By Christopher Guadagnino, Ph.D.
Darlene Kauffman is an associate director in payor relations at the Pennsylvania Medical Society, which recently released the report ConnectTheDocs.
PND: Why did the medical society survey physicians for its “ConnectTheDocs” report?
DK: The survey was conducted between May and July 2007. Over the years, when we’ve answered questions from physicians about practice management issues, we have had to fax information to them because most of them didn’t have e-mail in their practices. This led us to believe that practices were not using applications connected to broadband at the same level as other industries. We also understood, in our efforts to expand health information exchange in the Commonwealth, that infrastructure was going to be necessary in order to do that. Despite whatever internal applications they may purchase, such as electronic medical record systems, physicians would be limited in their ability to connect to other physicians and hospitals without broadband. We pursued a Broadband Outreach and Aggregation Fund (BOAF) grant through the Pennsylvania Department of Community and Economic Development to do a statewide assessment of physicians’ use of broadband and other health information technology.
Broadband is a reference to the bandwidth of an Internet connection: the wider the bandwidth – the “pipe” that is delivering the telecommunications – the more data can be sent at the same time. For example, in a physician practice, if you’re just sending a text file, you don’t need a lot of bandwidth. But physician practices often use digital images, and those take a lot of bandwidth to communicate. DSL is the lowest level of broadband in the U.S., and is faster than the older dial-up connection to the Internet. Other types of broadband include cable modem, T-1, Residential Fiber, T-3, and OC-3. Right now on the commercial market, the fiber optic connections are some of the best, but they’re not widely available in Pennsylvania.
PND: Why is broadband connectivity important to physicians?
DK: In the past, physicians have talked to hospitals using a telephone and exchanged records manually. They started to do some electronic transmissions over the last 20 years as more and more physicians submitted claims electronically to insurance companies. Most physicians do that now. What we’re finding, however, is that physicians are not adopting health information technology such as electronic medical records and electronic prescribing at a rate that is going to meet the goals of the federal government. Doctors who adopt electronic prescribing are often told by their vendor that a DSL connection is sufficient. Technically, that’s probably correct. A single physician submitting a script to a pharmacy, which is a very small file, should really not need more than DSL. The problem comes when you have multiple physicians in the practice who are using this connection at the same time. Perhaps the practice is also doing billing, using the connection for submitting claims to payors, all of which diminishes the functionality of the connection. Physicians can buy and use electronic medical records in their practice and not need the Internet, but the real value is when those records can be exchanged rapidly with other physicians and hospitals. We need to build that infrastructure so we’re ready for when more physicians have EMRs and these health information exchanges are built.
PND: What were the major findings of the survey?
DK: The first category of findings was the use of broadband itself in physician practices. About two percent of practices in Pa. are located in areas where they cannot have access to broadband. That’s about 300 physicians, generally in rural areas. Eighty-eight percent of physician practices do have some sort of Internet access, and 74 reported having at least basic broadband, including 31 percent who have DSL. Just one percent have fiber optic service. Two percent are still using dial-up connections, and that’s not limited to rural areas – even in Philadelphia there are physicians who have just dial-up access from their practice.
Our survey also examined physicians’ health information technology adoption. A federal law passed in July should motivate every physician to seriously consider implementing e-prescribing in their practice: Medicare will pay a bonus to successful electronic prescribers beginning in 2009 and will reduce Medicare payments to physicians who do not meet the electronic prescribing requirement beginning in 2012. Sooner or later the federal and/or state government is going to require that physicians use electronic medical records. We do think our survey is biased towards the more-connected physicians – we know that some of the larger groups that answered were more likely to have electronic medical records and other telecommunications. About 19.7 percent reported having an EMR system in their practice. Forty percent of those had an integrated e-prescribing system. That translates to 11 percent of all respondents who had an integrated electronic prescribing system, while 10.3 percent had a stand-alone electronic prescribing system.
The third area of our survey findings was access to care. When you look at some specialties, there are vast access issues in the “T” region of Pa. We found, for example, that three million Pennsylvanians – about 24 percent – live over 25 miles away from the nearest high-risk pregnancy specialist. We found that 800,000 Pennsylvanians live over 25 miles away from the nearest dermatologist. We have high concentrations of senior citizens in the rural areas of the state. Senior citizens are more likely to develop lesions and malignant lesions. Trips to dermatologists over that distance are difficult; even getting an appointment in more populated areas is difficult because of a shortage of dermatologists. Here is a population that is at risk of life-threatening problems because of lack of physician specialists in their area. Telemedicine can be a solution to help provide specialty care to some of these patients in underserved areas, but it isn’t well-developed. It requires a very high level of broadband service because it is a real-time connection, where the patient and doctor can interact remotely. I’m told that lesions can be better visualized using digital equipment than they can with the naked eye and a magnifying glass. We believe that there are opportunities to improve the health care of Pennsylvanians through expansion of broadband and the resulting use of telemedicine.
PND: On the basis of these findings, what actions does the report recommend?
DK: First of all, we need to build awareness among physicians and staff of the need for broadband, and how it can make a difference in the way they practice medicine. We also realize that telecommunication companies are not going to build out to areas that do not currently have access, and doctors are not going to spend more money than they’re already spending to adopt a technology unless there is a business case to do so. So, there are two groups we have to build a business case for. The business case can be developed for physicians because they need broadband to do EMR, electronic prescribing and other technologies. As we build the case for physicians, then we can create a demand for broadband that builds the business case for the telecom providers to reach out, and allow physicians to get the broadband they need more economically.
PND: What are the key obstacles to building a business case for physicians?
DK: There are some general themes that we hear, for example, that the cost is prohibitive. These systems are expensive. There is a cost for the system itself, the training, the ongoing maintenance. Most physician practices find that there is a decrease in productivity anywhere from a few weeks to a year, until all the physicians and staff get used to the system and they’re up and running. Physicians may feel that perhaps other entities are reaping the benefit from the use of EMRs and electronic prescribing – insurance companies, the government – and that there should be some shared cost in this, as well. Another obstacle is that some physician practices do not have technological expertise in-house and they’re reticent to make changes because they feel like they don’t know what they’re purchasing. They are also concerned about interoperability with other systems, as well as privacy and security issues.
PND: How will the medical society attempt to address some of these obstacles?
DK: Several efforts can help offset the costs. We received a second grant to do outreach and to do demand aggregation. We are doing statewide education of physicians to help them assess their needs and to build the business case for broadband, including face-to-face meetings, podcasts, a DVD, videoconferences and Webinars. To address lack of technology savvy during our demand aggregation project, our plan is to bring a selection of vendors along with us that could help physicians feel more confident in what they’re doing in their practice with technology, and overcome concerns about security and interoperability. When you’re buying an electronic medical record system, you want one that has already been certified by the Certification Commission for Healthcare Information Technology (CCHIT). That doesn’t mean that today you can just plug into any hospital and they’re going to be able to exchange data, but it does show that it meets their criteria for interoperability and is on the road to evolve as the standards evolve. That’s not to say that every system that is CCHIT-certified is going to be the best one for your practice, but there are so many certified systems that there is going to be something available that you’re going to like.
With our survey, we have also identified a number of areas in Pa. that have a need for broadband expansion, and we presented those locations to the Department of Community and Economic Development. They selected two of those for us to target: the first area is about 12 counties in northwestern Pa., and the other is in the Bucks County area. We will be reaching out to physicians, hospitals, assisted living, nursing homes, pharmacies and other businesses to aggregate the demand for broadband and put in an RFP to the telecom companies. We feel confident that we are going to be able to get a better price for the participants.
Separate from our ConnectTheDocs project, the medical society is looking into ways that we could aggregate demand for electronic medical records that would help drive down the costs for physicians. We’re not recommending any specific EMR vendors, but we can make them available for physicians to talk to. The federal overnment also has some initiatives that provide funding for some physicians. Highmark has announced recently a $29 million initiative to help pay for electronic prescribing.
Also, back in 2005 the medical society founded the Pennsylvania eHealth Initiative, a statewide group that is involved in the health information exchange area, and is working with the governor’s office to provide them with information – including interoperability, security and privacy issues – as they set forth on their own health information exchange initiative. The Pennsylvania eHealth Initiative is approaching these issues from a high level, and our ConnectTheDocs initiative is starting at the grassroots level. So, from both sides, we are working to expand adoption of EMR and to expand health information exchange in the Commonwealth.