ARRA/Stimulus Funds

Health Information Exchanges and Physicians Share Accountability for Safe Patient Care

The $800 billion 2009 American Recovery and Reinvestment Act (ARRA) set aside $36 billion toward health information technology (health IT) initiatives, including over $500 million for the State HIE Cooperative Program.  This federal program provides funds to each state for the successful planning and development of infrastructure that supports the exchange of electronic health data between physician electronic health records (EHRs), hospital EHRs, lab systems, radiology centers and other clinical IT systems.    For example, in Texas we are using these funds to support the development of local health information exchange entities, called HIEs, across the state and to concurrently develop the policies, standards and infrastructure needed to safely/securely connect these HIEs to each other.     The statewide HIE network will also be built to be compatible with national standards and efforts.      

Each state's effort to develop a network of community HIEs and/or a statewide HIE will be more successful with physicians involved upfront with governance and policy development.   When working with local HIEs most physicians will generally understand and appreciate the importance of protecting the privacy and security of electronic patient health information.  Their inherent knowledge on this issue will help guide policies in the right direction.   A more complex issue for physicians to understand is the relationship between HIEs and patient care.   A heightened awareness of this issue will allow physicians to properly inform HIE policymakers about the need to establish an environment where local HIEs, HIE networks and physicians share accountability for safe patient care.   

To deepen physician's understanding of this issue I encourage them and others to think about an HIE as a tool physicians use as a part of patient care, similar to a surgical tool.   If a patient is harmed by a surgical tool that broke because the physician used it incorrectly, the physician is negligent.  If the physician used the tool correctly but it still broke, but it has only broken 8 times in over 10,000 surgeries and the patient consent explains this remote risk of breakage, then no one is negligent.  However, if it broke and the issue had been reported to the vendor by many physicians on a repetitive basis, but the vendor failed to investigate the issue and fix the problem, or failed to inform physicians and patients of the increased risk in the meantime, then the vendor is negligent. 

This perpsective will help physicians advocate for policies that lead to an environment where HIEs and physicians share accountability for safe patient care.   Effective policies will lead to contracts and agreements which acknowledge that:

  1. HIEs and HIE infrastructure are tools used by physicians during the course of patient care
  2. HIEs are responsible for informing patients and doctors about the inherent risks of  the electronic health information exchange including changes in risks when issues are identified
  3. HIEs have a responsibility to continually monitor for and mitigate risks associated with their services that may impact quality of care provided by physicians


Bipartisan Health IT Support and ARRA Insulate EHR Incentive Funds From Budget Cuts

A physician colleague recently asked me why I am confident that CMS will not cut off EHR incentive funding in the future.   This question is important to him and other physicians who plan to qualify for up to $44,000 in CMS incentive payments by achieving the meaningful use of EHRs.   They fear that the dragging economy and political discord will result in budget reductions that will cut this and other important health IT funding programs.    What I see, though, is a decade-long track record of bipartisan support for health IT initiatives and a 2009 federal law that requires CMS to provide funding for the EHR incentives and other health IT programs.

In his 2004 State of the Union speech President Bush envisioned the adoption of EHRs for all Americans by 2014.   Since then bipartisan support at both the state and federal levels for health IT initiatives toward the achievement of that vision has held strong.   At the federal level CMS  not only established a new office in 2004 to support health IT, the Office of the National Coordinator of Health IT (ONC) but has also increased funds to support ONC initiatives which promote the adoption and use of EHRs.  CMS works collaboratively with ONC and has consistently shown an understanding that the broad adoption and effective use of EHRs are necessary to better manage spiraling healthcare costs.   CMS understands that the data captured by EHRs is superior to claims-based data when attempting to analyze quality and establish benchmarks.    Physicians have long complained that claims-based data is incomplete and does not fairly demonstrate the quality of care they provide.     EHRs must be broadly adopted in order to capture accurate and meaningful data that can then be used to improve quality or save costs.  

It is important to recognize that CMS is required to provide EHR incentives to physicians by law.   Specifically, the $800 billion American Recovery and Reinvestment Act (ARRA) of 2009, commonly refered to as the Stimulus Bill, allocates over $36 billion to health IT programs through the Health Information Technology for Economic and Clinical Health (HITECH) Act.   This funding includes an estimated $34 billion for the Medicare and Medicaid EHR Incentive Program and over $300 million to support state-wide health information exchange efforts.

In order to cut funding for EHR incentives, this means that bipartisan support would have to be garnered in the House and Senate to rescind ARRA or part of ARRA.   The intent of ARRA  initiatives is to stimulate economic activity and produce jobs.   In the current economic environment it would seem very risky, perhaps even foolish, for a politician to drum up support for new legislation that eliminates economic stimulus activity, especially if that activity is already producing jobs.

So, is the EHR Incentive Program stimulating the economy and producing good jobs?   I am not an economic expert, but from what I see around me the answer is clearly, "yes".    I see job openings in the local paper for healthcare system IT analysts and other staff, I speak with IT consultants most of whom are actively seeking personnel, I hear about physician offices investing into the economy $10,000-$70,000/doctor to implement EHRs or upgrade other office technologies, I read about physicians receiving $44,000 federal incentive payments and about hospitals receiving larger amounts, some of which is surely returned into local economies.  The graph below is a composite view of the 3-year stock performance of the health IT sector since 2009.   EHR vendors and other health IT companies appear to be thriving well since ARRA was passed despite the depressed economy.

HIT Sector performance

I suspect that several years from now when experts analyze the impact of the $800 billion stimulus package, the puny $36 billion provided to health IT initiatives through the HITECH portion of ARRA will go down as perhaps the most bang for the buck in terms of stimulating the economy.  

The EHR incentive funds appeared to be well insultated from budget cuts for these same reasons. 

Texas Medical Association video provides in-depth look at meaningful use, how RECs can help physicians

This video does a good job of describing Meaningful Use, the electronic health record (EHR) incentive program and how the four regional extension centers (RECs) in Texas leverage federal grants to subsidize services for physicians that help them select/implement or upgrade an EHR, and then use their EHR to improve quality of care and meet the Meaningful Use requirements.  

The four RECs in Texas currently charge primary care physicians only $300 for consulting services valued at $5,000.  These services include:

o    Select and implement a certified EHR (or upgrade your current EHR to a certified version)

o    Optimize your practice workflow,

o    Achieve meaningful use,

o    Qualify for EHR incentives, and

o    Obtain CME credit hours      

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Modifications to the HIPAA Privacy Rules Under HITECH Will Burden Small Physician Practices

The HITECH Act requires HHS to revise the HIPAA Privacy Rule to remove the exclusion for Accounting of Disclosures for treatment, payment and health care operations to the extent that the disclosures are made through an EHR.    In addition, it requires HHS to determine what information is to be collected and then included in these disclosures.    In 2010 HHS published a Request For Information (RFI) to seek comments on individual’s interests in learning of disclosures, the burdens on Covered Entities in accounting for these disclosures and the capabilities of current technologies to facilitate disclosures.    The resulting proposed rule is an attempt by HHS to balance the individual’s privacy rights against the burdens on Covered Entities.    HHS is accepting comments on this proposed rule up until August 1, 2011. 

At a high level, it appears that the proposed rule primarily does two things:

  1. Provides individuals a right to request a new "Access Report" that lists who has accessed their PHI in an electronic designated record set (which is basically medical records, billing records, or other electronic information that is used for payment or treatment decisions) for any purpose including for treatment, payment and health care operations.    The proposed rule limits the information in an Access Report to content which is already required by the Privacy Rule to be collected.    The assumption is that limiting content in this manner will enable a more automated process by which Covered Entities could produce an Access Report and that this would therefore ease their burden.
  2. Makes changes to "streamline" the Privacy Rule's current Accounting of Disclosures provision, such as limiting the types of disclosures that must be accounted for.     As with the Access Report, HHS showed consideration to the burden placed on Covered Entities by making a number of changes to the individual's existing right to an Accounting of Disclosures that would make it easier for Covered Entities to comply with the requirements.   

Despite these positive changes, the proposed rule significantly underestimates the burden on small physician practices.    Although I agree that these changes do, in general, ease some of the burden on Covered Entities, it is primarily the large healthcare systems that will be able to leverage these changes to their advantage.    I do not believe that these changes sufficiently ease the excessive burden on providers in small practices who do not have the resources to leverage the changes to their advantage.    

HHS uses the assumption that limiting content in the Access Report to that which is already required to be collected [i.e. in an EHR] will enable a more automated report and therefore ease the burden on Covered Entities when an individual requests a report.  This assumption is misleading because it assumes that all Covered Entities have the resources necessary to produce a report that meets all the requirements.   According to the proposed rule, the Access Report must meet certain specifications as defined in the rule, must consolidate content from multiple systems if they exist, must allow individuals to limit their requests to specific time periods or persons, and must be made available in an electronic format as requested by the individual if possible.    Although the information in the Access Report is limited to content already required to be collected, EHR vendor products are not required to provide an automated process to produce an electronic report that meets the proposed rule’s requirements.     Therefore, it will not typically be a simple automated process to produce the report.     Instead, the Covered Entities will have to produce the report through a manual process in which some technical skills are needed to design and configure the report to meet the proposed rule’s specifications, to consolidate content from multiple systems, to customize the report to meet requested limitations and/or to re-format the report.   

For example, programming skills will be needed to create an Access Report from a typical EHR that produces an automated audit log that only shows the User’s ID when a record is accessed, but not the individual’s name as required for the Access Report.    In that case the report must be re-configured to map the actual name of the individual in place of the recorded User ID.    As we know, when one change is made in an electronic report, other changes may be needed to accommodate the change.    In this example, mapping content from the NAME field to the USER ID field might also require the report writer to increase a character limit in the USER ID field so as to not cut off long names.    This second change could cause the report to extend beyond the set margins of the report’s design, therefore requiring the report writer to change the design of the report.    A small practice will not typically have someone with the expertise to program such a report and will therefore have to hire an IT consultant.

Covered Entities must utilize the time and effort people who have the needed technical skills to meet the proposed rule’s reporting requirements.    The difference between small practices and large providers is the availability of technical expertise to do this manual work.     Most large healthcare systems and some large physician practices have an IT Department or employ IT personnel who have the expertise and skills needed to design, configure and format reports.    For large entities, the Access Report does not create a significant new burden because they already have the expertise to produce their reports. But very few small physician practices have the resources necessary to do this.     So in order to produce an Access Report, a small practice will have to hire outside resources to design, configure and format the reports at variable costs.    The actual cost will be dependent on the complexity of each report and the IT consultant’s hourly rates ($100-$250/hour).     As the proposed rule is currently written, a small practice will typically have to hire external resources, at their own expense, to write the report and then be required to provide the report at no cost to the requesting individual.

As acknowledged in the proposed rule, the Accounting of Disclosure is recognized by HHS to be more complex and will require a “manual, expensive, and time consuming process for Covered Entities and Business Associates.”   One purpose of the new Access Report is to be an alternative to Accounting of Disclosures in order to mitigate this known burden of disclosures.    Nevertheless, the Access Reports will still require “manual” work that involves technical skills and will be a significant burden on small practices.    Also, since the Accounting of Disclosure reports are more complex they will require more manual work and technical skill than Access Reports.    The burden of disclosures on small practices will therefore be much greater than for large systems that already employ the technical expertise to design, configure and format the reports.

 In summary:

  1. The proposed rule requires small practices to provide requesting individuals with a new Access Report which places excessive burden on small practices at an unreasonable cost.    The burden of producing an Access Report should be on the vendor’s EHR product and not on the physician.     The proposed rule should be modified to require small practices to provide the system’s automated audit log, as configured by the vendor, if available, from any of their systems that store PHI.    The burden should be placed on the vendors to configure their products to produce automated reports that meet the specifications and requirements.    If a small practice has to hire IT consultants to design and configure or modify an Access Report, they should be allowed to charge the individual for the actual costs incurred.
  2. This proposed rule also requires small practices to provide requesting individuals with an Accounting of Disclosure which also places excessive burden on small practices at an unreasonable cost.    The burden of producing Disclosure reports should be on the vendor’s EHR product and not on the physician.    The burden should be placed on the vendors to configure their products to produce automated reports that meet the specifications and requirements.    If a small practice has to hire IT consultants to design and configure or modify an Accounting of Disclosure report, they should be allowed to charge the individual for the actual costs incurred.

Twitter Chats and Physicians (#eRx630)

Today I (as @drmattmurray) and @TexMed moderated our first Twitter Chat that focused on the topic of e-prescribing. To participate in a Twitter Chat a physician must have a Twitter account and must know the date, time and Twitter hashtag for the Twitter Chat.  In our case the hashtag-- #eRx630--refers to e-prescribing and the date, June 30th, by which time physicians must meet the CMS requirements regarding the use e-prescribing. Physicians who fail to use a qualified e-prescribing system or certified EHR to enter at least 10 e-prescriptions during eligible Medicare encounters will incur a 1% penalty on 2012 Medicare claims.    On the other hand, those who meet this requirement are eligible for a 1% bonus. 

Despite the high importance of this subject matter, there were not any other physicians participating on this particular Twitter Chat.   At least none that we heard from.   It was lonely.  

However, we considered this to be an experiment and a chance to experience what it is like to actually moderate a Twitter Chat.    Without a lot of participating "chit-chat", it was difficult to coordinate questions and answers with my friends @TexMed and @TexMedHIT.     We basically asked each other questions or even asked ourselves for our own answers.  I think we did get out some excellent information, but this would have been more valuable with some active back-and-forth dialogue.   Again, though, the purpose of this venture was to dip our toes in the water to see how this type of format could be used in the future. 

Twitter Chat among physicians will certainly have challenges, but I think it will find it's place as a useful mode of communication for specific purposes and in certain situations.  The format will need to be refined, and this means we will have to try it (like today!), experiment with it, refine it and keep doing that PDSA thing to it (Plan-Do-Study-Act).   Eventually it will find a place where it serves as an effective way to communicate some things.     I already have found Twitter useful at large medical conferences that use a hashtag to communicate real-time information.    It is a matter of finding the right niches. 

One of the useful aspects of a Twitter Chat is that a transcript can be created of the entire conversation.  This means that you don't have to be "online" and engaged in the Twitter stream for the entire duration of the chat.   Since most physicians are hard pressed to find an un-interrupted hour, they would find it very helpful to be able to access and peruse the transcript at their leisure.

Here is a transcript of today's Twitter Chat #eRx630:


Improve Physician Leadership Through Recruitment, Education and Training

A recent discussion among my colleagues about increasing physician leadership in this age of electronic health records (EHRs), Meaningful Use, healthcare reform and Accountable Care Organizations (ACOs) caused me to think about how a physician even starts to go about becoming a leader.   I considered physicians in my own community who are recognized leaders and appreciated that their rise to leadership started by simply getting involved in something.   Their leadership was born out of getting involved just like my colleagues were doing when they began discussing solutions to this particular issue!

Getting involved is a common attribute of physician leaders because there is obviously little merit or trust when a physician leads an effort without previously participating in a similar effort.   Participation is the initial step to gain such trust.   Once a physician gets involved with a successful initiative their community deposits a “coin of trust” into his pocket.    If the physician obstructs progress, though, some coins of trust are removed.   A physician who eventually collects a pocketful of coins is looked upon as a trusted “community leader” who is knowledgeable and experienced, even if he did not actually “lead” any effort.  This is because many successful healthcare initiatives are known to be moved forward by people who are catalysts for collaboration and effective at resolving conflicts between stakeholders.   One does not have to be an ACO board chairman or a formal project leader to be such a catalyst.  In fact, it is often advantageous to be in a more neutral position when exerting that type of influence.

So an increase in physician leadership will initially involve an increase in physician participation in healthcare initiatives.   A good place to start is with local health initiatives such as a Regional Extension Center (REC), health information exchange (HIE)  or Accountable Care Organization (ACO).   Participating in a local initiative provides physicians with the valuable experience of working together, perhaps for the first time, with multiple stakeholders.  Physicians will see the types of communal efforts that are successful at promoting change.  They will gain valuable knowledge about healthcare reform, health IT or other important topics.   They will learn how public policy is developed. They will encounter the frustrations and complexity of efforts that fail.   But they will learn to keep their focus on the long term and not be deterred by a short term failure that they come to realize will not matter at all in 40 years.     

Understanding this process illuminates a path to increase physician leadership.  It starts with the active recruitment of physicians into local, statewide or national activities.  It is accelerated through concurrent education and training to hone leadership skills.  County and state medical societies, who have established physician relationships and are experienced with physician education/training, are ideal entities to facilitate the growth of leadership.  The medical societies could actively identify new and ongoing healthcare initiatives and contact them to ensure there is adequate physician participation.   They could also assist with physician recruitment and training when needed.

Help Available For Small Physician Practices to Overcome Technology Challenges

American Medical Association (AMA) President, Cecil B. Wilson, M.D., said in an AMA Commentary this week, "Physicians should take the time to explore their practice needs, assess their practice's readiness to adopt health IT and select the right system for the practice --and its patients".    This is wise advice that I wholeheartedly agree with.

I also agree that the successful adoption and meaningful use of electronic health records (EHRs) impose many new challenges onto physician practices and that overcoming these barriers is especially difficult for physicians in small practices or solo practices that are constrained by limited resources.   My only disappointment with Dr. Wilson's message to physicians is that it failed to highlight how Regional Extension Centers (RECs) can be leveraged by physicians to address these issues with EHR adoption and use.

The HITECH portion of the 2009 Reinvestment Act (ARRA) included over $677 million in grant funds to establish RECs across the nation to cover every geographic region.   The purpose of each REC is to provide consulting services to physicians that help them overcome many of the described barriers to the adoption and use of EHRs.   It is important for physicians to know that the RECs receive federal subsidies specifically based on and proportionate to the number of primary care physicians in solo or small group practices (<10 physicians) that they successfully help adopt, implement and meaningfully use an EHR.  In other words, RECs are financially dependent on providing effective health IT consulting services to a segment of physicians who have the greatest need for such services.

In Texas there are four RECs including the North Texas REC (NTREC) for which I volunteer time as Board Chairman.    Other Texas physicians volunteer their time to comprise 50% of the governing boards for each of the four RECs.   Our goal is to ensure that our RECs are physician-friendly and remained focused on providing high quality services that meet the technology needs of small physician practices in each region.   Texas RECs collaborated with each other to create a common business plan that leverages the federal subsidies to charge Texas physicians a token fee of $300 for IT consulting services worth over $5,000.    

NTREC will receive 100% of their allotted subsidies if we successfully help 1,500 physicians adopt EHRs and achieve meaningful use.   Since last October more than 500 North Texas physicians have enrolled for NTREC services; over half of them have already successfully implemented an EHR and are now working on the achieving meaningful use of their investment.

My hope is that physicians in other states will emulate our efforts by actively engaging in the governance of their region's RECs to ensure that they are physician-centric and remain focused on addressing the unmet needs of the small physician practices.


Why should primary care physicians enroll for Regional Extension Center services?

Why should primary care physicians sign up for REC services?   What are the unique selling points and assistance they will receive as compared to other consultant organizations?  

These are excellent questions I am hearing from physicians in Texas regarding the four RECs that cover our entire state.  The RECs are subsidized by the federal government through the Health Information Technology for Economic and Clinical Health (HITECH) Act which appropriated $640 million in REC grant funds to create 62 RECs across the nation, including the four in Texas. 

Primary care physicians in Texas should use REC services because they will receive a steep discount for high quality services that are provided through a trustworthy, physician-centric organization that was specifically created to meet the technological needs of physicians in their region.

In Texas the four RECs have collaborated to develop a shared business plan that leverages the federal subsidies to provide onsite technical consulting for a token fee of $300.    For this $300 enrollment fee Texas physicians receive over $5,000 in consulting services which include:

  • EHR implementation and project management;
  • HIT education and training; 
  • Vendor selection and financial consultation; 
  • Practice and workflow redesign; 
  • Privacy and security compliance education; 
  • Meaningful use analysis, tracking, and monitoring; 
  • Assistance in meeting meaningful use requirements for CMS incentives; 
  • Collaboration with state and national health information exchange (HIE); 
  • Ongoing technical assistance; and 
  • Opportunities for CME credit hours

In addition to this steeply discounted enrollment fee, the Texas Medical Association (TMA) works closely with the RECs to help ensure that the RECs are physician-centric and focused on meeting physician needs.    Physicians hold 50% of the seats on each REC's governing board as a result of the TMA’s early efforts.

Another unique selling point is that the REC technical consultants are specifically focused on, and experienced with, the small physician practice.    Other IT consultants naturally give priority to large practices or healthcare systems where they get large amounts of money from a small number of contracts.    The REC consultants, on the other hand, only get a small amount of money per contract, but they get a large number of them.    This business strategy allows them to become more experienced with and more focused on the small practice.    The REC administrative staffs enable this strategy by facilitating the enrollment of a large number of physicians and by using the REC federal grant funds to offer physicians the steep discount.

The four RECs in Texas are:

For Meaningful Use Payment: Goin' to the CHPL, Gonna Get a "CMS EHR ID"

Use of certified electronic health record (EHR) technology is a core requirement for physicians and hospitals to become “meaningful users” and to be eligible for payments under the Medicare or Medicaid EHR incentive programs.    Operationally, CMS requires providers who apply for these payments to submit the "CMS EHR ID" that their certified EHR technology is assigned.   Physicians and hospitals will benefit from an awareness of several issues revolving around EHR certification and on this CMS EHR ID, especially when "goin' to the CHPL" as noted below.

Awareness Issue #1:  The Office of the National Coordinator for Health Information Technology (ONC) in 2010 established a temporary certification program for EHR products.    A permanent certification program, which builds upon the current temporary program, is expected to be ready to launch by the end of 2011.   This program uses ONC-Authorized Testing and Certification Bodies to test and certify EHR products.   The list of certified EHRs is updated as new products are certified and posted on the Certified HIT Product List (CHPL) website.    CHPL is maintained by ONC and is the sole, designated authoritative list of currently certified EHR products.  

Awareness Issue #2:    ONC certification is different from that provided by the Certification Commission for Health Information Technology (CCHIT).    CCHIT certification is based on more comprehensive criteria.    CCHIT certification continues to be an important resource for those who are in the process of selecting an EMR because of this more comprehensive testing.    ONC certification testing, on the other hand, is specifically based on the CMS Meaningful Use criteria. 

Awareness Issue #3:   EHR products are tested and certified by ONC as either a Complete EHR or a Modular EHR.   A Complete EHR product is defined as an EHR product that meets all of the certification criteria for meaningful use.  A Modular EHR product is defined as an EHR product that meets at least one but not all meaningful use criteria.

Awareness Issue #4:   When a physician or hospital apply for their incentive payment they are asked to submit to CMS the "CMS EHR ID" that is assigned to their EHR product(s).  The CHPL website is the only place where this ID number can be found.  

Awareness Issue #5:    When looking for this CMS EHR ID number, it is helpful to know that this is not the same number ONC provides the EHR vendors when they are certified.    This is because some providers may decide to use a modular approach and combine Modular EHR products from different vendors in order to achieve meaningful use (i.e. a basic EMR without e-prescribing from one vendor and an e-prescribing module from another).  

Awareness Issue #5:   As the website works today, the CMS EHR ID can only be found on the "Grocery Cart" page and only after the <Get CMS EHR ID> button is activated.    One first selects their EHR product(s), puts them in their "Grocery Cart" and then goes to their <Grocery Cart> page.    The button becomes available when one has either:

  • selected a certified Complete EHR product


  • selected a set of certified Modular EHR products that meet all of the certification criteria      

It interesting and helpful that CHPL provides real-time feedback when selecting a set of Modular EHRs.  Once all of the criteria are met, the <Get CMS EHR ID> button becomes available.  

Awareness Issue #6:    Regarding the modular option, the CMS certification process does not include integrated testing of all the possible permutations of Modular EHR sets that can be selected.    So even though a set of Modular EHR products may produce a CMS EHR ID on the CHPL website, this does not mean that the selected set of products were tested as an integrated unit.   This does mean that the physician or hospital who is in the EHR selection process should not depend on the CMS EHR ID to determine whether the selected products can be interfaced or work together.     Due diligence will still be needed to ensure all of the selected Modular EHR products are compatible.   

In other words, if you're goin' to the CHPL and gonna' get an CMS EHR ID, it's best to know your EHR partners well before purchasing and implementing them!

Watch Recording of Dr. Blumenthal Speaking to Texas Medical Association on EMRs, Meaningful Use and Quality Medicine

Dr. Blumenthal anticipates that Regional Extension Centers (RECs), such as the North Texas Regional Extension Center (, will be helpful to physicians who want to successfully implement electronic medical records (EMRs) and use them to enhance our ability to provide high quality of care.  He notes that the federal EMR incentive payment program (through the HITECH legislation) is a one-time offer from the government that physicians should strongly consider, especially if they plan to still be practicing medicine in 10-15 years when EMR use is likely to be an expectation.