New York City Program Promotes EHRs for Primary Care Practices

New York City is moving ahead with plans to equip more than 1,000 primary care physician offices with electronic health records, or EHRs, by the end of this year -- that's enough practices to cover about 1 million patients.

The city signed a contract with e-ClinicalWorks last March to help design and implement the program, and officials have spent the past several months developing the resulting system and recruiting practices interested in participating in the program. The city plans to recruit at least 80 primary care physician offices each month for the program and has signed up about 246 providers thus far.

"It only has been in the last two to three months that we have started implementing this program in earnest," said Farzad Mostashari, M.D., M.S.P.H., assistant health care commissioner for the New York City Department of Health and Mental Hygiene.

To qualify for the program, 30 percent of a practice's census must include patients who are either uninsured or on Medicaid. Physicians practicing in one of three high-need areas -- central Brooklyn, Harlem or the South Bronx -- also are eligible. "We are using public money, and so we felt that we should first deal with and help support physicians who practice in the poorest neighborhoods," said Mostashari.

The city provides a package of software and services, including two years of maintenance and support, and system training for participating physicians and their staff members. In return, each practice has to supply its own computer and Internet connection and contribute $4,000 to a technical assistance fund. The city, meanwhile, is spending $30 million on the program. It will receive $5 million from the federal government to evaluate the program.

Although individual patient data will be restricted to patients and their doctors under the terms of the program, the city's health department will be able to evaluate patient outcomes, which could lead to higher payments for physicians based on performance. There is a danger, however, that EHRs could "simply digitize inefficient workflows," said Mostashari.

"The potential benefits are enormous," he said. "But practices have to really rethink their workflows to take full advantage of it."

Mostashari is convinced that New York City's program will serve as a blueprint for the rest of the nation, providing essential support for primary care in general and the patient-centered medical home in particular. New York City officials plan to work with the National Committee for Quality Assurance, or NCQA, to help participating practices meet the criteria for recognition as patient-centered medical homes.

"We are going to be working with NCQA to devise a streamlined, facilitated path to medical home certification for the practices that participate in this (program) who use the electronic health record fully," said Mostashari.

Some AAFP members in New York City have raised questions about the program, saying that interoperability remains a prime concern, while others are enthusiastic about the opportunity.

"The system that the city has chosen may not be compatible with or interoperable with some of the systems our members may employ," said Vito Grasso, C.A.E., EVP of the New York AFP. "That is a constant issue in technology transfer -- whether the system is going to become antiquated in a short period of time."

There also is the cost issue. Marianne LaBarbera, M.D., of Staten Island, N.Y., is a solo FP in the final stages of implementing the New York City program's EHR system. She said she expects to spend about $20,000 on the needed software package, which does not include the $4,000 she will have to pay to the technical assistance fund. Nevertheless, LaBarbera expects the EHR to lead to "greater efficiencies" and to eventually make it easier to track and manage patient care.

Mark Krotowski, M.D., of Brooklyn, described the New York City initiative as a "great way to hop on the bandwagon and join the program at a subsidized rate." Krotowski qualified for the program but decided not to participate because he is planning to retire. However, he said, "I think this is a great thing for young physicians, especially those who are just starting in practice."

Mostashari noted "there is no age barrier" for adopting EHRs or for participating in the New York City program. He acknowledged, however, that the program is not right for "every practice or physician right now."

"There is no question it is hard work implementing health records," he said. "Anyone who tells you otherwise is not telling the truth."