An American Physicians Reflections On Australian eHealth Compared to the USA
Currently only 9 to 24 percent of US physicians use clinical software, what we call an EHR. This wide range in percent usage depends on whether youre referring to very basic software or fully functional software that creates a paperless office. Only 11 percent of US doctors currently prescribe medications electronically. We have no required software standards and precious little in the way of interoperability. By one account we have 319 EHR products and, unlike Australia, no single EHR product in the US accounts for more than 10% of market share. Our current national focus is on getting more physicians to use EHRs, not on getting systems to talk to one another. While we are starting to discuss interoperability issues, currently our efforts are in the early planning stages, with no government funding in sight.
In the US, physicians purchase all their own hardware, software and network connectivity, with no rebates or incentives from the government to do so. We have a few isolated examples of insurance companies and integrated healthcare systems pitching in, but they remain the exception. We do have very sophisticated electronic billing and scheduling software (what we call practice management software) and essentially 100% of US physicians have this. Its a necessity in our complex payment system with hundreds of different health insurance payers all having different rules and payment rates. Thus, most EHRs in the US require an electronic interface with the practice management software being used. This is changing. The trend is now toward developing software that integrates the practice management and EHR software.
A recent article in the journal Health Affairs entitled, Health Care Spending and Use of Information Technology in OECD Countries, stated that the US is at least 6 years behind Australia in terms of health information technology.
This isnt to say that there isnt a lot of enthusiasm for EHRs in the US. Most of us who use them, love them, and are convinced that they are the key to improved quality and efficiency. Many of us have even improved our incomes using them, by eliminating or reducing certain costs like transcription, paper chart and form costs, medical records staffing and staff overtime. Weve also been able to increase our revenue through better coding and more accurate charge capture.
EHRs hold enormous promise and the pace of adoption in the US appears to be accelerating. Starting July 1, 2007, the US government will offer a 1.5% bonus to physicians for performance reporting in our government funded insurance plan (also called Medicare.) Medicare, which covers only those who are 65 and older or disabled, accounts for nearly a quarter of US healthcare payments to physicians. If this bonus payment increases percentage-wise substantially in the future, and if the reporting requirements also increase, EHRs will likely become a necessity to qualify for this form of pay for performance. That certainly would help promote rapid EHR adoption (or widespread revolt).
In my short visit to Australia I was able to visit one GP surgery and talk to several GPs from different regions. I also interacted with a number of health information managers, and IT people from state departments of health and divisions of general practice at the eHealth 2006 conference in Sydney. I was impressed by Australias widespread adoption of clinical software (at least in the GP sphere), your heavy use of e-prescribing and your current focus on achieving interoperability. NEHTAs current approach of establishing standards first, and then pushing health information interchange certainly makes sense.
I was left with the impression, though, that many GPs are not using clinical software nearly as effectively as they could (a problem we have in the US too) and was struck with the large discrepancy in usage between GPs and specialists. I wonder if most Australian physicians view this software as simply a tool to enhance their current workflows rather than a means to create new workflows that are more efficient and effective. One example is the GP who uses the software primarily for e-prescribing and perhaps to receive pathology results, yet maintains a paper chart for notes and correspondence. This seems inherently inefficient, perhaps more so than exclusively using paper. Also, this approach will make future complete electronic interoperability impossible.
All in all I was excited by what I saw. It reinforced for me the notion that incentives drive behavior. In Australia, complex Medicare formulary requirements drove the widespread adoption of e-prescribing. In the US, complex insurance schemes drove the widespread adoption of practice management software. Now both our countries need to figure out the right set of incentives and requirements to drive EHR interoperability without breaking the bank.
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