I think that a mandate may be the best solution to the EMR dilemma that we face today. While EMR implementation is obviously occurring today -- and Massachusetts is fortunate to have higher use than most other states -- progress is spotty, slow, and in many ways, ineffectual.
There is a growing digital divide in health care delivery. Large systems like Partners and Harvard Vanguard (sorry, I just can't call them "Atrius" yet) have the organizational fortitude and financial resources to successfully invest in EMRs. However, smaller practices (those with 10 or fewer physicians), and particularly primary care practices, don't.
Nationally, only about 25% of small practices have an EMR; 5 years ago it was about 20%, so we're not getting anywhere fast with this group. Unfortunately for us patients, 90% of our outpatient care happens in small practices, not in the large, well-resourced ones. Thus, at the current pace of EMR growth, it's going to be a looooooong time before most of us get the benefits that EMRs have to offer.
The dilemma is that physicians in small practices don't feel a whole lot of urgency to invest in EMRs at present. That's because it costs a lot to get up and running on a good EMR (almost $40K per doctor), and there aren't strong incentives or mandates compelling them to move faster. Unlike most businesses, physicians can't pass the cost of capital improvements on to their customers. Yet, on the other side of the equation, they can't stop the benefits of those improvements from flowing to their customers either. It's a perfect recipe for under-investment.
A mandate would provide the urgency for EMR implementation that the market can't provide today. However, a mandate needs to be coupled with an approach to assisting physicians get over the hurdles that have prevented widespread EMR investment in the first place. Without such a bulwark, a mandate will be a complete disaster.
I believe that a mandate needs to be coupled with an approach that addresses five key questions:
- What is an "EMR"? This is still a nascent technology, and there are a lot of bad systems out there. We need to mandate that physicians implement only qualified EMR systems, and we need a way to facilitate that process.
- What does "implement" mean? EMRs are only valuable if they're used in a way that creates value. So a mandate needs to cover not only what they implement, but also how they use it once it's in place.
- Who's going to pay for this? An unfunded mandate will create chaos in the near-term, because you can't get blood out of a stone. If we don't create a funding mechanism that forces health insurers and employers to bear their share of the cost, we'll end up with a lot of physicians going out of business or leaving the state.
- Who's going to implement this? Retail EMR implementations have a 30-40% failure rate today. EMR implementation is hard, and the practices that need EMRs the most are the same ones who don't have the expertise to get it done effectively. In addition to funding, a mandate needs to be backed by an infrastructure that can assist physicians with rapid, effective implementation.
- What about health information exchange? One of the biggest problems with leaving EMR implementation to market forces is that the market doesn't address health information exchange, which is a pure "public good" that benefits society but that no one wants to invest in on their own. If we're going to have a mandate, it should include HIE, because that's where a lot of the value lies.
MAeHC has estimated that universal adoption would require that we outfit 8,000-10,000 physicians with an EMR who wouldn't otherwise get one on their own. We estimate that this would cost roughly $500 million if we include the cost of health information exchanges as well as EMRs (you need HIEs to get the cost reductions that everyone is looking for). This figure also includes the cost of an infrastructure to facilitate rapid and effective implementation. Spread this over 5 years, and it amounts to $100 million per year. Considering that we spend over $50 billion on health care in Massachusetts every year, this is a miniscule investment compared with the value that it will bring.
The universal health law will be merely a facade if we can't dampen health care cost growth. Indeed, current rates of growth threaten not only the universal health law, it affects all of our health care benefits. EMRs aren't a panacea, but they are key to ANY solution. That's why a mandate makes sense.
We are fortunate to live in a state that can actually provide practical solutions to make an EMR mandate effective -- there are few, if any, other states that can make that claim. An appropriately structured mandate that addresses the questions noted above will catapult Massachusetts into the next era of health care delivery and burnish our already well-earned reputation as a national beacon of health care innovation.