May 12

P.R. Medical Industry Faces Challenges to EHR Compliance


Local hospitals shut out of federal funding for program; costs pose problem across the board, but benefits outweigh obstaclesPuerto Rico’s private hospitals are pushing for a share of federal funding they say is vital to meet a 2015 deadline for all medical institutions and practitioners around the nation to implement electronic health records (EHRs) under the U.S. Health Information Technology for Economic & Clinical Health Act (Hitech).

Hitech, passed as part of President Barack Obama’s American Recovery & Reinvestment Act (ARRA) last year, calls for the development of a national electronic health-records system throughout the mainland U.S., Puerto Rico and other territories by encouraging the adoption of EHRs through incentive payments to physicians.

Although physicians and medical practices in Puerto Rico are eligible for federal incentives, the island’s hospitals were shut out of the program, leaving them $200 million short of what they expected to get to implement EHRs, hospital officials say.

At stake is a vital modernizatio! n initiative and potential cuts in Medicare payments starting in 2015 if the EHR deadline isn’t met.

Congress left the hospitals in Puerto Rico and the other territories out of the Hitech legislation because it was easier to draft a definition based on just the 50 states and Washington, D.C., according to Puerto Rico Hospitals Association President Jaime Plá Cortés.

“When the Hitech Act was approved, we thought we were in. But we were wrong,” said Plá, adding the congressional record doesn’t shed any light on how and why local hospitals were shut out.

Surprised by the exclusion, island hospitals are lobbying hard for funding to meet a federal requirement that does apply to the island’s medical facilities and practitioners. Plá has taken the case to Capitol Hill during various visits to Washington, D.C.

“Members of Congress agree there is no reason we should be left out,” he said.

“We feel it isn’t fair because we aren’t eligible for the financial aid but do have t! o comply with the law,” said Ashford Presbyterian Community Ho! spital E xecutive Director Pedro González, the incoming Hospitals Association president for 2011.

Resident Commissioner Pedro Pierluisi is aiming to fix the problem through legislation to amend Hitech. His H.R. 1501, or the Puerto Rico Medicare Reimbursement Equity Act of 2009, was co-sponsored by the three stateside Puerto Rican members of Congress— Rep. Luis Gutiérrez, D-Ill., and New York Democratic Reps. José Serrano and Nydia Velázquez—and has been sent to the U.S. House Ways & Means Committee.

“This lack of eligibility apparently stems from an involuntary mistake since Puerto Ricans pay the payroll taxes that finance this program,” said Pierluisi, adding the island Health Department, meanwhile, has received $7.7 million through ARRA for the implementation of EHRs in public medical facilities.

“There is no law that obligates anyone to incorporate EHRs,” said Dr. José Piovanetti, chief medical information officer at the island Health Department.

While no sanctions will be! levied for noncompliance, Medicare-funding cuts will come into play and will increase annually after the EHR incentives run out by the 2015 deadline, he said, noting hospitals with mostly older patients would be particularly hard hit.

EHR implementation at a midsize hospital costs roughly $10 million-$12 million, according to Piovanetti. Even with the federal funding issue unresolved, some local private hospitals are pushing ahead with EHR implementation, including Ashford, which has earmarked more than $2 million for the project.

“We are currently in phase five of six and the project will be completed by early 2011,” González said.

Plá said some hospitals might receive EHR funds through Medicaid, but “the local government is still deciding how the funds are going to be distributed.”

“Only hospitals with at least 10% of patients covered by Medicaid may be eligible for that money,” he said.

Other challenges for EHR implementation
Beyond the federal fundi! ng issue, the island’s medical community faces other significa! nt chall enges in implementing EHRs.

Piovanetti believes Puerto Rico should move quickly toward EHRs, but acknowledged the process poses obstacles across the medical field.

“It requires a change in the whole operation of the institution and the adoption of a new mechanism as well as a new dynamic in the doctor-patient relationship,” he said.

It can take up to two months to implement EHRs in a small practice while the process can extend to nine months in a primary-care clinic, according to industry executives.

The Health Department official said doctors fall into one of three categories in terms of the new system: The adopters, who are young and embrace technology; the sideliners, who will wait and see how the project develops; and the late adopters, who see the system as a headache rather than a benefit and will incorporate it only reluctantly.

“This is normal in a change of this sort. But the mid- and long-term benefits outweigh everything else,” said Piovanetti, adding th! at once widely adopted, people won’t be able to work without EHRs.

A potential problem with an HER system, according to Piovanetti, is that they are designed by technology specialists, not by health experts, which can complicate diagnosis and treatment efforts by doctors.

The Health Department chief medical information officer, however, brushed aside security and privacy concerns, saying EHRs are safeguarded from hackers and dramatically more secure than paper records.

‘Bar set too high’
A big obstacle to the implementation of EHRs in Puerto Rico is that “meaningful use” must be established to qualify for incentives under the Hitech Act, a standard that will be tough to meet, according to Plá.

“Meaningful use isn’t a possibility right now for island or U.S. mainland medical practices. The bar was set too high,” he said, adding the Federal Hospitals Association agrees with his assessment.

According to the Hitech regulations, medical practices should be us! ing EHRs by 2011, exchanging information through EHRs by 2013 ! and empl oying EHRs as a full tool for patients by 2015 to comply with the “meaningful use” standard. If doctors in medical practices don’t comply with 100% of the regulation they won’t receive a cent in federal incentives, Plá said.

Plá said the Puerto Rico Hospitals Association has submitted amendments to the regulations to make Hitech compliance easier, which includes extending the timeframe to implement the system.

“There are practices that will be able to comply with the meaningful-use clause, though many won’t,” Piovanetti said.

“If medical practices wait until 2011 to start the transformation process, there is a high probability they won’t receive any funds because they won’t be set on time,” he said. “Whoever hasn’t started yet is late, for both the meaningful-use compliance and the certification.”

However, the certifier of the correct use of EHRs, the U.S. Health & Human Services Department, hasn’t completed its regulation.

“Most certified providers are transitory ! while the department finishes the regulations,” Piovanetti said.

Despite the challenges, medical-industry officials say the benefits of EHRs outweigh the costs.

EHRs, which integrate the patient information from all health providers and can be exchanged, shouldn’t be confused with electronic medical records (EMRs), which carry patient information offered from one health provider.

“Our patients can be anywhere and, with just the touch of a button, we can assure they will be covered and taken care of correctly,” said Wanda Mims, the top official in Puerto Rico of the U.S. Department of Veterans Affairs, the only institution on the island that currently handles EHRs.

Former Humana President Dr. Víctor Gutiérrez worked for more than 10 years to establish a system that compiles all the clinical data for a patient into a single file.

“Many have long seen this as a logical process so patients and health professionals can have easy access to information and prevent duplic! ation. We wanted quality to go up but costs to go down,” Gutié! rrez sai d. Obama’s inclusion of EHRs in the ARRA stimulus package accelerated the process by making it a priority for medical practices to share information through a national database.

“You are able to look at a full patient profile. For patients, it will prevent any inconveniences in terms of picking up and taking documents from one place to another. It will also lower costs and will help a lot in quality of service,” Gutiérrez said.

Gutiérrez acknowledged the high hardware, software and training costs tied to EHR implementation but argued “there has to be a safe method for data storage and the Hitech Act can help cover these costs.”

“The government is providing us with the power to transform health services to attend to patient’s needs,” said Laura Morales, president of Smart Health, a company that provides health-information systems. She added that the current manual-records process is vulnerable to errors, privacy violations, duplication of prescriptions and treatments an! d is marked by fragmentized information.

For Piovanetti, the adoption of EHRs is also a matter of maintaining the competitiveness of the island’s healthcare system.

“Puerto Rico is too focused on its problems and isn’t looking beyond our coast to see how we rate,” said Piovanetti, arguing that the island lags far behind the medical industries in Europe, Mexico, Canada and other jurisdictions.

According to a study published by the World Economic Forum, Puerto Rico ranks 43 out of 133 in the network readiness index. Countries such as Tunisia, Qatar and Barbados are more technologically ready than Puerto Rico.

“This is a long process and it won’t be easy. There are a lot of people who aren’t technologically advanced,” Plá concluded.


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