United States to compel physicians to make “meaningful use” of electronic health records
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* Paul Christopher Webster

The contrast is startling. The United States government recently adopted regulations that will compel — and generously pay — American physicians to make “meaningful use” of electronic health records (EHRs).

But in Canada, the financial incentives aren’t as lucrative and no doctor is under obligation to actually use EHRs, even if they use government monies to purchase the technologies. As a consequence, EHR uptake remains low despite programs such as the province of Ontario’s $386-million EHR incentive program.

Under economic recovery legislation passed in 2009, the US government plans to spend as much as US$27 billion in EHR incentive payments to physicians over 10 years commencing in May, 2011. Doctors will be eligible to receive as much as US$63 000, and hospitals may also receive millions of dollars for using federally-certified EHRs.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/182/14/1500/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/182/14/1500/F1)

American doctors will receive as much as US$63 000 to purchase and use federally-certified electronic health record technologies. Image courtesy of © 2010 Jupiterimages Corp.

The US regulations, published July 28, are designed to ensure that the government’s investment leads to “meaningful use” and rapid adoption of EHRs ([http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf](http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf)).

To help forge an electronic health revolution, the US regulations set out a tight timetable for government efforts to certify a complex array of electronic health information systems and software that will stitch together the national health infostructure.

Once the certification process is completed later this year, the government hopes to move quickly to entice health care providers to apply for federal funding to purchase EHR systems.

But unlike an Ontario program that by April 2012, will pay up to 9000 physicians as much as $29 800 to buy EHR systems, US physicians will be required to clearly prove that they are making appropriate use of their government-provided technologies.

While the American Medical Association (AMA) approves of the initiative, it has warned that “the tight time-line for adoption and the high overall number of measures physicians are required to meet” are burdensome. “The final rule requires physicians to meet 20 measures in the first year which is still too high, especially for smaller practices that are new to the technology,” the AMA complained.

According to the AMA, the US government “expects EHR systems that support meaningful use to become available this fall, giving physicians just a few months to purchase, implement and assess the usability of EHR technology before the January 1, 2011, start date of the incentive program. This is no small feat, considering it can take a year or more to purchase and implement an EHR system.”

In a panel session at a gathering of EHR experts in Vancouver, British Columbia, in June, Dr. David Blumenthal, the US national coordinator for health information technology, described the meaningful use regulations as a “powerful organizing concept” aimed at transforming US health-care by driving down costs while improving healthcare ([http://e-healthconference.com/](http://e-healthconference.com/)).

His enthusiasm was warmly received by Canada Health Infoway President Richard Alvarez: “We’re going to be a lot more directive,” Alvarez pledged after expressing admiration for a more interventionist approach toward EHR uptake. “We’re learning from them.”

Alvarez said that while EHRs are taking root in some parts of the country, notably Alberta, progress has been marred by high turnover in provincial health bureaucracies and opposition among health care providers in other parts of the country. “We ran up against a whole lot of clinician groups,” he said.

Alvarez also noted that political leadership is an issue: “If this is not on your premier’s agenda, you don’t have a chance.”

Canadian analysts say the time may have come to adopt the US approach.

David Ludwick, general manager of the Sherwood Park — Strathcona County Primary Care Network in Alberta, says Canadian provinces should require that government-subsidized EHRs are properly used.

In a recent study of EHR certification efforts in seven countries and five provinces, Ludwick found that Saskatchewan and Manitoba have begun to link fee-for-service payments to EHR utlilization, a pattern which he describes as “a type of meaningful use requirement” (*Healthcare Quarterly* 2009; 12[3]:111–23).

Canadian politicians and EHR officials need to be far more aggressive about forcing providers to join the e-health revolution, he says. Canadian Health Infoway and provincial agencies such as eHealth Ontario should stop linking payments to installation of EHRs and instead borrow from the US approach by insisting on meaningful use.

Regulations will be needed to do that, he warns. “What do we gain if we pay for the installation of these technologies and then we don’t use them? Look at all the money we are pouring in and all the wastage. How hard will it really be to get laws passed?”

Toronto, Ontario-based physician and ehealth consultant Karim Keshav-jee notes that an internal 2008, study for the Ontario Ministry of Health and Long-Term Care and the Ontario Medical Association, found that overall, “not a lot of meaningful use” of EHRs has been made.

Keshavjee adds that only 40% of doctors were found to use EHRs for managing prevention and screening activities. “And although 90% of physicians use it for ‘e-prescribing’, there are no electronic connections for those prescriptions to flow, so they print them off and give them to their patients on paper.”

Keshavjee strongly endorses the US approach, even if implemented strictly at the provincial level. “It would be more efficient if they were defined federally, but since health care is regulated provincially, it makes more sense to have them regulated at the provincial level,” he says.

## Eleventh in a series on electronic health records

**Part I: Canada’s electronic health records initiative stalled by federal funding freeze** ([www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3183](http://www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3183))

**Part II: Ontario’s plan for electronic health records is at risk, official says** ([www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3193](http://www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3193))

**Part III: Electronic health records a “strong priority” for US government** ([www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3218](http://www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3218))

**Part IV: The pocketbook impact of electronic health records: PRO** ([www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3225](http://www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3225))

**Part V: The pocketbook impact of electronic health records: CON** ([www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3226](http://www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3226))

**Part VI: National standards for electronic health records remain remote** ([www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3239](http://www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3239))

**Part VII: National electronic health records initiative remains muddled, auditors say** ([www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3242](http://www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3242))

**Part VIII: New electronic health record blueprint to call for increased patient participation** ([www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3265](http://www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3265))

**Part IX: Albertans to gain electronic access to personal health files** ([www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3270](http://www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3270))

**Part X: Canadian hospitals make uneven strides in utilization of electronic health records** ([www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3288](http://www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3288))

## Footnotes

*   Previously published at [www.cmaj.ca](http://www.cmaj.ca)