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Too Much, Too Fast? – Physicians and Healthcare IT Mandates For Change

April 30, 2012
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My role and that of most CMOs, CMIOs, and CHIOs (Chief Health Information Officer) often positions us in one way or another as representatives of all practicing physicians.  Of late, there has been a loud resurgence of the collective physician voice on the topic of healthcare IT mandates. 

In effect it is saying, “too much, too fast, with insufficient regard to sustainability, incentives and penalties.”  The recent CMS announcement to delay ICD-10 by one year adds credence to this position.     

Further, the most succinct, coherent, and cogent message I have seen to date on this subject is contained in a March 28 letter to HHS.  The signatories were 112 critical components of the physician voice including the AMA, many state associations and medical colleges.  A copy of that letter is here.

Assembled forcibly, the arguments noted in the letter are deeply based on objective practical issues (time and available talent constraints), economic considerations (revenue, ROI and cash flow), and tech-related issues.  Too often, such arguments are wrongfully discussed in an overly simplistic manner that focuses on orienting the user, customization, training, or attempts to standardize beyond what is effective.

The most simplistic of these relates to physicians’ temperament when they are stereotyped as resistant to change or otherwise inappropriately engaged.  Understanding this is critical to driving adoption for meaningful use.  Let me explain further.

•  Community Physicians don’t experience a personal benefit from problem lists and other rigors of MU.  The docs like to get things out of EMRs, but generally do not want or perceive a need to put anything into them. 

 •  Hospitalists are a different story for a variety of reasons:

-  They are shift workers

-  They have different professional standards and workflow, with more patient hand-offs

-  They have the higher cognitive burden of intensively ill patients, often with multiple active problems and safety risks 

-  They maintained problem lists before MU, albeit uncodified and in their progress notes, to facilitate making sure they track all the complexity and not forget anything

•  Physicians in academic teaching institutions with attending, fellows, residents, interns, students, and often with multiple services involved in each patient’s care present a whole different set of challenges.  The need for coordination and communication between a dozen or more physicians demands tools more akin to MS Outlook, with Inboxes, Tasks, Rules, Shared Calendar views, etc.  Therefore, it is resonable to conclude that getting EHRs to work effectively, assuring quality and cost-effective care is, at best, a work in progress and likely will be for years to come.  

In my experience, independent of the practice settings, physicians universally share a vision for better care.  Only by focusing correctly on physician temperament, and therefore adoption, usability and satisfaction, can we make meaningful use of the systems available to improve the quality of patient care. 

Your opinion?

P.S.:  As supplemental reading, I suggest the IOM November 2011 report, Health IT and Patient Safety: Building Safer Systems for Better Care, which noted, “Safety is a characteristic of a sociotechnical system.”  Click here for the link.  And if you’re looking for an excellent interview with Erica Drazen of CSC on this topic, written by Mark Hagland in Healthcare Informatics, you’ll find it here.

Joseph I. Bormel, MD, MPH
Vice President & Chief Medical Officer

QuadraMed Corporation



Good post. Complex subject matter to say the very least.

To help simplify things a little, could you tell us what your hearing, from your personal discussions with docs, as to what their specific concerns are as they relate to the IT mandates?


Thanks for the kind words and the question.

Again, per the post, it varies by physician type. What I hear, loud and clear from community physicians, is the productivity and therefore potential revenue hit associated with documentation and coding burden contained in the transition to ICD-10. One example I heard last week was this: "When I diagnose and treat sinusitis as an outpatient, I don't have specific data on which sinuses are involved, required to code ICD-10. The coding is, therefore, unrealistic."

An ICD-10 certified coding specialist pointed out that physicians in the ambulatory setting are paid on the office visit procedure, not on the specificity of the visit diagnosis. As such, it's perfectly appropriate for physician to use the sinusitis, non-specific ICD-10 code. They would be reimbursed based on the visit procedure, not the diagnostic code. Even the case mix calculation would not be expected to be impacted by the use of the "non-specific" code.

The hospitalists and the academic physicians are heads down on attestation for Stage 1 meaningful use. At this point, there's a time crunch driving enhancements in workflow to address problem list, quality reporting and med rec. (See my Medication Reconciliation series, here , for example of process work that is required. The Pareto on CHF from Novaces/Kamataris helps bring the workflow into focus.)

Dr. Joe,
Could not agree with you more.
Been saying that for years, see my essay:
CPOE and the Doc Dilemma (almost 2 yrs old!)

Thanks for bringing it up again...

Frank Poggio
The Kelzon Group