Throughout time, ambitious people have studied how best to effect change: How can they get others to do what they want? A popular school of thought goes something like this — if you can show the other person that what you want them to do is really in their own interests, the battle is largely won. But what if, despite such “carrot-like” efforts, the desired change doesn't come about? What if the object of influence is so intransigent that no degree of cajoling will work? According to many, that means it's time for the stick.
Partners HealthCare in Boston decided in March 2007 that it was definitely stick time. The integrated health system — founded by Brigham and Women's Hospital and Massachusetts General Hospital, now including community hospitals, specialty hospitals, community health centers and a physician network — stipulated that all its network physicians had to agree to adopt an EMR by the end of 2007. To make sure they followed up, Partners further stipulated that the physicians had to be up and running on an EMR by the end of 2008 (dates are for primary docs, specialists have another year).
Failure to meet these milestones results in removal from the network. For physicians in Boston, no longer being able to refer patients to Massachusetts General or Brigham and Women's is serious business.
Evolution of a mandate
The process started in 2003, says Cindy Bero, CIO of Partners Community Healthcare Inc., when the organization formed a committee to look at different paradigms for requiring physician EMR adoption. PCHI is the network for Partners which includes about 2,500 affiliated community physicians (who are not employees of Massachusetts General or the Brigham physician organizations).
In 2004, Bero's boss, PCHI CEO Thomas Lee, M.D. (reporting to Partners Healthcare CEO James Mongan, M.D.) was in favor of mandating such a deadline. But Bero demurred, noting that only about 9 percent of the network physicians at that time were live on an EMR. A mandate, she said, would be premature and counterproductive. Carrots were needed first, then sticks. “If you come out with a heavy-handed message too early in the process, you will alienate everyone,” Bero says. “We wanted to be one step ahead of the network, not five or six.”
Those carrots took the form of incentive-laden managed-care contracts, negotiated between Partners and the largest area insurers, that offered higher payouts to docs using EMRs.
Today, insurer incentives aren't the only method for inducing EMR adoption. With recent clarifications to the Stark regulation, why hasn't Partners chosen to pick up the tab for the physician EMRs (through reimbursing docs for up to 80 percent of the costs)? Partners HealthCare CIO John Glaser, Ph.D., says that's not a model to promote continued usage once implementation is over.
The Stark relaxation, he says, is a good and necessary first step, “but it's incapable of getting us to the next step just by the way it's put together, so going through the plan route (for incentives) is certainly the better long-term move. Sooner or later, even those who have taken advantage of the Stark provision will have to move into the incentive realm if they want to take that next step.”
Complementing the managed-care incentives, Partners strategy had another tenet — primary docs first. Primary doctors have the most managed care patients, and thus the most to gain financially from using EMRs. Specialists, Bero reasoned, would soon follow, so as not to be disconnected from the primaries who feed their referral pipeline.
“That strategy worked out beautifully,” Lee says.
One, two, or many?
Telling physicians that they must adopt an EMR is one thing — but ordering them to adopt a particular one is another. Health systems around the country are now facing the same decision Partners did in balancing EMR freedom of choice with the realities of ambulatory EMR/inpatient hospital information system integration.
On the extreme side of the freedom scale, the health system even toyed with the idea of putting out functionality guidelines, then letting practices go from there. Bero was concerned about a “you choose” approach. “If you go with multiple or dozens of products, our ability to function like a network will be limited. I think that message resonated,” she says.
On the other end of the spectrum, Lee explains, “The idea of telling everyone that they had to use the Partners electronic record was a non-starter, because a number of people were wary that they would then be married to Partners forever.”
Some timely guidance came in the form of a Boston Globe article. The article, which came out on Feb. 3, 2005, days before an important Partners board meeting, ranked nine of the area's integrated delivery networks, with Partners coming in at number two. Not happy with anything other than first place, the team closely looked at the number one player, Harvard Vanguard Medical Associates, to find out what they were doing differently.
“We figured out that they had all their docs using the same electronic medical record,” Lee says. The non-IT folks on Partners board then pushed for the one-and-only approach, “but that was just not saleable (to the network physician community),” Lee says.
A compromise approach seemed the best way to move forward.