Making Electronic Health Tools Work

When Dr. William Muller works with patients at Tri-River Family Health Center in Uxbridge today, he can do things that would have been impossible not long ago.

Muller can pull up images of X-rays taken the day before in Worcester and walk the patient through a specialist's case notes. If he gets a call from a patient when he's not in the office, he can find their medical records remotely, look at the medications they're using and prescribe medicine through a web portal.

Muller said it's clear why hospitals and public officials are working hard to make electronic health information systems universal in Massachusetts and elsewhere.

"There's certainly power to it," he said.

But Muller, who's also vice president of medical affairs at Milford Regional Medical Center in Milford, said the systems can be frustrating as well. He said it's increasingly common for health insurance companies to use pay-for-performance contracts that tap into the electronic records to determine whether providers are performing the right tests on the right patients. But many patients at Tri-River, which is part of the UMass Memorial Health Care system, get tests done at Milford. And while insurance companies say they'll take tests performed at any facility into account automatically when they look at doctors' performance, Muller said it doesn't always turn out that way.

Dealing with different brands of software (UMass uses a system made by Chicago-based Allscripts, while Milford goes with Meditech, which is headquartered in Westwood) also makes Muller's interactions with patients trickier.

"In the office, when I'm seeing a patient, I'm constantly toggling back and forth between Allscripts and the Milford Regional System," Muller said.

He added that the situation is much tougher for emergency room doctors, who may need to access seven or eight different systems, each with a different password and a different navigation format.

Record Boom

Electronic health records, or EHRs, are a booming business, thanks in large part to the federal government. The HITECH Act, part of the 2009 stimulus package, provided $19 billion to encourage hospitals and doctors to adopt electronic systems. To get the money, and, later, avoid penalties, providers need to meet increasingly tough standards for "meaningful use" of the technology, which is broken out in three stages that range from simply capturing data to creating a comprehensive patient health information exchange.

While they say it's difficult to determine how much of their business has come from the federal push, local medical records companies have seen massive growth in recent years.

Meditech, which made headlines last year when it opened a new 500-employee site in Foxborough, enjoyed its best year ever in 2012 with $597 million in revenue, according to Paul Berthiaume, the company's senior manager of communications. Berthiaume said the company has hit new sales records every year since 2009.

"The HITECH Act has fueled a lot of our company's growth, and it's fueled a lot of activity throughout our industry," he said.

At eClinicalWorks of Westborough, revenue had been rising steeply even before the stimulus, from $40 million in 2006 to $104 million in 2009, according to the company. By 2012, revenue reached $260 million.

eClinicalWorks has also had notable successes outside the financial realm. CEO Girish Kumar Navani points to New York City's Primary Care Information Project, in which the company's technology led to measurable improvements in blood pressure management, diabetes control and other health metrics.

For many providers, though, EHRs' promise of financial savings, simpler workflows and better patient care haven't yet been realized, and the process of getting there still looks long and complicated.

Trail Blazer

One place that serves as an example of what can be achieved is Worcester-based Reliant Medical Group. Larry Garber, medical director for informatics, said the organization's EHR system has been live since 2006.

"We did this because at the time it seemed like the right thing for us to do to promote our mission of high-quality, low-cost care," he said.

That's panned out, Garber said. After seven years, he said Reliant is now "just about breaking even" on its investment. When it comes to patient care, he said, the system is working as it should. Among other things, it helps ensure that doctors check ongoing issues every time they see a patient and order any tests that are due.

"At any point in contact with my patients, I'm required to think about things I wouldn't necessarily bother to think about when they come in and their ear is bothering them," Garber said.

"We give great medical care now," he said. "Better than we've ever done."

It helps, Garber said, that Reliant is a large group with its own specialists, reducing the need to work with other electronic systems. But he said another big advantage is the way the system was set up to begin with.

Rather than just use a vendor's off-the-shelf software, Reliant had a team of three doctors, two nurses and a medical assistant — all with a hands-on understanding of providers' day-to-day needs — help tweak and implement the system. The team spent several weeks training with their EHR vendor, Epic Systems, in Wisconsin. Reliant staff made changes, like one that allows doctors to order medications with one click instead of four or five. And Garber himself, despite being a practicing physician, now spends three quarters of his time working on the IT side of the organization.

He noted that small practices simply don't have the resources to do what Reliant has done.

Helping Smaller Providers

The state understands that smaller providers can't commit the kind of time and resources Reliant has, and that's where the Massachusetts eHealth Institute (MeHI), a division of the Massachusetts Technology Collaborative, comes in.

"MeHI tries to be an educational resource for providers," said the group's director, Laurance Stuntz.

The organization operates a regional center that helps medical groups figure out their needs and implement EHR systems in a way that will not only fulfill the technical requirements for meaningful use, but also improve the way the practices operate, Stuntz said.

Another big part of MeHI's mission is enabling communications between different EHR systems. The group works with vendors and providers to set standards and build bridges between different practices.

EHR companies are also working toward interoperability, both with MeHI and on their own. Berthiaume said clients frequently come to Meditech looking for ways to connect with other providers using different systems, and the company is able to handle the exchanges on a case-by-case basis.

"We have a hospital client that is saying to us, 'Hey, I really need to connect into this physicians' network that's using eClinicalWorks,'" he said. "They get right in front of us. Each hospital has a sales and service team constantly on top of what's going on."

Navani said eClinicalWorks is also working with other industry players to make systems work together without those kind of one-off solutions.

"That's how cell phone interoperability came into play," he said. "Eventually vendors will find ways to make (that) happen."

Vendor Duty

At the same time, Navani said, vendors need to work on other aspects of making EHRs truly valuable for providers. He said eClinicalWorks prides itself on systems that let end users customize them as they go along, without specialized technical knowledge. That allows doctors and nurses to avoid, for example, getting so many alerts from the system that they can't pay attention to all of them.

Stuntz said vendors are starting to focus more on user-friendly systems.

"I think there's just a huge emphasis on user-centered design that hasn't gone into these systems yet," he said. "I think a key piece of where [EHR vendors are] going to go and be able to compete on is on that usability aspect."

Stuntz said a maturing of the EHR industry will involve providers switching systems and the disappearance of some lower-performing vendors.

"We are definitely seeing that the market is consolidating for EHRs," he said. "Vendors are falling out of the market, particularly smaller vendors."

But for some established EHR companies, the future continues to look bright. Providers continue to buy more advanced systems and move away from lower-performing vendors. At eClinicalWorks, Navani said there is every expectation that sales of traditional EHR systems will go well in the coming years, and the company is also rolling out new products. In just the past year it has introduced a patient-facing health and wellness system for mobile devices, a site focused on "big data" around managing a population of patients and a system to help providers manage their revenue cycles and handle billing. Navani said all three are making money and are close to profitability.

"I can assure you the company will double in size in the next four years," he said.

And while some providers, like Reliant, believe electronic systems are leading to better care, the systems haven't yet resulted in the kind of health care cost savings touted by advocates.

But Garber thinks the advances in interoperability that are underway now will make a big difference when it comes to avoiding redundant tests and streamlining administration — at least as long as the systems are easy for doctors and nurses to use.

"When implemented properly they can truly do the vision we all expected," Garber said. n

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