A few days after the University of California Medical Center in Irvine went live with its new electronic medical record system, a letter arrived on the desk of the hospital administrator.

"I think the person who chose the [EMR] system should be shot first and then fired," the note read.

Pamela Griffith, RN, director of applications for the UC Medical Center, displayed the note at the annual conference of the Health Information and Management Systems Society in Orlando, Fla., in late February, where a lot of discussion focused on how to get physicians to use technology.

Only a few years ago, many of the chief technology officers, vendors, hospital administrators and others who attended HIMSS thought that as technology became more pervasive, physicians would have no choice but to adapt. It turned out that assumption was false. Griffith presented the angry doctor's note as evidence of the backlash her hospital failed to anticipate.

She and others shared success stories, as well as lessons learned, of implementing new technology. The common thread was the realization that for major IT projects to be successful, physicians need to be on board, early and often. The solution, many found, was engaging doctors in leadership roles before implementation.

Sometimes it's the reluctant ones who make good leaders, said William McClatchey, MD, chief medical information officer of the Atlanta-based Piedmont Hospital system. He found involving physicians who are opposed to the technology gave the IT staff and hospital administrators a better sense of the backlash they could anticipate, and hopefully prevent, at go-live time.

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In an attempt to make its personal health records more interactive, Aetna announced last month the launch of Smart Source, a personalized search engine from which members can access medical information specific to their conditions and demographics.

While Aetna claims the system is a way to help its members make more informed decisions regarding their health, others fear insurer-run systems could create a way for health information to be used against members and physicians.

Aetna partnered with Healthline, a health information technology company based in San Francisco, to make searches through SmartSource relevant to each user's profile. The system takes into account the user's gender, age, ZIP code, health plan and employer in addition to information stored in the PHR to produce search results specific to that user.

Information includes basic health educational materials, commonly used medications and treatments for specific conditions, estimated health care costs, doctors in specific plans and information on Aetna programs that the member might be eligible for.

PHRs recently released by Microsoft and Google also allow users to link their records with relevant Web-based research. Those two systems allow the patient to control who can add to or view their records.

Edward L. Langston, MD, chair of the American Medical Association Board of Trustees, said while the AMA believes PHRs are "an important service" for patients, "[W]e are concerned that granting access to PHRs to a health insurer may have harmful implications for both patients and physicians.

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A survey shows hospital executives nationwide have some negative opinions of health plans, but no health plan is more roundly disliked than UnitedHealthcare.

The survey, released in March by California-based Davies Public Affairs, finds 91% of hospital executives have a somewhat or very unfavorable opinion of United. The company is the most ubiquitous -- it's contracted with 96% of the hospitals represented in the survey -- but its negative rating is nearly twice the 47% of Cigna, which was represented in 93% of the surveyed hospitals.

United also was No. 1 -- at 64% -- in being rated the most difficult company with which to negotiate. United was rated worst in timeliness of payment, reimbursement rates, honesty and candor in negotiations, denial of claims, dealings with hospitals and dealings with physicians.

"I think what the survey results show very clearly is that the reason United was rated very poorly was because they behave in a way that deserves to be rated poorly," said Brandon Edwards, who manages Davies' health care segment.

United spokesman Tyler Mason said the Davies firm used questionable methods in collecting its data, and said the survey appeared to be motivated to single out United specifically. Davies' client list includes hospitals. This "is a poorly disguised PR stunt conducted by a PR firm with a questionable reputation," Mason said in an e-mailed statement.

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New York Attorney General Andrew Cuomo has issued numerous subpoenas to health plans in the state as part of his investigation of a UnitedHealth Group subsidiary used by the plans to set out-of-network payment rates.

Cuomo's office issued 20 subpoenas March 6, including four to the CEOs of Aetna, Cigna, UnitedHealth Group and WellPoint, ordering them to testify in depositions about their companies' practices around out-of-network payments. The inquiry centers on United subsidiary Ingenix, which sells access to a database used by most insurers to set out-of-network reimbursement amounts known as "usual, customary and reasonable." The attorney general notified United of his intent to sue the company and Ingenix, but has not yet done so.

Cuomo alleges that Ingenix intentionally underset UCR rates to save money for its health plan clients, resulting in patients being stuck with a larger portion of their doctors' bills. United denies the allegations.

The office subpoenaed WellPoint subsidiary Empire BlueCross BlueShield, Excellus BlueCross BlueShield, Group Health Inc./Health Insurance Plan of Greater New York, as well as HMOs HealthNow New York (parent company of two New York Blues plans), MVP/Preferred Care, Capital District Physicians Health Plan and Independent Health.

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Health insurers are offering incentives to persuade members to see doctors regularly for "well visits" and to manage chronic illnesses. Physicians know that treating an acute problem pays better and is easier to bill than prevention.

Consultants and physicians say learning how to code, bill and schedule around prevention can bolster patient care and fair payments. But doctors often struggle with insurers to ensure that coding will be recognized and that they are paid fairly.

The difficulty in documenting and billing for preventive care and sick care is encapsulated in a common situation: A patient comes in for a checkup then mentions a symptom -- shortness of breath, chest pain -- that merits its own conversation and examination. Or, conversely, the patient comes for a specific treatment, but then wants to discuss how to stop smoking or how to avoid the heart disease that runs in her family.

"It's always a challenge when doing preventive care and disease care during the same visit," said Tom Weida, MD, medical director for Penn State Milton S. Hershey Medical Center's family practice in Hershey, Pa. Doing both kinds of medicine provides an opportunity, but also a trap. If you can get reimbursed only for a sick visit or an annual exam, which do you do, and which do you bill for?

"It's so hard to do the differentiation. ... We bill for pretty much what they came in for and gift the other things," Dr. Weida said.

To help physicians parse what specific type of care they give, the Current Procedural Terminology manual includes detailed guidance about preventive visits, screenings and disease management. But often the line between sick and well care is fuzzy, leaving doctors or staffs to decide how to bill.

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