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The HIT Realist Column

Why Most Physicians Should Not Buy a HITECT Act Certified Electronic Health Record (c-EHR)

September, 2009

This month there will be numerous town-hall style meetings across the nation trying to convince physicians that they should submit to the HITECH Act’s mandate provisions and to try to earn the promised $44,000.00 grants.1

I disagree with these incentives, because unlike what vendors and politicians think, it’s not all about the money, and even if it were, it is not nearly enough to cover costs.Large practices who see large Medicare panels may realize enormous bonus payments, but smaller practices may find it impossible to make a profit. What is at stake is the autonomy and viability of the small physician office.

Here are the reasons why the physicians should ignore these new mandates, and possibly reconsider their association with Medicare:

  1. Medicare is going bankrupt. The Medicare Hospital Insurance Trust Fund is projected to be exhausted by 2017.2
  2. The HITECH Act seems to have been written using major input by EMR vendors whose companies most likely will reap major windfalls if physicians comply with the HITECH Act. Lobbyists associated with “enterprise” EHR companies, including the likes of Allsricpts, Cerner, GE, eCW, Partners Healthcare, and Athenahealth, surround the president.3
  3. Medicare routinely rejects or delays payment on a significant portion of claims due to computer glitches, changes in payment methods, and outright incompetance. A whistleblower years ago even admitted to the use of a machine referred to as “Jaws” which shredded thousands of letters.4
  4. The HITECH Act’s grants will be very difficult to attain. In the past PQRI projects, the majority of physicians and offices have failed to receive payments, and those that did received low payments for all of their efforts. The payments are not given up front, but rather given out as a rebate based on exact performance parameters. An important hurdle is the required minimum patient panel sizes (see HITECH Act for particulars). Another reason is that CMS/Medicare does not provide enough interim feedback leaving providers unable to correct them in time. Lastly, there usually is little to no process for physicians to appeal CMS’s determination of whether a practice has successfully submitted sufficient data to be eligible for a full bonus payment.5,6
  5. Medicare patients are sicker and take more time to see. In my practice Medicare can make up 20% of a typical schedule, but since Medicare patients are older and more complicated, it can require 30% of my time expended for about 10% less pay. The workflow changes associated with capturing and coding quality data will be significant and the new administrative burdens will be costly.7,8
  6. The HITECH Act mandate lacks important detail. CMS has not set a specific date or method for issuing bonus payments, and on top of this are still detailing and changing what they consider “significant use” of an EHR system. On 7/16/2009 the HHS announced that it would not use the Certification Commission for Health Information Technology (CCHIT) as the certification agency that will determine what is a HITECH c-EHR. Unfortunately, their “ONC certification” scheme is not set up and it is unknown if  “CCHIT-certified” EHR systems will be grandfathered.9
  7. The central core of “significant use” is interoperability, which has yet to be codified by EMR venders. Many states are trying to set up health information exchanges (HIEs), but most of these centralized exchanges in the past, known as “RHIOs,” have not only had major financial difficulties.10,11
  8. CMS/Medicare is planning on significantly cutting payment to physicians in 2010, with Cardiology and oncology being cut a full 21% which will dwarf any bonus payment.12
  9. Most physicians are not computer literate and cannot handle the complexities of “significantly using” these large, expensive c-EHR systems. The current crop of EHR systems have a very difficult interface to use which has resulted in a 50% installation failure rate and a reported 8% deinstallation rate thereafter.13,14 In some early adoption localites, the deinstallation rate has been higher, as is now being seen in Arizona where physicians pressured to purchase expensive c-EHR systems have found themselves unable to economically survive ownership of their systems.15
  10. Data mining. Big government wants to use c-EHR “granular” data on patients. There is a lot of concern about patient privacy, as required by HIPAA.16
  11. Lastly, the concept of PQRI quality reporting can be used as another weapon to control costs by limiting, through penalties, physician payments. This is on top of the fact that Medicare already reimburses 35 to 50 cents on the dollar of charges submitted for patient care, barely covering overhead costs.17

           Medicare’s long held policy of fair play and of upholding the clinical autonomy of physicians is gone. It is time for physicians, who still overwhelmingly accept Medicare, to walk away from the HITECH Act and/or from full participation in Medicare during the upcoming 11/15/09 to 12/31/2009 period. Failure to evaluate your options objectively will be a big mistake.18,19

Al Borges MD


  1. http://medicaleconomics.modernmedicine.com/memag/News+You+Can+Use/Maryland-doctors-to-see-double-bonus-for-EHR-adopt/ArticleStandard/Article/detail/607959?contextCategoryId=7152
  2. http://www.hpnonline.com/du-print/HPN_Daily_Update090828.doc


  1. http://www.box.net/shared/leceh5pvnb
  2. http://www.jpands.org/vol8no4/burr.pdf
  3. http://www.ama-assn.org/amednews/2008/08/04/prl20804.htm
  4. http://www.ama-assn.org/amednews/2007/08/06/gvl10806.htm
  5. http://www.spokesman.com/stories/2009/sep/05/had-enough-of-medicare/
  6. http://www.hcplive.com/mdnglive/articles/PC_Medicare_HIT_mandate
  7. http://www.thehealthcareblog.com/the_health_care_blog/2009/08/finally-a-reasonable-plan-for-certification-of-ehr-technologies.html
  8. http://www.thehealthcareblog.com/the_health_care_blog/2009/04/on-clinical-groupware-interoperability-and-the-hitech-bill.html
  9. http://www.metrocorpcounsel.com/current.php?artType=view&artMonth=August&artYear=2009&EntryNo=9458, http://www.bio-itworld.com/hitw/newsletters/2007/08/21/winona-rhio/ 
  10. http://www.ama-assn.org/amednews/2009/03/02/gvl10302.htm
  11. http://tinyurl.com/cds6uh
  12. http://tinyurl.com/cqo3sd
  13. http://home.healthleaders-interstudy.com/index.php?p=press-releases-detailed&pr=pr_62309MO
  14. http://www.aapsonline.org/newsoftheday/00185
  15. http://www.physiciansnews.com/physician-pay-for-reporting-launched/
  16. http://www.ssa.gov/history/pdf/MedicarePhysicalAutonomy.pdf
  17. http://www.cahabagba.com/part_b/enroll_update_your_records/faqs/participate.htm

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Alberto Borges, MD
Alberto Borges, MD, is in private practice and is an assistant clinical professor of medicine at The George Washington University School of Medicine and Health Sciences in Washington, DC. Check out his website at http://msofficeemrproject.com. The opinions expressed in this blog do not necessarily reflect those of HCPLive. If you like what Dr. Borges has to say, make sure to read his print column of The HIT Realist published in MDNG.



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