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Federal Financial Incentives May Not Spur Wholesale EHR Adoption By Neurologists
Experts Recommend an Incremental Approach to Purchasing Systems

By dangling a $44,000 carrot in front of physicians, the federal government is hoping they will stampede to the electronic health record (EHR) technology marketplace.

But EHR watchers at the AAN Professional Association (AANPA) doubt the financial incentive available through the federal economic stimulus package will spur many neurologists to take action. Meanwhile, a longtime advocate of EHR technology thinks physicians would be wise to hold their horses for the next few months — and then trot before they gallop.

“They're going to hear voices out there saying, ‘You must buy something now in order to be ready to receive the first payment in 2011,’” said David C. Kibbe, MD, MBA, founding director of the American Academy of Family Physicians Center for Health Information Technology and an advisor to the AANPA Practice Management and Technology Committee. “But quite frankly, I think this is a good time to sit tight.”

The potential improvements in health care quality and efficiency that could come from this information technology have not been realized, in part, because many physicians are daunted by the high cost of EHR systems.

The Health Information Technology for Economic and Clinical Health (HITECH) Act, a component of the American Recovery and Reinvestment Act of 2009, was created to help physicians get beyond the cost barrier to EHR adoption. Over a five-year period starting in 2011, the government will provide qualifying physicians up to $44,000 for showing “meaningful use” of an EHR system. After 2015, physicians who cannot show “meaningful use” will be subject to as-yet-unspecified financial penalties.

The definition of “meaningful use” will not be finalized until later this year. Dr. Kibbe, who is tracking the issue, expects that functionalities such as decision support, physician order entry, health information exchange, quality reporting, and patient engagement will be included.


OVER A FIVE-YEAR PERIOD starting in 2011, the government will provide qualifying physicians up to $44,000 for showing “meaningful use” of an electronic health record system. Credit: istockphoto


Steven J. Zuckerman, MD, a solo practitioner in Baton Rouge, LA, has been using online EHR technology for nearly a decade and plans to upgrade to a more sophisticated system — also available online through a subscription — to be eligible for the financial incentive.

Despite that, he expects relatively few neurologists will follow suit because of widespread discomfort with technology.

“I think that ‘free’ is not cheap enough,” said Dr. Zuckerman, a member of the AANPA Practice Management and Technology Subcommittee. “Even if they get $44,000, the extent to which EHR implementation may affect their productivity and ability to enjoy their practice may be so impacted, a lot of people are still going to be hesitant to jump in.”

Dr. Zuckerman said the use of an EHR system increases his productivity. He has access to his patients' records anywhere he has an Internet connection and, because he has developed order sets for specific medical situations, he can write orders much more quickly than his paper-only colleagues. On top of those benefits, he is upgrading to a system that integrates clinical and financial data because he thinks it will increase his revenue.

“These systems do allow you to get a greater amount of money for the amount of work that you do,” he said.

All that said, Dr. Zuckerman thinks many comprehensive EHR systems do not correspond to the way physicians work and he shares his colleagues' frustration with the so-called “incentive discrepancy.”

“The doctor does all the work and yet the insurance company benefits, the patient benefits, the government benefits, but frequently the doctor doesn't benefit,” he said. “Until the products are such that the doctor's work is easier and he can actually see concrete examples of how patient care has improved, I think the medical community is going to fight adoption.”


Actually, the rate of EHR use among neurologists appears to be higher than that of physicians in general, said Gregory Esper, MD, MBA, director of General Neurology at Emory University School of Medicine, citing his preliminary review of data from a survey of neurologists, conducted in 2008 by the AANPA Practice Management and Technology Subcommittee. The full results will be published later this year.

That finding may reflect the fact that a relatively high proportion of neurologists practice in either academic medical centers, where technology investments are borne by the university, or large medical practices, where financial and staff resources can support EHR implementation more easily than at a small practice.

The survey results suggest that most neurologists are using EHR technology for a rather limited set of functions, with clinical documentation being the most frequent use.

“The percentage of neurologists that are actually using the electronic health record to its fullest potential is probably somewhere around the national average for specialists, which is much less than 15 percent,” said Dr. Esper, who also serves on AANPA Practice Management and Technology Subcommittee.

An early adopter of new technologies, Dr. Esper advocates ways to use technologies together — for example, a voice-recognition system along with the electronic record — to improve efficiency.

Despite that, he shares Dr. Zuckerman's view that the financial incentive for technology adoption available from the economic stimulus package may not influence physicians as much as its proponents hope. Although EHR technology can improve a physician's productivity, he noted that it typically takes at least a year and a willingness to use many EHR functions together to achieve those gains.

Dr. Esper contends that, regardless of the financial incentives, technology adoption will continue to be a slow process for the vast majority of physicians who completed their training in a pre-electronic era. The tipping point for widespread adoption, he said, will be patient demand. Google, Microsoft, and other vendors are working to convince patients that their family's health will be improved if they maintain a complete online record of all diagnoses, medications and other health data, and that will require physicians to make electronic data available.

“Physicians who don't use electronic health records are not going to be competitive because patients aren't going to want to go to them,” he said. “If you don't start now, if you continue to put your head in the sand and you don't realize what's coming, then you're going to be obsolete sooner than you think.”


Dr. Kibbe, who chairs an international health care informatics committee, is one of America's foremost proponents of physicians using technology. But, unless a medical practice has everything in place — money available, new work processes in place, and a system selected — he advises against buying a comprehensive EHR system right now.

For one thing, the process of how EHR technology will be certified so that it can help practices attain “meaningful use” criteria is in flux. Until the process — and the organizations that are authorized to provide certification — are known, the purchase of a big EHR system includes the risk that it will not be certified and eligible for the financial incentives.

Beyond that, however, Dr. Kibbe believes that a “modular” approach to technology makes more sense for many medical practices than the purchase of a comprehensive system. He advises physicians to identify functions they want — for example, a Web portal that allows patients to communicate securely with physicians online, electronic prescribing, or a disease registry application — and adopt technology incrementally. (A summary of six standalone information technology components — including voice recognition software, smart phones, and personal health records — is available at

In addition to being less costly — indeed, some physicians are receiving e-prescribing technology for free — the incremental approach is less disruptive to a practice workflow. And Dr. Kibbe contends that the policymakers who will determine the “meaningful use” definition and the certification process support a modular approach so physicians who use it will still be eligible for the financial incentive payments.

“There's plenty of time for physicians to make up their mind about what they want to do,” he said. “I wouldn't encourage them to go out and buy something.”