Mary Ellen Schneider

Dr. David O. Meltzer, the chief of hospital medicine at the University of Chicago, has no problem keeping busy.

When he's not fulfilling clinical and administrative duties directly associated with his hospitalist role, he's doing research, working on a book about hospitalists, or leading discussions about the best use of limited national funds for health research. But Dr. Meltzer loves the variety, and he thinks that young hospitalists can avoid burnout by developing diverse professional roles.

A key lesson of early research on hospitalists is that they do a better job as they gain more experience, Dr. Meltzer said. So at the University of Chicago, he and his colleagues have focused on how to design “sustainable jobs” for hospitalists. As they looked into what worked at their institution, they realized that physicians with well-defined academic niches—in administration, teaching, or research, for example—tended to be the happiest and stay the longest.

That finding led to the creation of the Hospitalist Scholars Program, which lets hospitalists get training in research and pursue scholarship in medical education early in their hospital medicine careers. The program, which typically lasts 2 years, combines master's-level courses with mentored research. Physicians in the program devote most of their time to the academic training and spend the remaining 3 months of the year doing clinical work.

After completing the program, hospitalists are prepared to pursue academic interests in the time not filled by their clinical responsibilities. That's important, Dr. Meltzer explained, because there's a maximum amount of time that most hospitalists can devote to clinical duties without burning out, but they need to find other responsibilities to fill the rest of their professional time. So far the program has been a success, with the vast majority of those who complete the scholars program staying in academic hospital medicine.

Along with making hospitalist careers more sustainable on the individual level, Dr. Meltzer said he sees potential for the program to advance the specialty as a whole. Physicians who come out of the scholars program can incorporate research and scholarship into what they do on a daily basis, he said. “It's helping to build the field as an academic field,” he said. “That will help inspire the best residents to go into hospital medicine.”

In his own career, Dr. Meltzer never has the chance to burn out because he's always pursuing new projects. This year, he's completing work on a research project exploring what happens to patients after they have been treated by a hospitalist and discharged. Analysis of data from many hospitals has shown that patients treated by hospitalists tend to have a shorter length of stay, but questions remain as to whether that might lead to higher readmission rates or a greater need for outpatient services. Using Medicare data, Dr. Meltzer and his colleagues found trends suggesting that hospitalists really do provide better care, and that shorter lengths of stay do not boost overall utilization, he said.

He's also working on a book on the historical origins and development of the U.S. hospitalist movement. Funded through a grant from the Robert Wood Johnson Foundation, the project will look at why hospital medicine grew and what its origins mean for the future of the specialty. Dr. Meltzer said he's enthusiastic about the project because a better understanding of the history of hospital medicine can help ensure the sustainability of the specialty, as all of medicine braces for the uncertainty that will come with reform of the health care system.

An early and somewhat surprising finding from his book research is that hospital medicine grew mainly because many ambulatory physicians no longer wanted the job of caring for the patient in the hospital. “Hospitalists came in and filled the gap,” Dr. Meltzer said.

The wild card in charting the speciality's future will be the impact of health care reform, especially the bundling of payments for inpatient and outpatient services. “We're going to be in a pretty uncertain environment in hospital medicine for the next few years,” he said.

The Hospitalist Scholars Program is 'helping to build the field as an academic field.'

Dr. David O. Meltzer, the chief of hospital medicine at the University of Chicago, has no problem keeping busy.

When he's not fulfilling clinical and administrative duties directly associated with his hospitalist role, he's doing research, working on a book about hospitalists, or leading discussions about the best use of limited national funds for health research. But Dr. Meltzer loves the variety, and he thinks that young hospitalists can avoid burnout by developing diverse professional roles.

A key lesson of early research on hospitalists is that they do a better job as they gain more experience, Dr. Meltzer said. So at the University of Chicago, he and his colleagues have focused on how to design “sustainable jobs” for hospitalists. As they looked into what worked at their institution, they realized that physicians with well-defined academic niches—in administration, teaching, or research, for example—tended to be the happiest and stay the longest.

That finding led to the creation of the Hospitalist Scholars Program, which lets hospitalists get training in research and pursue scholarship in medical education early in their hospital medicine careers. The program, which typically lasts 2 years, combines master's-level courses with mentored research. Physicians in the program devote most of their time to the academic training and spend the remaining 3 months of the year doing clinical work.

After completing the program, hospitalists are prepared to pursue academic interests in the time not filled by their clinical responsibilities. That's important, Dr. Meltzer explained, because there's a maximum amount of time that most hospitalists can devote to clinical duties without burning out, but they need to find other responsibilities to fill the rest of their professional time. So far the program has been a success, with the vast majority of those who complete the scholars program staying in academic hospital medicine.

Along with making hospitalist careers more sustainable on the individual level, Dr. Meltzer said he sees potential for the program to advance the specialty as a whole. Physicians who come out of the scholars program can incorporate research and scholarship into what they do on a daily basis, he said. “It's helping to build the field as an academic field,” he said. “That will help inspire the best residents to go into hospital medicine.”

In his own career, Dr. Meltzer never has the chance to burn out because he's always pursuing new projects. This year, he's completing work on a research project exploring what happens to patients after they have been treated by a hospitalist and discharged. Analysis of data from many hospitals has shown that patients treated by hospitalists tend to have a shorter length of stay, but questions remain as to whether that might lead to higher readmission rates or a greater need for outpatient services. Using Medicare data, Dr. Meltzer and his colleagues found trends suggesting that hospitalists really do provide better care, and that shorter lengths of stay do not boost overall utilization, he said.

He's also working on a book on the historical origins and development of the U.S. hospitalist movement. Funded through a grant from the Robert Wood Johnson Foundation, the project will look at why hospital medicine grew and what its origins mean for the future of the specialty. Dr. Meltzer said he's enthusiastic about the project because a better understanding of the history of hospital medicine can help ensure the sustainability of the specialty, as all of medicine braces for the uncertainty that will come with reform of the health care system.

An early and somewhat surprising finding from his book research is that hospital medicine grew mainly because many ambulatory physicians no longer wanted the job of caring for the patient in the hospital. “Hospitalists came in and filled the gap,” Dr. Meltzer said.

The wild card in charting the speciality's future will be the impact of health care reform, especially the bundling of payments for inpatient and outpatient services. “We're going to be in a pretty uncertain environment in hospital medicine for the next few years,” he said.

The Hospitalist Scholars Program is 'helping to build the field as an academic field.'

Dr. David O. Meltzer, the chief of hospital medicine at the University of Chicago, has no problem keeping busy.

When he's not fulfilling clinical and administrative duties directly associated with his hospitalist role, he's doing research, working on a book about hospitalists, or leading discussions about the best use of limited national funds for health research. But Dr. Meltzer loves the variety, and he thinks that young hospitalists can avoid burnout by developing diverse professional roles.

A key lesson of early research on hospitalists is that they do a better job as they gain more experience, Dr. Meltzer said. So at the University of Chicago, he and his colleagues have focused on how to design “sustainable jobs” for hospitalists. As they looked into what worked at their institution, they realized that physicians with well-defined academic niches—in administration, teaching, or research, for example—tended to be the happiest and stay the longest.

That finding led to the creation of the Hospitalist Scholars Program, which lets hospitalists get training in research and pursue scholarship in medical education early in their hospital medicine careers. The program, which typically lasts 2 years, combines master's-level courses with mentored research. Physicians in the program devote most of their time to the academic training and spend the remaining 3 months of the year doing clinical work.

After completing the program, hospitalists are prepared to pursue academic interests in the time not filled by their clinical responsibilities. That's important, Dr. Meltzer explained, because there's a maximum amount of time that most hospitalists can devote to clinical duties without burning out, but they need to find other responsibilities to fill the rest of their professional time. So far the program has been a success, with the vast majority of those who complete the scholars program staying in academic hospital medicine.

Along with making hospitalist careers more sustainable on the individual level, Dr. Meltzer said he sees potential for the program to advance the specialty as a whole. Physicians who come out of the scholars program can incorporate research and scholarship into what they do on a daily basis, he said. “It's helping to build the field as an academic field,” he said. “That will help inspire the best residents to go into hospital medicine.”

In his own career, Dr. Meltzer never has the chance to burn out because he's always pursuing new projects. This year, he's completing work on a research project exploring what happens to patients after they have been treated by a hospitalist and discharged. Analysis of data from many hospitals has shown that patients treated by hospitalists tend to have a shorter length of stay, but questions remain as to whether that might lead to higher readmission rates or a greater need for outpatient services. Using Medicare data, Dr. Meltzer and his colleagues found trends suggesting that hospitalists really do provide better care, and that shorter lengths of stay do not boost overall utilization, he said.

He's also working on a book on the historical origins and development of the U.S. hospitalist movement. Funded through a grant from the Robert Wood Johnson Foundation, the project will look at why hospital medicine grew and what its origins mean for the future of the specialty. Dr. Meltzer said he's enthusiastic about the project because a better understanding of the history of hospital medicine can help ensure the sustainability of the specialty, as all of medicine braces for the uncertainty that will come with reform of the health care system.

An early and somewhat surprising finding from his book research is that hospital medicine grew mainly because many ambulatory physicians no longer wanted the job of caring for the patient in the hospital. “Hospitalists came in and filled the gap,” Dr. Meltzer said.

The wild card in charting the speciality's future will be the impact of health care reform, especially the bundling of payments for inpatient and outpatient services. “We're going to be in a pretty uncertain environment in hospital medicine for the next few years,” he said.

The Hospitalist Scholars Program is 'helping to build the field as an academic field.'

When recruiting top personnel to a hospital, it's crucial to gain the approval of the candidate's spouse and family, according to an online survey conducted by the executive search and consulting firm MillicanSolutions.

The survey, which included responses from 36 academic medical centers in the United States and Canada, showed that although work environment and salary were the top challenges in retaining faculty members, the concerns of family members and spouses were the most important elements in the recruiting process. The survey was conducted in collaboration with the Association of Administrators in Academic Pediatrics.

More than a third of the respondents ranked family and spouse concerns as the greatest challenge in recruiting faculty. About 21% cited salary and benefits, and only 10% of academic medical centers said that work environment was a major factor. Similarly, family and spouse concerns were the top reasons cited by candidates in rejecting a job offer. Family matters also topped the reasons for resignation in the survey.

Hospital executives should pay attention to this trend and bring families into the interview process early, said Wesley D. Millican, CEO of MillicanSolutions. Typically, spouses and family members don't visit the facility until the second interview. Hospitals can save time and money by involving families right away and finding out what they want, which may have more to do with sports and music opportunities for children than with salary and advancement opportunities, Mr. Millican said.

When recruiting top personnel to a hospital, it's crucial to gain the approval of the candidate's spouse and family, according to an online survey conducted by the executive search and consulting firm MillicanSolutions.

The survey, which included responses from 36 academic medical centers in the United States and Canada, showed that although work environment and salary were the top challenges in retaining faculty members, the concerns of family members and spouses were the most important elements in the recruiting process. The survey was conducted in collaboration with the Association of Administrators in Academic Pediatrics.

More than a third of the respondents ranked family and spouse concerns as the greatest challenge in recruiting faculty. About 21% cited salary and benefits, and only 10% of academic medical centers said that work environment was a major factor. Similarly, family and spouse concerns were the top reasons cited by candidates in rejecting a job offer. Family matters also topped the reasons for resignation in the survey.

Hospital executives should pay attention to this trend and bring families into the interview process early, said Wesley D. Millican, CEO of MillicanSolutions. Typically, spouses and family members don't visit the facility until the second interview. Hospitals can save time and money by involving families right away and finding out what they want, which may have more to do with sports and music opportunities for children than with salary and advancement opportunities, Mr. Millican said.

When recruiting top personnel to a hospital, it's crucial to gain the approval of the candidate's spouse and family, according to an online survey conducted by the executive search and consulting firm MillicanSolutions.

The survey, which included responses from 36 academic medical centers in the United States and Canada, showed that although work environment and salary were the top challenges in retaining faculty members, the concerns of family members and spouses were the most important elements in the recruiting process. The survey was conducted in collaboration with the Association of Administrators in Academic Pediatrics.

More than a third of the respondents ranked family and spouse concerns as the greatest challenge in recruiting faculty. About 21% cited salary and benefits, and only 10% of academic medical centers said that work environment was a major factor. Similarly, family and spouse concerns were the top reasons cited by candidates in rejecting a job offer. Family matters also topped the reasons for resignation in the survey.

Hospital executives should pay attention to this trend and bring families into the interview process early, said Wesley D. Millican, CEO of MillicanSolutions. Typically, spouses and family members don't visit the facility until the second interview. Hospitals can save time and money by involving families right away and finding out what they want, which may have more to do with sports and music opportunities for children than with salary and advancement opportunities, Mr. Millican said.

Health care facilities around the country have added new infection prevention measures aimed at stopping the spread of Clostridium difficile infections, but few have been able to add staff to help cope with the problem, according to an online survey conducted by the Association for Professionals in Infection Control and Epidemiology.

Overall, 53% of the health care facilities surveyed by APIC had adopted new interventions to address C. difficile in the last 18 months; of those that had not, 21% were planning to do so in the next year. But only 23% of the facilities reported that they had added more infection prevention staff or increased the hours dedicated to infection prevention. And about 34% of the respondents said that their facility could be doing more to control the spread of C. difficile.

APIC conducted the survey in February and March of this year to gauge progress following a November 2008 APIC report showing that the prevalence of C. difficile was 6–20 times greater than previously estimated. The survey yielded responses from nearly 1,800 APIC members, most of whom are nursing directors or patient safety officers working in acute care facilities.

The survey findings suggest that some hospitals are heeding the data on increased prevalence as a call to action. For example, over the past 18 months, about 60% of the facilities surveyed have implemented additional or more aggressive hand hygiene interventions, 77% have started staff education programs about C. difficile, and 50% have added patient education programs about the infection.

But the survey also showed that hospitals could be doing a better job when it comes to tracking colectomies, which can indicate the presence of a more severe strain of C. difficile. Fewer than 30% of facilities reported that they monitor the number of colectomies performed, and 46% said they didn't know if the colectomy rate had increased during the past 18 months.

The full survey report is available at www.apic.org

Health care facilities around the country have added new infection prevention measures aimed at stopping the spread of Clostridium difficile infections, but few have been able to add staff to help cope with the problem, according to an online survey conducted by the Association for Professionals in Infection Control and Epidemiology.

Overall, 53% of the health care facilities surveyed by APIC had adopted new interventions to address C. difficile in the last 18 months; of those that had not, 21% were planning to do so in the next year. But only 23% of the facilities reported that they had added more infection prevention staff or increased the hours dedicated to infection prevention. And about 34% of the respondents said that their facility could be doing more to control the spread of C. difficile.

APIC conducted the survey in February and March of this year to gauge progress following a November 2008 APIC report showing that the prevalence of C. difficile was 6–20 times greater than previously estimated. The survey yielded responses from nearly 1,800 APIC members, most of whom are nursing directors or patient safety officers working in acute care facilities.

The survey findings suggest that some hospitals are heeding the data on increased prevalence as a call to action. For example, over the past 18 months, about 60% of the facilities surveyed have implemented additional or more aggressive hand hygiene interventions, 77% have started staff education programs about C. difficile, and 50% have added patient education programs about the infection.

But the survey also showed that hospitals could be doing a better job when it comes to tracking colectomies, which can indicate the presence of a more severe strain of C. difficile. Fewer than 30% of facilities reported that they monitor the number of colectomies performed, and 46% said they didn't know if the colectomy rate had increased during the past 18 months.

The full survey report is available at www.apic.org

Health care facilities around the country have added new infection prevention measures aimed at stopping the spread of Clostridium difficile infections, but few have been able to add staff to help cope with the problem, according to an online survey conducted by the Association for Professionals in Infection Control and Epidemiology.

Overall, 53% of the health care facilities surveyed by APIC had adopted new interventions to address C. difficile in the last 18 months; of those that had not, 21% were planning to do so in the next year. But only 23% of the facilities reported that they had added more infection prevention staff or increased the hours dedicated to infection prevention. And about 34% of the respondents said that their facility could be doing more to control the spread of C. difficile.

APIC conducted the survey in February and March of this year to gauge progress following a November 2008 APIC report showing that the prevalence of C. difficile was 6–20 times greater than previously estimated. The survey yielded responses from nearly 1,800 APIC members, most of whom are nursing directors or patient safety officers working in acute care facilities.

The survey findings suggest that some hospitals are heeding the data on increased prevalence as a call to action. For example, over the past 18 months, about 60% of the facilities surveyed have implemented additional or more aggressive hand hygiene interventions, 77% have started staff education programs about C. difficile, and 50% have added patient education programs about the infection.

But the survey also showed that hospitals could be doing a better job when it comes to tracking colectomies, which can indicate the presence of a more severe strain of C. difficile. Fewer than 30% of facilities reported that they monitor the number of colectomies performed, and 46% said they didn't know if the colectomy rate had increased during the past 18 months.

The full survey report is available at www.apic.org

Check your mailbox. If you provided covered out-of-network services to patients insured by UnitedHealth Group between March 1994 and November 2009, you may be eligible to receive payments as part of a $350 million settlement reached last year.

The $350 million settlement comes after a nearly decade-long legal battle between UnitedHealth Group and several plaintiffs, including the American Medical Association, the Medical Society of the State of New York, and the Missouri State Medical Association. The groups alleged that UnitedHealth Group conspired to systematically underpay physicians for out-of-network medical services by using an industry database of charges to justify lower reimbursements.

Last year, UnitedHealth Group reached a settlement with New York State Attorney General Andrew Cuomo to discontinue use of the database, and the company committed $50 million to fund the development of a new, independent database that will determine the rates paid for out-of-network care.

In a separate settlement, the company agreed to pay $350 million to reimburse health plan members and out-of-network providers who were underpaid as a result of the flawed database calculations.

Physicians and patients have until July 27, 2010, to opt out of the settlement. Claims for payments from the settlement fund are due by Oct. 5, 2010.

To be eligible to receive part of the settlement, physicians must have provided covered out-of-network services or supplies between March 15, 1994, and Nov. 18, 2009, to patients covered by a health plan that was either administered or insured by UnitedHealthcare, Oxford Health Plans, Metropolitan Life Insurance Companies, American Airlines, or one of their affiliates. In addition, in order to be eligible, physicians must have been given an assignment by the patient to bill the health plan.

Physicians billed via an assignment if they received a payment directly from the health plan, if they completed box 13 on the HCFA/CMS 1500 form, or if they marked yes in the benefits assignment indicator on an electronic health care claim, according to the AMA.

For more information, contact the Berdon Claims Administration LLC at 800-443-1073 or unitedhealthcare@berdonclaimsllc.com

Check your mailbox. If you provided covered out-of-network services to patients insured by UnitedHealth Group between March 1994 and November 2009, you may be eligible to receive payments as part of a $350 million settlement reached last year.

The $350 million settlement comes after a nearly decade-long legal battle between UnitedHealth Group and several plaintiffs, including the American Medical Association, the Medical Society of the State of New York, and the Missouri State Medical Association. The groups alleged that UnitedHealth Group conspired to systematically underpay physicians for out-of-network medical services by using an industry database of charges to justify lower reimbursements.

Last year, UnitedHealth Group reached a settlement with New York State Attorney General Andrew Cuomo to discontinue use of the database, and the company committed $50 million to fund the development of a new, independent database that will determine the rates paid for out-of-network care.

In a separate settlement, the company agreed to pay $350 million to reimburse health plan members and out-of-network providers who were underpaid as a result of the flawed database calculations.

Physicians and patients have until July 27, 2010, to opt out of the settlement. Claims for payments from the settlement fund are due by Oct. 5, 2010.

To be eligible to receive part of the settlement, physicians must have provided covered out-of-network services or supplies between March 15, 1994, and Nov. 18, 2009, to patients covered by a health plan that was either administered or insured by UnitedHealthcare, Oxford Health Plans, Metropolitan Life Insurance Companies, American Airlines, or one of their affiliates. In addition, in order to be eligible, physicians must have been given an assignment by the patient to bill the health plan.

Physicians billed via an assignment if they received a payment directly from the health plan, if they completed box 13 on the HCFA/CMS 1500 form, or if they marked yes in the benefits assignment indicator on an electronic health care claim, according to the AMA.

For more information, contact the Berdon Claims Administration LLC at 800-443-1073 or unitedhealthcare@berdonclaimsllc.com

Check your mailbox. If you provided covered out-of-network services to patients insured by UnitedHealth Group between March 1994 and November 2009, you may be eligible to receive payments as part of a $350 million settlement reached last year.

The $350 million settlement comes after a nearly decade-long legal battle between UnitedHealth Group and several plaintiffs, including the American Medical Association, the Medical Society of the State of New York, and the Missouri State Medical Association. The groups alleged that UnitedHealth Group conspired to systematically underpay physicians for out-of-network medical services by using an industry database of charges to justify lower reimbursements.

Last year, UnitedHealth Group reached a settlement with New York State Attorney General Andrew Cuomo to discontinue use of the database, and the company committed $50 million to fund the development of a new, independent database that will determine the rates paid for out-of-network care.

In a separate settlement, the company agreed to pay $350 million to reimburse health plan members and out-of-network providers who were underpaid as a result of the flawed database calculations.

Physicians and patients have until July 27, 2010, to opt out of the settlement. Claims for payments from the settlement fund are due by Oct. 5, 2010.

To be eligible to receive part of the settlement, physicians must have provided covered out-of-network services or supplies between March 15, 1994, and Nov. 18, 2009, to patients covered by a health plan that was either administered or insured by UnitedHealthcare, Oxford Health Plans, Metropolitan Life Insurance Companies, American Airlines, or one of their affiliates. In addition, in order to be eligible, physicians must have been given an assignment by the patient to bill the health plan.

Physicians billed via an assignment if they received a payment directly from the health plan, if they completed box 13 on the HCFA/CMS 1500 form, or if they marked yes in the benefits assignment indicator on an electronic health care claim, according to the AMA.

For more information, contact the Berdon Claims Administration LLC at 800-443-1073 or unitedhealthcare@berdonclaimsllc.com

TORONTO — The American Board of Internal Medicine is working to make maintenance of certification less redundant, more continuous, and possibly more transparent to the public.

Dr. Wendy S. Levinson, ABIM board chair, told internists at the annual meeting that she understands their frustration with having to report the same type of quality information in so many different ways to various bodies.

“We ourselves live in this world as members of the board who practice,” she said. “There are so many requirements on doctors to tell someone how they're doing.”

With that in mind, the ABIM and other medical specialty certification boards are working closely with state licensing boards to see if maintenance of certification (MOC) can fulfill some of their reporting requirements.

In addition, the recently enacted health reform law, the Affordable Care Act, includes language about using MOC to satisfy the quality reporting requirements of Medicare's Physician Quality Reporting Initiative. But how that is going to be implemented is still unclear, Dr. Levinson said.

Ideally, officials at the ABIM would like to see MOC become part of a more seamless process, she said.

For example, physicians someday might be able to log in to the ABIM Web site to complete their MOC requirements, then with a few clicks, send that information along to their state licensing board and a health plan's pay-for-performance program, as well as to hospitals for credentialing.

The ABIM also aims to transform MOC into a more continuous process so that physicians would be doing some aspect of MOC every 1-2 years. This wouldn't mean that physicians would have to take the secure exam more regularly, but they might need to fulfill other MOC requirements on a different schedule. “We know that a 10-year cycle is too long,” Dr. Levinson said.

Other boards, such as the American Board of Emergency Medicine, already have annual requirements for their physicians. This type of schedule would help if MOC was to be used in the future to help maintain state medical licenses, she said, which need to be renewed every 1-2 years.

It would also help to meet the public's expectations that physicians are up-to-date on current techniques and research.

The question of how much information to make available to the public about certification is another area that the ABIM board is addressing. The American Board of Medical Specialties, the umbrella group for the 24 medical specialty boards, is encouraging all of the boards to start publishing online information on whether physicians are participating in MOC. Right now, the public can see only if a physician is certified or recertified, not whether the physician is participating.

The ABIM isn't yet ready to make that change, Dr. Levinson said. Going forward, the key will be to make sure that any published information is “meaningful and relevant” for the public, while also being “fair and appropriate” for the physician community, she said.

'There are so many requirements on doctors to tell someone how they're doing.'

Source DR. LEVINSON

TORONTO — The American Board of Internal Medicine is working to make maintenance of certification less redundant, more continuous, and possibly more transparent to the public.

Dr. Wendy S. Levinson, ABIM board chair, told internists at the annual meeting that she understands their frustration with having to report the same type of quality information in so many different ways to various bodies.

“We ourselves live in this world as members of the board who practice,” she said. “There are so many requirements on doctors to tell someone how they're doing.”

With that in mind, the ABIM and other medical specialty certification boards are working closely with state licensing boards to see if maintenance of certification (MOC) can fulfill some of their reporting requirements.

In addition, the recently enacted health reform law, the Affordable Care Act, includes language about using MOC to satisfy the quality reporting requirements of Medicare's Physician Quality Reporting Initiative. But how that is going to be implemented is still unclear, Dr. Levinson said.

Ideally, officials at the ABIM would like to see MOC become part of a more seamless process, she said.

For example, physicians someday might be able to log in to the ABIM Web site to complete their MOC requirements, then with a few clicks, send that information along to their state licensing board and a health plan's pay-for-performance program, as well as to hospitals for credentialing.

The ABIM also aims to transform MOC into a more continuous process so that physicians would be doing some aspect of MOC every 1-2 years. This wouldn't mean that physicians would have to take the secure exam more regularly, but they might need to fulfill other MOC requirements on a different schedule. “We know that a 10-year cycle is too long,” Dr. Levinson said.

Other boards, such as the American Board of Emergency Medicine, already have annual requirements for their physicians. This type of schedule would help if MOC was to be used in the future to help maintain state medical licenses, she said, which need to be renewed every 1-2 years.

It would also help to meet the public's expectations that physicians are up-to-date on current techniques and research.

The question of how much information to make available to the public about certification is another area that the ABIM board is addressing. The American Board of Medical Specialties, the umbrella group for the 24 medical specialty boards, is encouraging all of the boards to start publishing online information on whether physicians are participating in MOC. Right now, the public can see only if a physician is certified or recertified, not whether the physician is participating.

The ABIM isn't yet ready to make that change, Dr. Levinson said. Going forward, the key will be to make sure that any published information is “meaningful and relevant” for the public, while also being “fair and appropriate” for the physician community, she said.

'There are so many requirements on doctors to tell someone how they're doing.'

Source DR. LEVINSON

TORONTO — The American Board of Internal Medicine is working to make maintenance of certification less redundant, more continuous, and possibly more transparent to the public.

Dr. Wendy S. Levinson, ABIM board chair, told internists at the annual meeting that she understands their frustration with having to report the same type of quality information in so many different ways to various bodies.

“We ourselves live in this world as members of the board who practice,” she said. “There are so many requirements on doctors to tell someone how they're doing.”

With that in mind, the ABIM and other medical specialty certification boards are working closely with state licensing boards to see if maintenance of certification (MOC) can fulfill some of their reporting requirements.

In addition, the recently enacted health reform law, the Affordable Care Act, includes language about using MOC to satisfy the quality reporting requirements of Medicare's Physician Quality Reporting Initiative. But how that is going to be implemented is still unclear, Dr. Levinson said.

Ideally, officials at the ABIM would like to see MOC become part of a more seamless process, she said.

For example, physicians someday might be able to log in to the ABIM Web site to complete their MOC requirements, then with a few clicks, send that information along to their state licensing board and a health plan's pay-for-performance program, as well as to hospitals for credentialing.

The ABIM also aims to transform MOC into a more continuous process so that physicians would be doing some aspect of MOC every 1-2 years. This wouldn't mean that physicians would have to take the secure exam more regularly, but they might need to fulfill other MOC requirements on a different schedule. “We know that a 10-year cycle is too long,” Dr. Levinson said.

Other boards, such as the American Board of Emergency Medicine, already have annual requirements for their physicians. This type of schedule would help if MOC was to be used in the future to help maintain state medical licenses, she said, which need to be renewed every 1-2 years.

It would also help to meet the public's expectations that physicians are up-to-date on current techniques and research.

The question of how much information to make available to the public about certification is another area that the ABIM board is addressing. The American Board of Medical Specialties, the umbrella group for the 24 medical specialty boards, is encouraging all of the boards to start publishing online information on whether physicians are participating in MOC. Right now, the public can see only if a physician is certified or recertified, not whether the physician is participating.

The ABIM isn't yet ready to make that change, Dr. Levinson said. Going forward, the key will be to make sure that any published information is “meaningful and relevant” for the public, while also being “fair and appropriate” for the physician community, she said.

'There are so many requirements on doctors to tell someone how they're doing.'

Source DR. LEVINSON

Major Finding: At 7 months, 17 of 18 supported practices met NCQA patient-centered medical home criteria. One practice did not report data at follow-up.

Data Source: Randomized, controlled trial of a 2-year medical home demonstration project.

Disclosures: The medical home demonstration was funded by insurer EmblemHealth. The outside evaluation was funded by the Commonwealth Fund. No other disclosures were reported.

TORONTO — Small and solo practices can successfully transition to a patient-centered medical home model, but the change requires intensive outside support, according to early findings released at the annual meeting of the American College of Physicians.

In the first randomized, controlled trial evaluating the transition to the medical home, small practices that received hands-on support and financial incentives were able to rapidly transform to meet the National Committee for Quality Assurance (NCQA) criteria for a patient-centered medical home, according to Judith Fifield, Ph.D., who performed the external evaluation of the medical home project.

Dr. Fifield and her team at the Ethel Donaghue Center for Translating Research into Practice and Policy at the University of Connecticut, Farmington, are still evaluating data from the medical home project, but the initial findings show that, with proper support, the transition can happen in just over 6 months, even in very small practices.

The demonstration project involved 38 primary care practices in the New York City area. Half of the practices were randomized to receive intensive, in-person support and pay-for-performance incentive payments. The other 19 practices were given a $5,000 annual stipend and asked to make the transition to the medical home on their own.

Of the initial 19 supported practices, 1 practice withdrew. In the control arm, four practices withdrew before the study's end. At baseline, there were no significant differences between the supported and control arms of the study. Overall, about 40% of the participating practices were solo and 60% were small. About half of the practices had electronic health record (EHR) systems or were under contract to purchase one at baseline. The evaluation of the study was funded by the Commonwealth Fund.

Those practices in the supported group received on-site help from trained facilitators and nurse care managers. The facilitators provided guidance and training on how to use an EHR for patient communication, care coordination, and practice management. The practices without an EHR were given guidance on how to use their existing technology and paper-based systems to increase efficiency.

The nurse care managers, who were on site in the practices about once a week, helped staff members identify high-risk patients, assisted with care planning, and conducted group visits for patients with newly diagnosed diabetes. The nurses were often matched to the ethnicity and language of patients at the site, Dr. Fifield said.

The support teams “really became a big part of the care at the site,” she said.

The supported practices also were eligible to receive up to $5 per member per month in addition to their regular fee for service payments. The incentives were based on meeting the NCQA criteria for the medical home, as well as meeting clinical quality and patient experience benchmarks.

Preliminary data from the first year of the project show that supported practices earned between $3,300 and $55,000 in total pay-for-performance incentives.

Of the 18 supported practices that completed the project, only 1 practice could meet NCQA criteria at baseline. After 7 months, 17 of the supported practices met the criteria and 10 qualified for the highest level of NCQA recognition. One supported practice did not report data at the 7-month follow-up.

Dr. Fifield did not discuss outcomes for the control group during her review of the study's preliminary results.

Conversations with study participants also revealed that providers and staff were happy with the transition to the medical home, she said. Although there was some frustration at the beginning of the project, that quickly changed. Physicians reported that they were excited to learn how to do more with their EHRs, and staff members said that the process to convert to a medical home gave them new skills and made them feel like a more valued part of the care team.

The biggest concern, Dr. Fifield said, is the sustainability of the change, since so much of it depended on assistance from outside contractors.

“It requires a great deal of support,” she said. “It is a very high-touch operation, especially to do it this quickly”.

'It requires a great deal of support. It is a very high-touch operation, especially to do it this quickly.'

Source DR. FIFIELD

Major Finding: At 7 months, 17 of 18 supported practices met NCQA patient-centered medical home criteria. One practice did not report data at follow-up.

Data Source: Randomized, controlled trial of a 2-year medical home demonstration project.

Disclosures: The medical home demonstration was funded by insurer EmblemHealth. The outside evaluation was funded by the Commonwealth Fund. No other disclosures were reported.

TORONTO — Small and solo practices can successfully transition to a patient-centered medical home model, but the change requires intensive outside support, according to early findings released at the annual meeting of the American College of Physicians.

In the first randomized, controlled trial evaluating the transition to the medical home, small practices that received hands-on support and financial incentives were able to rapidly transform to meet the National Committee for Quality Assurance (NCQA) criteria for a patient-centered medical home, according to Judith Fifield, Ph.D., who performed the external evaluation of the medical home project.

Dr. Fifield and her team at the Ethel Donaghue Center for Translating Research into Practice and Policy at the University of Connecticut, Farmington, are still evaluating data from the medical home project, but the initial findings show that, with proper support, the transition can happen in just over 6 months, even in very small practices.

The demonstration project involved 38 primary care practices in the New York City area. Half of the practices were randomized to receive intensive, in-person support and pay-for-performance incentive payments. The other 19 practices were given a $5,000 annual stipend and asked to make the transition to the medical home on their own.

Of the initial 19 supported practices, 1 practice withdrew. In the control arm, four practices withdrew before the study's end. At baseline, there were no significant differences between the supported and control arms of the study. Overall, about 40% of the participating practices were solo and 60% were small. About half of the practices had electronic health record (EHR) systems or were under contract to purchase one at baseline. The evaluation of the study was funded by the Commonwealth Fund.

Those practices in the supported group received on-site help from trained facilitators and nurse care managers. The facilitators provided guidance and training on how to use an EHR for patient communication, care coordination, and practice management. The practices without an EHR were given guidance on how to use their existing technology and paper-based systems to increase efficiency.

The nurse care managers, who were on site in the practices about once a week, helped staff members identify high-risk patients, assisted with care planning, and conducted group visits for patients with newly diagnosed diabetes. The nurses were often matched to the ethnicity and language of patients at the site, Dr. Fifield said.

The support teams “really became a big part of the care at the site,” she said.

The supported practices also were eligible to receive up to $5 per member per month in addition to their regular fee for service payments. The incentives were based on meeting the NCQA criteria for the medical home, as well as meeting clinical quality and patient experience benchmarks.

Preliminary data from the first year of the project show that supported practices earned between $3,300 and $55,000 in total pay-for-performance incentives.

Of the 18 supported practices that completed the project, only 1 practice could meet NCQA criteria at baseline. After 7 months, 17 of the supported practices met the criteria and 10 qualified for the highest level of NCQA recognition. One supported practice did not report data at the 7-month follow-up.

Dr. Fifield did not discuss outcomes for the control group during her review of the study's preliminary results.

Conversations with study participants also revealed that providers and staff were happy with the transition to the medical home, she said. Although there was some frustration at the beginning of the project, that quickly changed. Physicians reported that they were excited to learn how to do more with their EHRs, and staff members said that the process to convert to a medical home gave them new skills and made them feel like a more valued part of the care team.

The biggest concern, Dr. Fifield said, is the sustainability of the change, since so much of it depended on assistance from outside contractors.

“It requires a great deal of support,” she said. “It is a very high-touch operation, especially to do it this quickly”.

'It requires a great deal of support. It is a very high-touch operation, especially to do it this quickly.'

Source DR. FIFIELD

Major Finding: At 7 months, 17 of 18 supported practices met NCQA patient-centered medical home criteria. One practice did not report data at follow-up.

Data Source: Randomized, controlled trial of a 2-year medical home demonstration project.

Disclosures: The medical home demonstration was funded by insurer EmblemHealth. The outside evaluation was funded by the Commonwealth Fund. No other disclosures were reported.

TORONTO — Small and solo practices can successfully transition to a patient-centered medical home model, but the change requires intensive outside support, according to early findings released at the annual meeting of the American College of Physicians.

In the first randomized, controlled trial evaluating the transition to the medical home, small practices that received hands-on support and financial incentives were able to rapidly transform to meet the National Committee for Quality Assurance (NCQA) criteria for a patient-centered medical home, according to Judith Fifield, Ph.D., who performed the external evaluation of the medical home project.

Dr. Fifield and her team at the Ethel Donaghue Center for Translating Research into Practice and Policy at the University of Connecticut, Farmington, are still evaluating data from the medical home project, but the initial findings show that, with proper support, the transition can happen in just over 6 months, even in very small practices.

The demonstration project involved 38 primary care practices in the New York City area. Half of the practices were randomized to receive intensive, in-person support and pay-for-performance incentive payments. The other 19 practices were given a $5,000 annual stipend and asked to make the transition to the medical home on their own.

Of the initial 19 supported practices, 1 practice withdrew. In the control arm, four practices withdrew before the study's end. At baseline, there were no significant differences between the supported and control arms of the study. Overall, about 40% of the participating practices were solo and 60% were small. About half of the practices had electronic health record (EHR) systems or were under contract to purchase one at baseline. The evaluation of the study was funded by the Commonwealth Fund.

Those practices in the supported group received on-site help from trained facilitators and nurse care managers. The facilitators provided guidance and training on how to use an EHR for patient communication, care coordination, and practice management. The practices without an EHR were given guidance on how to use their existing technology and paper-based systems to increase efficiency.

The nurse care managers, who were on site in the practices about once a week, helped staff members identify high-risk patients, assisted with care planning, and conducted group visits for patients with newly diagnosed diabetes. The nurses were often matched to the ethnicity and language of patients at the site, Dr. Fifield said.

The support teams “really became a big part of the care at the site,” she said.

The supported practices also were eligible to receive up to $5 per member per month in addition to their regular fee for service payments. The incentives were based on meeting the NCQA criteria for the medical home, as well as meeting clinical quality and patient experience benchmarks.

Preliminary data from the first year of the project show that supported practices earned between $3,300 and $55,000 in total pay-for-performance incentives.

Of the 18 supported practices that completed the project, only 1 practice could meet NCQA criteria at baseline. After 7 months, 17 of the supported practices met the criteria and 10 qualified for the highest level of NCQA recognition. One supported practice did not report data at the 7-month follow-up.

Dr. Fifield did not discuss outcomes for the control group during her review of the study's preliminary results.

Conversations with study participants also revealed that providers and staff were happy with the transition to the medical home, she said. Although there was some frustration at the beginning of the project, that quickly changed. Physicians reported that they were excited to learn how to do more with their EHRs, and staff members said that the process to convert to a medical home gave them new skills and made them feel like a more valued part of the care team.

The biggest concern, Dr. Fifield said, is the sustainability of the change, since so much of it depended on assistance from outside contractors.

“It requires a great deal of support,” she said. “It is a very high-touch operation, especially to do it this quickly”.

'It requires a great deal of support. It is a very high-touch operation, especially to do it this quickly.'

Source DR. FIFIELD

TORONTO — Six years ago, Dr. Jon Yardney, a general internist in Wayne, Pa., was struggling to practice primary care medicine in a way that he felt offered his patients the best care.

After 25 years in practice, his patients were getting older and their medical needs were becoming more complicated. But even as they needed more time with him, Dr. Yardney was being forced to keep visits short. On a typical day, he would walk into the exam room and greet an 80-year-old woman with 10 medical problems, who was seeing five subspecialists and taking 15 medications. Sitting next to her would be her daughter, carrying a list of questions.

After spending nearly half of the 15-minute appointment on documentation, he would have time to answer just one question. He would then ask the patient to make a new appointment to address the rest of her concerns, an appointment she probably wouldn't be able to get for another 6 weeks, he said.

“I'm watching the faces of those ladies sitting there in my office, and saying to myself, 'My God, I'm failing them,'” Dr. Yardney told physicians at the annual meeting. “This is not what they signed up for. This is not what I signed up for.”

Then he saw a brochure promoting concierge-style practice. He worked with MDVIP, a national network of more than 350 primary care physicians who practice retainer-style medicine, to set up his new practice. A year later, he became an MDVIP-affiliated physician and opened his new practice with fewer than 500 patients. “Practicing this way has been a personal revelation for me,” he said.

Letting Patients Choose

For Dr. Matthew J. Killion, the move to offer retainer services was driven by patient demand. He had stopped accepting private insurance, and patients started to ask about a retainer program. He decided to try it as a voluntary pilot program, letting his patients choose to join the retainer program or stay in the regular practice.

Today, Dr. Killion's internal medicine practice in Philadelphia is still made up mainly of fee-for-service and Medicare patients, but he also sees more than 100 retainer patients—a number that's growing. He said that his own experience illustrates one way for the medical profession to achieve a larger goal: changing the primary care practice model to encourage physicians to stay in internal medicine.

Over time, Dr. Killion said he would like to expand the retainer part of the practice, and he's experimenting with offering different packages based on patient needs. For example, older patients may opt to pay a higher annual fee and get more services. “It can be very individualized,” he said in an interview.

The transition hasn't been a big money maker, Dr. Killion told attendees at the ACP meeting, but it has made a real difference in his lifestyle. Before accepting retainer patients, he saw 20-25 patients a day. Now he sees about 12 patients a day and still has time to pick up his kids from school and spend time with them.

The 'Private Medicine' Model

These experiences aren't unique, said Tom Blue, executive director of the American Academy of Private Physicians. For most physicians who transition from a traditional practice to a concierge or retainer model, frustration with the unsustainable primary care business model is the chief motivator. Others may feel that a high volume of patients is a barrier to providing high-quality care, Mr. Blue said.

“They just can't keep running faster and faster on the treadmill,” he said.

The perception of concierge or retainer medicine is that it's a luxury medical product for rich people, driven by physician greed, Mr. Blue said—but the opposite is true.

More than a decade after the first physicians began this movement, concierge medicine can mean anything from a $25 monthly fee to a $20,000 annual retainer, he said. About 3,500 U.S. physicians now practice using the concierge model, which Mr. Blue calls the “private medicine” model, meaning that the practice offers some services that are privately funded by patients.

Mr. Blue predicts that the number of “private medicine” physicians is likely to double annually for the next 3 years. He said he has seen a lot of interest from medical students and residents, who see the practice model as innovative and more sustainable.

Darin Engelhardt, who is president of MDVIP, agrees. He said the retainer practice model provides an incentive for younger physicians to consider primary care as a profession. And he thinks that retainer-style practice has helped experienced physicians stay in practice longer. Many of the physicians who join MDVIP, he said, are at a crossroads professionally and are contemplating leaving primary care altogether.

Medical Home Advantage

But Dr. J. Fred Ralston Jr., incoming president of the American College of Physicians, thinks that the patient-centered medical home, if fairly compensated, should be able to attract and retain doctors in general internal medicine. As a care delivery model, the medical home can provide care for a greater number of patients—an advantage that will be especially important as more people gain insurance coverage under the new health care reform law, he said.

The ACP has no official position on the concierge or retainer medicine practice model. Dr. Ralston said that as a practicing physician in Fayetteville, Tenn., he understands the frustrations that drive some physicians to choose the concierge model. But for its part, the ACP position is that the patient-centered medical home is an excellent care model to improve both patient care and primary care practice.

Both the medical home model and concierge care allow physicians to spend more time with patients. However, the medical home relies more heavily on a multidisciplinary team of providers than the concierge model, and thus will allow physicians to reach far more patients, Dr. Ralston said.

“Practicing this way has been a personal revelation for me,” said Dr. Jon Yardney, who now has fewer than 500 patients in his Wayne, Pa., practice.

TORONTO — Six years ago, Dr. Jon Yardney, a general internist in Wayne, Pa., was struggling to practice primary care medicine in a way that he felt offered his patients the best care.

After 25 years in practice, his patients were getting older and their medical needs were becoming more complicated. But even as they needed more time with him, Dr. Yardney was being forced to keep visits short. On a typical day, he would walk into the exam room and greet an 80-year-old woman with 10 medical problems, who was seeing five subspecialists and taking 15 medications. Sitting next to her would be her daughter, carrying a list of questions.

After spending nearly half of the 15-minute appointment on documentation, he would have time to answer just one question. He would then ask the patient to make a new appointment to address the rest of her concerns, an appointment she probably wouldn't be able to get for another 6 weeks, he said.

“I'm watching the faces of those ladies sitting there in my office, and saying to myself, 'My God, I'm failing them,'” Dr. Yardney told physicians at the annual meeting. “This is not what they signed up for. This is not what I signed up for.”

Then he saw a brochure promoting concierge-style practice. He worked with MDVIP, a national network of more than 350 primary care physicians who practice retainer-style medicine, to set up his new practice. A year later, he became an MDVIP-affiliated physician and opened his new practice with fewer than 500 patients. “Practicing this way has been a personal revelation for me,” he said.

Letting Patients Choose

For Dr. Matthew J. Killion, the move to offer retainer services was driven by patient demand. He had stopped accepting private insurance, and patients started to ask about a retainer program. He decided to try it as a voluntary pilot program, letting his patients choose to join the retainer program or stay in the regular practice.

Today, Dr. Killion's internal medicine practice in Philadelphia is still made up mainly of fee-for-service and Medicare patients, but he also sees more than 100 retainer patients—a number that's growing. He said that his own experience illustrates one way for the medical profession to achieve a larger goal: changing the primary care practice model to encourage physicians to stay in internal medicine.

Over time, Dr. Killion said he would like to expand the retainer part of the practice, and he's experimenting with offering different packages based on patient needs. For example, older patients may opt to pay a higher annual fee and get more services. “It can be very individualized,” he said in an interview.

The transition hasn't been a big money maker, Dr. Killion told attendees at the ACP meeting, but it has made a real difference in his lifestyle. Before accepting retainer patients, he saw 20-25 patients a day. Now he sees about 12 patients a day and still has time to pick up his kids from school and spend time with them.

The 'Private Medicine' Model

These experiences aren't unique, said Tom Blue, executive director of the American Academy of Private Physicians. For most physicians who transition from a traditional practice to a concierge or retainer model, frustration with the unsustainable primary care business model is the chief motivator. Others may feel that a high volume of patients is a barrier to providing high-quality care, Mr. Blue said.

“They just can't keep running faster and faster on the treadmill,” he said.

The perception of concierge or retainer medicine is that it's a luxury medical product for rich people, driven by physician greed, Mr. Blue said—but the opposite is true.

More than a decade after the first physicians began this movement, concierge medicine can mean anything from a $25 monthly fee to a $20,000 annual retainer, he said. About 3,500 U.S. physicians now practice using the concierge model, which Mr. Blue calls the “private medicine” model, meaning that the practice offers some services that are privately funded by patients.

Mr. Blue predicts that the number of “private medicine” physicians is likely to double annually for the next 3 years. He said he has seen a lot of interest from medical students and residents, who see the practice model as innovative and more sustainable.

Darin Engelhardt, who is president of MDVIP, agrees. He said the retainer practice model provides an incentive for younger physicians to consider primary care as a profession. And he thinks that retainer-style practice has helped experienced physicians stay in practice longer. Many of the physicians who join MDVIP, he said, are at a crossroads professionally and are contemplating leaving primary care altogether.

Medical Home Advantage

But Dr. J. Fred Ralston Jr., incoming president of the American College of Physicians, thinks that the patient-centered medical home, if fairly compensated, should be able to attract and retain doctors in general internal medicine. As a care delivery model, the medical home can provide care for a greater number of patients—an advantage that will be especially important as more people gain insurance coverage under the new health care reform law, he said.

The ACP has no official position on the concierge or retainer medicine practice model. Dr. Ralston said that as a practicing physician in Fayetteville, Tenn., he understands the frustrations that drive some physicians to choose the concierge model. But for its part, the ACP position is that the patient-centered medical home is an excellent care model to improve both patient care and primary care practice.

Both the medical home model and concierge care allow physicians to spend more time with patients. However, the medical home relies more heavily on a multidisciplinary team of providers than the concierge model, and thus will allow physicians to reach far more patients, Dr. Ralston said.

“Practicing this way has been a personal revelation for me,” said Dr. Jon Yardney, who now has fewer than 500 patients in his Wayne, Pa., practice.

TORONTO — Six years ago, Dr. Jon Yardney, a general internist in Wayne, Pa., was struggling to practice primary care medicine in a way that he felt offered his patients the best care.

After 25 years in practice, his patients were getting older and their medical needs were becoming more complicated. But even as they needed more time with him, Dr. Yardney was being forced to keep visits short. On a typical day, he would walk into the exam room and greet an 80-year-old woman with 10 medical problems, who was seeing five subspecialists and taking 15 medications. Sitting next to her would be her daughter, carrying a list of questions.

After spending nearly half of the 15-minute appointment on documentation, he would have time to answer just one question. He would then ask the patient to make a new appointment to address the rest of her concerns, an appointment she probably wouldn't be able to get for another 6 weeks, he said.

“I'm watching the faces of those ladies sitting there in my office, and saying to myself, 'My God, I'm failing them,'” Dr. Yardney told physicians at the annual meeting. “This is not what they signed up for. This is not what I signed up for.”

Then he saw a brochure promoting concierge-style practice. He worked with MDVIP, a national network of more than 350 primary care physicians who practice retainer-style medicine, to set up his new practice. A year later, he became an MDVIP-affiliated physician and opened his new practice with fewer than 500 patients. “Practicing this way has been a personal revelation for me,” he said.

Letting Patients Choose

For Dr. Matthew J. Killion, the move to offer retainer services was driven by patient demand. He had stopped accepting private insurance, and patients started to ask about a retainer program. He decided to try it as a voluntary pilot program, letting his patients choose to join the retainer program or stay in the regular practice.

Today, Dr. Killion's internal medicine practice in Philadelphia is still made up mainly of fee-for-service and Medicare patients, but he also sees more than 100 retainer patients—a number that's growing. He said that his own experience illustrates one way for the medical profession to achieve a larger goal: changing the primary care practice model to encourage physicians to stay in internal medicine.

Over time, Dr. Killion said he would like to expand the retainer part of the practice, and he's experimenting with offering different packages based on patient needs. For example, older patients may opt to pay a higher annual fee and get more services. “It can be very individualized,” he said in an interview.

The transition hasn't been a big money maker, Dr. Killion told attendees at the ACP meeting, but it has made a real difference in his lifestyle. Before accepting retainer patients, he saw 20-25 patients a day. Now he sees about 12 patients a day and still has time to pick up his kids from school and spend time with them.

The 'Private Medicine' Model

These experiences aren't unique, said Tom Blue, executive director of the American Academy of Private Physicians. For most physicians who transition from a traditional practice to a concierge or retainer model, frustration with the unsustainable primary care business model is the chief motivator. Others may feel that a high volume of patients is a barrier to providing high-quality care, Mr. Blue said.

“They just can't keep running faster and faster on the treadmill,” he said.

The perception of concierge or retainer medicine is that it's a luxury medical product for rich people, driven by physician greed, Mr. Blue said—but the opposite is true.

More than a decade after the first physicians began this movement, concierge medicine can mean anything from a $25 monthly fee to a $20,000 annual retainer, he said. About 3,500 U.S. physicians now practice using the concierge model, which Mr. Blue calls the “private medicine” model, meaning that the practice offers some services that are privately funded by patients.

Mr. Blue predicts that the number of “private medicine” physicians is likely to double annually for the next 3 years. He said he has seen a lot of interest from medical students and residents, who see the practice model as innovative and more sustainable.

Darin Engelhardt, who is president of MDVIP, agrees. He said the retainer practice model provides an incentive for younger physicians to consider primary care as a profession. And he thinks that retainer-style practice has helped experienced physicians stay in practice longer. Many of the physicians who join MDVIP, he said, are at a crossroads professionally and are contemplating leaving primary care altogether.

Medical Home Advantage

But Dr. J. Fred Ralston Jr., incoming president of the American College of Physicians, thinks that the patient-centered medical home, if fairly compensated, should be able to attract and retain doctors in general internal medicine. As a care delivery model, the medical home can provide care for a greater number of patients—an advantage that will be especially important as more people gain insurance coverage under the new health care reform law, he said.

The ACP has no official position on the concierge or retainer medicine practice model. Dr. Ralston said that as a practicing physician in Fayetteville, Tenn., he understands the frustrations that drive some physicians to choose the concierge model. But for its part, the ACP position is that the patient-centered medical home is an excellent care model to improve both patient care and primary care practice.

Both the medical home model and concierge care allow physicians to spend more time with patients. However, the medical home relies more heavily on a multidisciplinary team of providers than the concierge model, and thus will allow physicians to reach far more patients, Dr. Ralston said.

“Practicing this way has been a personal revelation for me,” said Dr. Jon Yardney, who now has fewer than 500 patients in his Wayne, Pa., practice.

Institutions that receive funding from the National Institutes of Health soon will have to publicly post information about any significant financial interests related to their government-funded research under proposed federal regulations published May 21.

The proposed regulation, which has been in the works for about a year, follows several high-profile cases in which NIH-funded researchers failed to disclose large amounts of industry funding. Federal regulations on this subject have not been updated since 1995

In a commentary published online by JAMA on May 24, Dr. Francis S. Collins, NIH director, and Sally J. Rockey, Ph.D., acting director of the NIH Office of Extramural Research, wrote that the 1995 regulations needed to be "clarified and strengthened" in order to maintain the public's trust in federally funded research (doi: 10.1001/jama.2010.774).

"The public may not always understand the intricacies of rigorous science, but most individuals quickly grasp the concept of bias," Dr. Collins and Dr. Rockey wrote in JAMA. "Plain and simple, Americans do not want financial conflicts of interest to influence the federally funded research they hope will yield better ways to fight disease and improve health."

Under the proposed regulation, researchers would be required to make broader disclosures and institutions are given greater responsibility for determining whether a disclosed financial interest would impact research.

Currently, individual researchers are only required to report significant financial interests that could affect their NIH-funded research or any significant financial interest they have in a company whose own monetary interests could affect the research.

The proposed rule would require researchers to report all significant financial interests. It would then be the institution's responsibility to determine whether those could reasonably appear to affect their NIH-funded research. Additionally, the proposal would lower the threshold for reporting financial interests from $10,000 to $5,000 for all equity interests and payment for services.

Along with evaluating potential financial conflicts, institutions also would be required to create a management plan for every identified financial conflict of interest. The management plan would be aimed at either reducing or eliminating the conflict, and institutions would have to report those plans to the NIH.

The proposed rule also aims to improve transparency regarding financial conflicts of interest. Under the rule, NIH would require every institution that receives NIH funding to post information on potential conflicts of interest on a publicly accessible Web site. Institutions would be required to post the researcher's name, role in the study, nature of the financial interest, and the approximate dollar value.

The public may comment on the proposed federal regulation until July 20; it is expected to be made final before the end of the year.

Institutions that receive funding from the National Institutes of Health soon will have to publicly post information about any significant financial interests related to their government-funded research under proposed federal regulations published May 21.

The proposed regulation, which has been in the works for about a year, follows several high-profile cases in which NIH-funded researchers failed to disclose large amounts of industry funding. Federal regulations on this subject have not been updated since 1995

In a commentary published online by JAMA on May 24, Dr. Francis S. Collins, NIH director, and Sally J. Rockey, Ph.D., acting director of the NIH Office of Extramural Research, wrote that the 1995 regulations needed to be "clarified and strengthened" in order to maintain the public's trust in federally funded research (doi: 10.1001/jama.2010.774).

"The public may not always understand the intricacies of rigorous science, but most individuals quickly grasp the concept of bias," Dr. Collins and Dr. Rockey wrote in JAMA. "Plain and simple, Americans do not want financial conflicts of interest to influence the federally funded research they hope will yield better ways to fight disease and improve health."

Under the proposed regulation, researchers would be required to make broader disclosures and institutions are given greater responsibility for determining whether a disclosed financial interest would impact research.

Currently, individual researchers are only required to report significant financial interests that could affect their NIH-funded research or any significant financial interest they have in a company whose own monetary interests could affect the research.

The proposed rule would require researchers to report all significant financial interests. It would then be the institution's responsibility to determine whether those could reasonably appear to affect their NIH-funded research. Additionally, the proposal would lower the threshold for reporting financial interests from $10,000 to $5,000 for all equity interests and payment for services.

Along with evaluating potential financial conflicts, institutions also would be required to create a management plan for every identified financial conflict of interest. The management plan would be aimed at either reducing or eliminating the conflict, and institutions would have to report those plans to the NIH.

The proposed rule also aims to improve transparency regarding financial conflicts of interest. Under the rule, NIH would require every institution that receives NIH funding to post information on potential conflicts of interest on a publicly accessible Web site. Institutions would be required to post the researcher's name, role in the study, nature of the financial interest, and the approximate dollar value.

The public may comment on the proposed federal regulation until July 20; it is expected to be made final before the end of the year.

Institutions that receive funding from the National Institutes of Health soon will have to publicly post information about any significant financial interests related to their government-funded research under proposed federal regulations published May 21.

The proposed regulation, which has been in the works for about a year, follows several high-profile cases in which NIH-funded researchers failed to disclose large amounts of industry funding. Federal regulations on this subject have not been updated since 1995

In a commentary published online by JAMA on May 24, Dr. Francis S. Collins, NIH director, and Sally J. Rockey, Ph.D., acting director of the NIH Office of Extramural Research, wrote that the 1995 regulations needed to be "clarified and strengthened" in order to maintain the public's trust in federally funded research (doi: 10.1001/jama.2010.774).

"The public may not always understand the intricacies of rigorous science, but most individuals quickly grasp the concept of bias," Dr. Collins and Dr. Rockey wrote in JAMA. "Plain and simple, Americans do not want financial conflicts of interest to influence the federally funded research they hope will yield better ways to fight disease and improve health."

Under the proposed regulation, researchers would be required to make broader disclosures and institutions are given greater responsibility for determining whether a disclosed financial interest would impact research.

Currently, individual researchers are only required to report significant financial interests that could affect their NIH-funded research or any significant financial interest they have in a company whose own monetary interests could affect the research.

The proposed rule would require researchers to report all significant financial interests. It would then be the institution's responsibility to determine whether those could reasonably appear to affect their NIH-funded research. Additionally, the proposal would lower the threshold for reporting financial interests from $10,000 to $5,000 for all equity interests and payment for services.

Along with evaluating potential financial conflicts, institutions also would be required to create a management plan for every identified financial conflict of interest. The management plan would be aimed at either reducing or eliminating the conflict, and institutions would have to report those plans to the NIH.

The proposed rule also aims to improve transparency regarding financial conflicts of interest. Under the rule, NIH would require every institution that receives NIH funding to post information on potential conflicts of interest on a publicly accessible Web site. Institutions would be required to post the researcher's name, role in the study, nature of the financial interest, and the approximate dollar value.

The public may comment on the proposed federal regulation until July 20; it is expected to be made final before the end of the year.

The federal government has put forward its plan to test and certify electronic health records in preparation for the Medicare and Medicaid incentive program that will reward physicians for the use of health information technology.

The proposed rule establishes a temporary certification program in which the National Coordinator for Health Information Technology, Dr. David Blumenthal, will designate certain organizations to test and certify complete EHRs and related modules.

Under the temporary program, Dr. Blumenthal's office would take on many of the functions, such as accreditation, that will later be performed by private groups. The idea behind the temporary program is to ensure that certified EHR products are available before the first incentives for use of certified systems begin in 2011.

The rule also proposes the creation of a permanent certification program that would eventually replace the temporary one. The permanent program would be more sophisticated, dividing the responsibility for testing and certification among different organizations. The permanent program also would include accreditation processes and set forth the requirement that certification bodies perform surveillance of certified EHR products. Certification bodies also may be able to assess additional health information technology products beyond EHRs and their modules.

Both certification programs would be voluntary.

The federal government has put forward its plan to test and certify electronic health records in preparation for the Medicare and Medicaid incentive program that will reward physicians for the use of health information technology.

The proposed rule establishes a temporary certification program in which the National Coordinator for Health Information Technology, Dr. David Blumenthal, will designate certain organizations to test and certify complete EHRs and related modules.

Under the temporary program, Dr. Blumenthal's office would take on many of the functions, such as accreditation, that will later be performed by private groups. The idea behind the temporary program is to ensure that certified EHR products are available before the first incentives for use of certified systems begin in 2011.

The rule also proposes the creation of a permanent certification program that would eventually replace the temporary one. The permanent program would be more sophisticated, dividing the responsibility for testing and certification among different organizations. The permanent program also would include accreditation processes and set forth the requirement that certification bodies perform surveillance of certified EHR products. Certification bodies also may be able to assess additional health information technology products beyond EHRs and their modules.

Both certification programs would be voluntary.

The federal government has put forward its plan to test and certify electronic health records in preparation for the Medicare and Medicaid incentive program that will reward physicians for the use of health information technology.

The proposed rule establishes a temporary certification program in which the National Coordinator for Health Information Technology, Dr. David Blumenthal, will designate certain organizations to test and certify complete EHRs and related modules.

Under the temporary program, Dr. Blumenthal's office would take on many of the functions, such as accreditation, that will later be performed by private groups. The idea behind the temporary program is to ensure that certified EHR products are available before the first incentives for use of certified systems begin in 2011.

The rule also proposes the creation of a permanent certification program that would eventually replace the temporary one. The permanent program would be more sophisticated, dividing the responsibility for testing and certification among different organizations. The permanent program also would include accreditation processes and set forth the requirement that certification bodies perform surveillance of certified EHR products. Certification bodies also may be able to assess additional health information technology products beyond EHRs and their modules.

Both certification programs would be voluntary.

TORONTO — For electronic health records to have real value, physicians need to use them to improve quality, and not just to improve documentation and coding.

That's the message the American College of Physicians is sending to doctors, policy makers, and the health information technology industry with the release of a position paper on EHR-based quality measurement and reporting. Released in April during the ACP's annual meeting, the paper outlines several objectives to maximize the use of EHRs for reporting quality measures. For example, EHR-based quality reporting should use only those measures that are clinically relevant and that help improve outcomes.

The ACP also advised that any EHR-based measurement should use information that is routinely collected during a visit, including data provided by patients. This will likely require EHR systems to include new functionalities that are not part of today's standard systems, such as practice-based registries that allow reporting on a population of patients, as well as connections to patient portals.

It's critical that the collection of information does not create another administrative burden for physicians, said Dr. Michael S. Barr, the ACP's vice president for practice advocacy and improvement. “If we layer additional processes onto the daily workload of doctors, especially without taking away other responsibilities, we won't get the potential of EHRs because physicians will not implement them the way we're talking about,” he said.

The paper also emphasizes the need for EHRs to provide real-time clinical decision support systems that are linked to quality reporting. This type of functionality would allow physicians to get patient-specific recommendations after entering routine clinical information into the system.

This kind of real-time feedback has been lacking in current quality reporting programs such as Medicare's Physician Quality Reporting Initiative (PQRI), said Dr. Joseph W. Stubbs, ACP president. Dr. Stubbs said there is often a long lag time between when physicians report on measures and when they receive reports on their performance under PQRI. For example, he submitted his final 2008 quality measures in December 2008 and did not receive feedback until October 2009.

Most current EHR systems can't provide the level of functionality described in the ACP's policy paper. But technology is not the major obstacle, Dr. Barr said. A bigger barrier is the cultural change required of each member of the clinical team in rethinking the office workflow as part of EHR implementation, he said.

The other hurdle for implementing widespread use of EHRs for quality reporting is the physician payment system. The current volume-based payment system doesn't allow physicians to be paid for actually improving quality, Dr. Stubbs said. “Without the business model for practicing better quality of care, it's an extraordinarily expensive prospect for physicians, particularly in small groups, to think about putting in an electronic health record,” he said.

Despite these obstacles, the ACP is encouraging its members to adopt EHRs, and is launching new resources for evaluating the technology. At the annual meeting, the ACP demonstrated its new AmericanEHR Partners program (www.americanehr.com

The focus on using EHRs for quality comes as the federal government is finalizing regulations on what constitutes “meaningful use” of EHRs, the standard for qualifying for Medicare and Medicaid incentive payments under the Health Information Technology for Economic and Clinical Health Act. Physicians who demonstrate meaningful use of certified EHR technology can earn up to $44,000 in bonus payments under Medicare starting in 2011. A similar program under Medicaid allows eligible physicians to earn nearly $64,000 in incentive payments.

Dr. Stubbs said the federal incentives could be a big boost for physicians looking to purchase EHR systems. But the success of the program depends on whether the meaningful use criteria can actually be achieved. The worst thing would be for physicians to invest money up front to purchase EHRs, but find out later that they fell short of meaningful use by one measure and thus won't get any incentive dollars. “That would do more to destroy the effort than anything,” Dr. Stubbs said.

As written, the proposed rule on meaningful use is not achievable, said Dr. Peter Basch, medical director for ambulatory, EHR, and health IT policy at MedStar Health in the Baltimore-Washington area. But Dr. Basch, who also is a member of the ACP's Medical Informatics Subcommittee, said he is hopeful that the Centers for Medicare and Medicaid Services will modify the requirements so that the average physician can achieve meaningful use in 2011 or 2012. “These are dollars they do want to pay out,” he said. “They do want to make this reasonable for doctors to do.”

The ACP position paper is available online at www.acponline.org/advocacy/where_we_stand/health_information_technology/ehrs.pdf

Small Practices Benefit Less From EHRs

The return on investment that physicians can expect to see after implementing an electronic health record is likely to differ greatly based on the size of their practice, according to one health information technology expert.

In large practices, physicians can anticipate significant cost reductions from elimination of chart pulls and improved intra-office communication. And such practices are likely to achieve savings from improvements in process throughput, coding, elimination of transcription, reductions in physician-to-staff ratios, and increased productivity, Dr. Basch said.

But the return on investment equation is quite different for small practices, Dr. Basch said. For example, small practices can't bank on saving much by reducing or eliminating chart pulls, because they typically keep charts right in the office and don't pay $8-$15 per chart pull the way large practices do. Small practices have the potential to reduce some staff following EHR adoption, but that won't happen immediately. Also, if the practice is already fairly lean there may not be much trimming of staff costs, he said.

The greatest potential for savings comes from better coding and the elimination of transcription. “Most of us tend to undercode, and EHRs can help us with coding,” Dr. Basch said.

Small practices have additional obstacles when implementing an EHR, he noted. They generally don't have sufficient capital to invest in an expensive system, so they have to borrow money or take a reduction in income during the initial start-up period. Practices that aren't interested in taking out loans or reducing their income can consider an application service provider model, which essentially allows them to lease an EHR system. This isn't a good fit for every practice, Dr. Basch said, but it is attractive because it doesn't involve a large cash outlay upfront.

For practices considering the leasing approach, the monthly cost will be important. Those costs have typically ranged from $500 to $1,000 per month, but they appear to be coming down, Dr. Basch said. “As those monthly figures begin to move down because of market pressure, this could certainly make an EHR investment a lot more affordable for many, many people,” he said.

TORONTO — For electronic health records to have real value, physicians need to use them to improve quality, and not just to improve documentation and coding.

That's the message the American College of Physicians is sending to doctors, policy makers, and the health information technology industry with the release of a position paper on EHR-based quality measurement and reporting. Released in April during the ACP's annual meeting, the paper outlines several objectives to maximize the use of EHRs for reporting quality measures. For example, EHR-based quality reporting should use only those measures that are clinically relevant and that help improve outcomes.

The ACP also advised that any EHR-based measurement should use information that is routinely collected during a visit, including data provided by patients. This will likely require EHR systems to include new functionalities that are not part of today's standard systems, such as practice-based registries that allow reporting on a population of patients, as well as connections to patient portals.

It's critical that the collection of information does not create another administrative burden for physicians, said Dr. Michael S. Barr, the ACP's vice president for practice advocacy and improvement. “If we layer additional processes onto the daily workload of doctors, especially without taking away other responsibilities, we won't get the potential of EHRs because physicians will not implement them the way we're talking about,” he said.

The paper also emphasizes the need for EHRs to provide real-time clinical decision support systems that are linked to quality reporting. This type of functionality would allow physicians to get patient-specific recommendations after entering routine clinical information into the system.

This kind of real-time feedback has been lacking in current quality reporting programs such as Medicare's Physician Quality Reporting Initiative (PQRI), said Dr. Joseph W. Stubbs, ACP president. Dr. Stubbs said there is often a long lag time between when physicians report on measures and when they receive reports on their performance under PQRI. For example, he submitted his final 2008 quality measures in December 2008 and did not receive feedback until October 2009.

Most current EHR systems can't provide the level of functionality described in the ACP's policy paper. But technology is not the major obstacle, Dr. Barr said. A bigger barrier is the cultural change required of each member of the clinical team in rethinking the office workflow as part of EHR implementation, he said.

The other hurdle for implementing widespread use of EHRs for quality reporting is the physician payment system. The current volume-based payment system doesn't allow physicians to be paid for actually improving quality, Dr. Stubbs said. “Without the business model for practicing better quality of care, it's an extraordinarily expensive prospect for physicians, particularly in small groups, to think about putting in an electronic health record,” he said.

Despite these obstacles, the ACP is encouraging its members to adopt EHRs, and is launching new resources for evaluating the technology. At the annual meeting, the ACP demonstrated its new AmericanEHR Partners program (www.americanehr.com

The focus on using EHRs for quality comes as the federal government is finalizing regulations on what constitutes “meaningful use” of EHRs, the standard for qualifying for Medicare and Medicaid incentive payments under the Health Information Technology for Economic and Clinical Health Act. Physicians who demonstrate meaningful use of certified EHR technology can earn up to $44,000 in bonus payments under Medicare starting in 2011. A similar program under Medicaid allows eligible physicians to earn nearly $64,000 in incentive payments.

Dr. Stubbs said the federal incentives could be a big boost for physicians looking to purchase EHR systems. But the success of the program depends on whether the meaningful use criteria can actually be achieved. The worst thing would be for physicians to invest money up front to purchase EHRs, but find out later that they fell short of meaningful use by one measure and thus won't get any incentive dollars. “That would do more to destroy the effort than anything,” Dr. Stubbs said.

As written, the proposed rule on meaningful use is not achievable, said Dr. Peter Basch, medical director for ambulatory, EHR, and health IT policy at MedStar Health in the Baltimore-Washington area. But Dr. Basch, who also is a member of the ACP's Medical Informatics Subcommittee, said he is hopeful that the Centers for Medicare and Medicaid Services will modify the requirements so that the average physician can achieve meaningful use in 2011 or 2012. “These are dollars they do want to pay out,” he said. “They do want to make this reasonable for doctors to do.”

The ACP position paper is available online at www.acponline.org/advocacy/where_we_stand/health_information_technology/ehrs.pdf

Small Practices Benefit Less From EHRs

The return on investment that physicians can expect to see after implementing an electronic health record is likely to differ greatly based on the size of their practice, according to one health information technology expert.

In large practices, physicians can anticipate significant cost reductions from elimination of chart pulls and improved intra-office communication. And such practices are likely to achieve savings from improvements in process throughput, coding, elimination of transcription, reductions in physician-to-staff ratios, and increased productivity, Dr. Basch said.

But the return on investment equation is quite different for small practices, Dr. Basch said. For example, small practices can't bank on saving much by reducing or eliminating chart pulls, because they typically keep charts right in the office and don't pay $8-$15 per chart pull the way large practices do. Small practices have the potential to reduce some staff following EHR adoption, but that won't happen immediately. Also, if the practice is already fairly lean there may not be much trimming of staff costs, he said.

The greatest potential for savings comes from better coding and the elimination of transcription. “Most of us tend to undercode, and EHRs can help us with coding,” Dr. Basch said.

Small practices have additional obstacles when implementing an EHR, he noted. They generally don't have sufficient capital to invest in an expensive system, so they have to borrow money or take a reduction in income during the initial start-up period. Practices that aren't interested in taking out loans or reducing their income can consider an application service provider model, which essentially allows them to lease an EHR system. This isn't a good fit for every practice, Dr. Basch said, but it is attractive because it doesn't involve a large cash outlay upfront.

For practices considering the leasing approach, the monthly cost will be important. Those costs have typically ranged from $500 to $1,000 per month, but they appear to be coming down, Dr. Basch said. “As those monthly figures begin to move down because of market pressure, this could certainly make an EHR investment a lot more affordable for many, many people,” he said.

TORONTO — For electronic health records to have real value, physicians need to use them to improve quality, and not just to improve documentation and coding.

That's the message the American College of Physicians is sending to doctors, policy makers, and the health information technology industry with the release of a position paper on EHR-based quality measurement and reporting. Released in April during the ACP's annual meeting, the paper outlines several objectives to maximize the use of EHRs for reporting quality measures. For example, EHR-based quality reporting should use only those measures that are clinically relevant and that help improve outcomes.

The ACP also advised that any EHR-based measurement should use information that is routinely collected during a visit, including data provided by patients. This will likely require EHR systems to include new functionalities that are not part of today's standard systems, such as practice-based registries that allow reporting on a population of patients, as well as connections to patient portals.

It's critical that the collection of information does not create another administrative burden for physicians, said Dr. Michael S. Barr, the ACP's vice president for practice advocacy and improvement. “If we layer additional processes onto the daily workload of doctors, especially without taking away other responsibilities, we won't get the potential of EHRs because physicians will not implement them the way we're talking about,” he said.

The paper also emphasizes the need for EHRs to provide real-time clinical decision support systems that are linked to quality reporting. This type of functionality would allow physicians to get patient-specific recommendations after entering routine clinical information into the system.

This kind of real-time feedback has been lacking in current quality reporting programs such as Medicare's Physician Quality Reporting Initiative (PQRI), said Dr. Joseph W. Stubbs, ACP president. Dr. Stubbs said there is often a long lag time between when physicians report on measures and when they receive reports on their performance under PQRI. For example, he submitted his final 2008 quality measures in December 2008 and did not receive feedback until October 2009.

Most current EHR systems can't provide the level of functionality described in the ACP's policy paper. But technology is not the major obstacle, Dr. Barr said. A bigger barrier is the cultural change required of each member of the clinical team in rethinking the office workflow as part of EHR implementation, he said.

The other hurdle for implementing widespread use of EHRs for quality reporting is the physician payment system. The current volume-based payment system doesn't allow physicians to be paid for actually improving quality, Dr. Stubbs said. “Without the business model for practicing better quality of care, it's an extraordinarily expensive prospect for physicians, particularly in small groups, to think about putting in an electronic health record,” he said.

Despite these obstacles, the ACP is encouraging its members to adopt EHRs, and is launching new resources for evaluating the technology. At the annual meeting, the ACP demonstrated its new AmericanEHR Partners program (www.americanehr.com

The focus on using EHRs for quality comes as the federal government is finalizing regulations on what constitutes “meaningful use” of EHRs, the standard for qualifying for Medicare and Medicaid incentive payments under the Health Information Technology for Economic and Clinical Health Act. Physicians who demonstrate meaningful use of certified EHR technology can earn up to $44,000 in bonus payments under Medicare starting in 2011. A similar program under Medicaid allows eligible physicians to earn nearly $64,000 in incentive payments.

Dr. Stubbs said the federal incentives could be a big boost for physicians looking to purchase EHR systems. But the success of the program depends on whether the meaningful use criteria can actually be achieved. The worst thing would be for physicians to invest money up front to purchase EHRs, but find out later that they fell short of meaningful use by one measure and thus won't get any incentive dollars. “That would do more to destroy the effort than anything,” Dr. Stubbs said.

As written, the proposed rule on meaningful use is not achievable, said Dr. Peter Basch, medical director for ambulatory, EHR, and health IT policy at MedStar Health in the Baltimore-Washington area. But Dr. Basch, who also is a member of the ACP's Medical Informatics Subcommittee, said he is hopeful that the Centers for Medicare and Medicaid Services will modify the requirements so that the average physician can achieve meaningful use in 2011 or 2012. “These are dollars they do want to pay out,” he said. “They do want to make this reasonable for doctors to do.”

The ACP position paper is available online at www.acponline.org/advocacy/where_we_stand/health_information_technology/ehrs.pdf

Small Practices Benefit Less From EHRs

The return on investment that physicians can expect to see after implementing an electronic health record is likely to differ greatly based on the size of their practice, according to one health information technology expert.

In large practices, physicians can anticipate significant cost reductions from elimination of chart pulls and improved intra-office communication. And such practices are likely to achieve savings from improvements in process throughput, coding, elimination of transcription, reductions in physician-to-staff ratios, and increased productivity, Dr. Basch said.

But the return on investment equation is quite different for small practices, Dr. Basch said. For example, small practices can't bank on saving much by reducing or eliminating chart pulls, because they typically keep charts right in the office and don't pay $8-$15 per chart pull the way large practices do. Small practices have the potential to reduce some staff following EHR adoption, but that won't happen immediately. Also, if the practice is already fairly lean there may not be much trimming of staff costs, he said.

The greatest potential for savings comes from better coding and the elimination of transcription. “Most of us tend to undercode, and EHRs can help us with coding,” Dr. Basch said.

Small practices have additional obstacles when implementing an EHR, he noted. They generally don't have sufficient capital to invest in an expensive system, so they have to borrow money or take a reduction in income during the initial start-up period. Practices that aren't interested in taking out loans or reducing their income can consider an application service provider model, which essentially allows them to lease an EHR system. This isn't a good fit for every practice, Dr. Basch said, but it is attractive because it doesn't involve a large cash outlay upfront.

For practices considering the leasing approach, the monthly cost will be important. Those costs have typically ranged from $500 to $1,000 per month, but they appear to be coming down, Dr. Basch said. “As those monthly figures begin to move down because of market pressure, this could certainly make an EHR investment a lot more affordable for many, many people,” he said.