Look anywhere in the health care world and acronyms like EHR, EMR, PHR and PHI pop up.  What are they? That is pretty easy!  An EHR is an EMR with interoperability that feeds a PHR with PHI.  There you go – my work is done.  Seriously though, in today’s world acronyms abound.  So let me offer a few baseline definitions, just to level set for this blog:

EMR (electronic medical record) - The electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual’s health and care

EHR (electronic health record) - The aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individual’s health and care. An EHR is an EMR with all levels of interoperability

PHR (personal health record) - An electronic, cumulative record of health-related information on an individual, drawn from multiple sources, that is created, gathered, and managed by the individual. The integrity of the data in the PHR and control of access to that data is the responsibility of the individual.

PHI (personal or protected health information) – any recorded information in any format, e.g., oral, written, or electronic, regarding the physical or mental condition of an individual, health care provision, or health care payment. PHI also contains demographic information able to specifically distinguish an individual.

Health Information Exchange (HIE) - The electronic movement of health-related information among organizations according to nationally recognized standards.

Health Information Organization (HIO)  - An organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards.

Regional Health Information Organization (RHIO)  - A health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community.

Electronic Patient Record - In 2002 McGraw-Hill defined an electronic patient record as the personal health library providing access to all resources on a patient’s health history and insurance information

The real heart of this blog is not simply to provide definitions offered.  Rather the goal is to pick an acronym from the list and try to figure out why adoption rates as so low and so slow to climb. 

EHR adoption rates in the United States are very low. A study entitled "Electronic Health Records in Ambulatory Care -- A National Survey of Physicians," was published by the New England Journal of Medicine and is available to readers at no charge.  The researchers said that other recent estimates of EHR adoption rates -- ranging from 9 percent to 29 percent -- may have been too high because those rates were "derived from studies that either had a small number of respondents or incompletely specified definitions of an electronic health record.  Our study indicates that electronic health records are available in the office setting to only a small minority (17 percent) of U.S. physicians at present."  Of the 83 percent of respondents who said they did not have an EHR, 16 percent reported that they had purchased but not yet implemented a system. Another 26 percent said that they had plans to purchase an EHR within two years. In the same report, a survey was given to the physicians with a fully functional EHR (this was a staggeringly small 4% of the approximately 2,700 physicians included in as the population of for the report) and the results showed a very positive review:

·         97% said they used all of the functions some of the time,

·         82% reported positive effects on the quality of their clinical decisions,

·         92% communicated with other health care professionals via the EHR,

·         72% communicated with patients through the EHR,

·         97% reported timely access to medical records, and

·         86% said medication errors were avoided

·         85% of physicians with high-functioning EHRs reported a positive effect on the delivery of long-term and preventive care.

So with these glowing accolades why does adoption remain in the basement? A potential three-legged stool exists with two of the legs being cost and complexity.  The third leg, perhaps the most subtle and important is organizational readiness and specifically the preparedness of the medical staff governance model within a hospital or Integrated Delivery Network (IDN). 

So, how do physicians and hospitals structure their working relationship?  What are the challenges for hospital management in the traditional relationship between hospitals and physicians?  What are the factors that are driving change in that relationship and how is it changing?

Physician/Hospital Employment Model

The relationship between hospitals and physicians is fairly unique in the business world because at any given hospital, many of the physicians with admitting privileges to a specific hospital are not employed directly by the hospitals, in other words they are independent of the hospital. This model presents some interesting challenges since hospitals are dependent on admissions to generate a majority of their revenue, and these non-employed physicians generate the majority of the admissions.  The net is that the hospitals have traditionally had to be very cautious in how this relationship is managed.

Although the majority of the “admitters” are self-employed, there are several categories of physicians that are directly employed by the hospitals.  These categories include hospitalists, intensivists, and administrative types such the CEO, CMO, CMIO and others.  Other roles such emergency room doctors, faculty at teaching hospitals and researchers can be employed, independent or contracted and are usually a mix.  In any case, this is a very tenuous relationship between hospitals and physicians that is usually managed with kid gloves since if the “admitters” go away so does the revenue.  This employment model makes it much more difficult for hospitals to insist on HIT usage and thus there is no solid and consistent way to incentivize usage/adoption.

Governance of the Medical Staff Within the Hospital

The medical staff, i.e., the physicians given privileges to provide care at the site, can be broken into the following categories:

·   Active

·   Affiliated

·   Honorary

·   Consulting

·   Teaching Affiliate

·   Courtesy

·   House Staff

The medical staff is often governed by a separate and relatively independent organizational structure that is established within the hospital and is usually hierarchical.  Additionally, the medical staff officers notwithstanding, the medical staff governance is usually structured by specialty and follows this order/structure:

1.  The  Medical Staff Officers, i.e., President, Vice President, Secretary, and Treasurer
2. An executive committee
3.  A series of committee chairs
4.  A series of department heads

All physicians that have privileges at a hospitals, whether employed, independent or contracted, are members of the medical staff and as such are governed by a series of hospital board approved bylaws that cover things such as:

·         ·         Medical Staff Membership, Qualifications and Privileges  Ethics
·         Disciplinary Procedures
·         Medical Staff Structure and Terms
·         Overall rules and regulations

Challenges With the Traditional Model

As previously discussed, traditionally independent physicians made up the majority of medical staff members and have done an effective job of “self-policing” through models similar to those described above.  Essentially, in the traditional model the hospital takes care of managing the physical plant and provides “workspace” for the physicians to work, i.e., provide care to individual patients.  This model has worked well in the past, but as new pressures for the meaningful use of HIT come to bear and financial incentives and penalties are introduced as Bob Dylan says “The Times They Are A-Changin’”.

The hospital/physician relationship is becoming increasingly complex in the changing world of healthcare.  Physicians traditional role of treatment of patients, is transitioning  more and more as the physician can be a vendor, partner, board member/trustee, contractor and/or an employee of the hospital. In many cases a physician can have multiple roles. Combine this morphing of traditional roles with the intense pressure the hospitals are receiving to adopt HIT, improve quality and patient safety, provide community-based care and build market share while coping with with dropping reimbursements and it becomes apparent that the hospital and physicians are intertwined and cannot go this alone.  The traditional model draws clear and succinct lines between the hospital and the medical staff, the changing and complex business environment smudges and blurs those lines to a degree the traditional medical staff model can no longer support.  The hospital and medical staff must move as one, not as independent entities. 

How is the Medical Staff Model Changing?

From a practical perspective, many hospitals are requiring physicians to sign employment agreements and exclusive contracts.  This helps untangle, to a degree, the relationship web and enables the hospitals to exert more control over quality of care, patient safety, IT deployment and usage as well as provides a manageable level of staff stability.

From a more conceptual level, the traditional medical staff governance model has to be redesigned into an integrated and key component of the hospital, not as an independent organization within the hospital.  These shifts will cause the medical staff to be more accountable for the goals of the hospital as opposed to viewing the hospital as “leased space” – in other words these shifts are intended to get the medical staff more “bought in” to the daily operations of the hospital as well as the hospital’s long-term vision.

From the hospital perspective, changes in the medical staff model will require hospitals to include physicians in:

·         Long term strategy development

·         Approaches to improve quality, safety and general operations

Succinctly stated, the new model requires a partnership where hospitals become more inclusive and physicians become more trusting and willing to operate as a unit.

And the point…

When deploying, upgrading, or acquiring an EHR, organizational readiness/sponsorship has been regularly reported to be more important the actual technology.  If the medical staff is not properly aligned, adoption will not succeed and the EHR project will be a black hole that devours cash, time and careers. Bottom line, as organizations assess their readiness for HIT, they must not forget the medical staff and how they are governed and interact. 

Dale Will

Associate Partner