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Friday Apr 25, 2014

Changing the Conversation: What Would It Take to Make Using Our EHRs Truly Meaningful?

During one of the state chapter meetings I attended as a member of the AAFP Board of Directors, I asked participants if they were using electronic health records (EHRs). About 80 percent said they were. Then I asked the group how many of them were satisfied with their EHRs. Only a few hands went up. In fact, I heard some angry comments.

Administrative hassles are hindering family physicians. “Just one more thing,” is a common refrain, with the implication being that if there is one more thing to report or document -- or anything else that gets in the way of patient care -- it could be the “one more thing” that prompts a physician to quit.

ICD-10, the Physician Quality Reporting System, meaningful use -- how much more will it take before family docs just say no?

It's clear the creators of meaningful use had good intentions. The concept was intended to help physicians transition to EHRs. The carrot was financial. The money saved throughout the health care system by using EHRs could be shared with physicians, thus encouraging them to implement EHRs. (With the stick, of course, being a financial penalty for not complying.)

The idea was that going electronic would:

  • improve patient care, 
  • decrease medical errors,
  • improve office efficiency and
  • avoid redundancy in ordering tests.

Having healthier patients, fewer medical errors, less testing and improved efficiency would net an obvious health care savings. In fact, researchers predicted in 2005 that health information technology would save the country more than $80 billion a year. Yet U.S. health care expenditures have continued to skyrocket due to many factors, including the health IT shortcomings.

So, did we go wrong somewhere?

Interoperability has been, and remains, a major stumbling block despite the Academy's hard work on the issue for more than a decade. Back in 2003, there was a lack of awareness among policymakers and EHR vendors that interoperability was even an issue. So, the AAFP worked with legislators, federal agencies and vendors to get it on their radar.

The AAFP knew standards were needed, so next, the Academy collaborated with other stakeholders to help create the ASTM Continuity of Care Record (CCR), a patient health summary that can be created, read and interpreted by EHRs developed by different software companies. That standard has become part of meaningful use.

Family physicians have led the way and been early adapters of electronic records, but the technology still falls short of what we want and need in terms of useability and interoperability.

As AAFP President-elect Robert Wergin, M.D., of Milford, Neb., recently pointed out in his blog on the topic, when a patient leaves a primary care practice for a subspecialist consultation, the respective EHRs at the primary care practice and the subspecialist’s practice aren’t necessarily able to communicate. This is a barrier to care coordination, and the Academy continues to work with the Office of the National Coordinator (ONC) for Health Information Technology on this issue.

This critical shortcoming is why the Academy was an early contributor and founding member of the direct exchange project, which allows physicians to send secure, confidential emails to other physicians.

Unfortunately, EHR developers have little incentive to change. The ONC recently issued a proposed rule for 2015 that included voluntary updates related to certification criteria, interoperability and regulatory improvements. In a letter to the ONC, the AAFP said that voluntary guidelines would create confusion about what is and isn't required, adding undue complexity to an already complex program. The Academy urged the agency to urge work with stakeholders to create better means than a voluntary certification program.

It seems unlikely that EHR developers are going to fix the issue of interoperability on a volunteer basis. But just think how much more “meaningful” my use of an EHR would be if it could communicate with the EHR of the radiologist or cardiologist across town.

Add to that the fact that many EHRs aren’t user-friendly at all. Documentation and reporting has become cumbersome, and being conscientious about keeping thorough electronic patient records results in less time for patient encounters. In fact, there have been indications that EHRs that satisfy meaningful use and appropriate coding protocols can:

The main thing that electronic records have accomplished is improved billing. But surely this isn't all we want to see come from this investment. We are seeking a system that would improve patient satisfaction and improve patient outcomes. The electronic record is a natural for following patients with chronic disease and surveying your patient population for health concerns.

While tracking specific metrics such as a hemoglobin A1c has improved with use of electronic records, tracking actual improvements in health has not worked so well. What would it take to make this happen?

It is estimated that one-third of health care expenditures overall can be attributed to unnecessary administrative burden. Of that, the time spent doing administrative work and documentation during a patient encounter has been estimated to be as high as 60 percent.

There is a section in the Patient Protection and Affordable Care Act -- Section 1104 -- that seeks to improve these hassles. This "administrative simplification" section was passed by Congress even before meaningful use reporting began. However, the same rules should apply. The section includes operating rules for HIPAA transactions, utilizing a unique identifier and setting up certain rules that would simplify reporting for health plans.

Wouldn't it be great to see a patient and not have to worry about how many bullets are included in the current history of illness? Instead, you could just look at the past medical history as it applies to the patient, review only symptoms that are specific to the patient's problem and pursue only clinical decision-making specific to patient care needs. Charting this way would involve minimal amount of physician time, and patient care documentation would be the purpose. The dual worries of coding and reporting would go away.

My practice is sending one of our physicians to an out-of-town course to become an EHR "superuser" so he can help the rest of us become more efficient in using our system. It seems odd that after years of medical training we need even more training to become IT experts.

Through our state chapter visits and other channels, the members of the AAFP Board of Directors have heard members' concerns -- believe me! We will continue working to ease administrative burdens. We are looking at ways to decrease the number of codes and the complexity of coding. In the meantime, we can all continue to educate ourselves so we can make best use of the current system.

And don't forget that the AAFP is offering webinars and other resources to help us learn and meet reporting requirements.

So here's my final question: For better or worse, how has using an EHR changed your practice?

Daniel Spogen, M.D., is a member of the AAFP Board of Directors.

Comments:

"Wouldn't it be great to see a patient and not have to worry about how many bullets are included in the current history of illness? Instead, you could just look at the past medical history as it applies to the patient, review only symptoms that are specific to the patient's problem and pursue only clinical decision-making specific to patient care needs. Charting this way would involve minimal amount of physician time, and patient care documentation would be the purpose. The dual worries of coding and reporting would go away. " Isn't that the way it used to be (and still is for me) by using SOAP notes and a transcriptionist or voice recognition software?

Posted by Keith Dinklage on April 28, 2014 at 07:04 AM CDT #

To answer your final question EMR has been an overall negative experience for me and I think I can speak for the roughly 150 providers I have trained that it's been on overall negative experience for the majority of them too. Yes, it's sad you need to send one of your partners off so they can teach highly educated individuals how to press buttons on a little box. Good luck changing Meaningful Use. The arbitrary MU stage 2 requirement #7 appears potentially unsafe and a Kaiser study and my experience would confirm this concern. Multiple communications from me to HHS, Sebelius, my Congressman and Senators, physician Senators Coburn and Barrasso and Paul, Department of HIT, federal website for rules and regulations, CMS, and the director of HIT all failed to get a single response except a cursory acknowledgement from one of my Senators and multiple requests for donations from Senator Paul. The government appears totally unresponsive. The MU train is rolling down the tracks and I do not see any stopping it. Three years into using EMR I think the most complimentary thing I can say is that it was a very expensive lateral move. I read the ACA bill before it passed. One of the most certain things I could determine from reading the ACA bill was that EMR software vendors would prosper. Look at Cerner stock and see where it was before the bill passed and where it is now. Cerner stock has increase at over twice the rate of the S&P 500 index the past 5 years.

Posted by John Sherard on May 16, 2014 at 07:20 AM CDT #

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.