office you go to, the information is standardized, so it makes it easier for them to get access,” she said. “And regardless of which office you go to, all of the basic information (patient history) is going to be documented, so you don’t have to give that again.” Laboratory, pathology and radiology reports also automatically interface data into the system.

The Iowa Clinic P.C., which employs physicians in 37 specialties, has had an EMR system in place for the past two years. Dr. Tom Luft, an internal medicine specialist at the clinic, said the system provides a number of advantages to the physicians.

“It’s quicker at getting prescriptions to pharmacies, and I can get information from other departments and even the hospital in real-time, as opposed to the days it would take to get it through the mail,” Luft said. “The other nice thing is that I can take this home with me when I’m on call and have their chart readily available at home. If I’m on vacation and work’s piling up, I can get into it and catch up.”

Statewide system

The lack of a truly portable electronic health record that can be accessed wherever a person receives care is a hurdle that must still be overcome, said Mike Speight, senior director of operations in the quality management unit of the IFMC.

“So one emphasis is to allow exchange of data so they can make better decisions for care,” he said.

The stimulus bill has designated up to $20 million that each state can apply for to develop a statewide health information exchange system. The IFMC has assisted physician groups across the state in assessing and implementing systems.

The Iowa Legislature last year enacted a health-care-reform measure that requires the Iowa Department of Public Health to develop a statewide health information exchange plan by July 1, 2010. Now, that effort has expanded to include writing a proposal for the stimulus funds.

“Clearly, I think (the stimulus funds) will have a positive impact,” Speight said.

Another factor that should help provide more funding for electronic medical records, he said, is that the federal anti-kickback rules that had prohibited hospitals from providing any direct financial support to physicians’ offices to buy EMR systems have been eased. “So hospitals that had resources and were willing to help their physicians get EMRs were prevented from doing so,” he said. “Last year, those regulations were relaxed, and that will help.”

There are other barriers, however, that the stimulus bill won’t affect, Speight said, such as uncertainty by physicians about which system to select, “particularly when they hear horror stories from their peers when they’ve had to start over again,” he said. “So there are practices out there unwilling to spend tens of millions of dollars and not really knowing what they’re going to be getting as a result.”

Another barrier is not really knowing how to take advantage of an EMR system, “because practices think it’s just a matter of buying it and that it won’t affect their workflow,” Speight said. “If you do that, you just have an inefficient automated process.”

Back at Mercy, Thomas said having a large pool of stimulus funds will be a major factor in moving these systems forward.

“The challenge has been, until this recent legislation, there were no state or federal dollars to help offset the cost of these systems,” she said, noting that the bulk of EMR funding provided last year by the state was redirected following the floods of 2008. “So today you have a large funding source over a number of years.”