The EHR: Love it, hate it; here to stay

In a world where information technology is inextricably entwined in how we live (when was the last time you spent more than 24 hours without online access?), it’s often baffling to see how slowly health care has embraced all things digital.

To be sure, most hospitals and medical groups are making progress. A majority of physicians now have the ability to e-prescribe, and it would be hard to find a health care organization that doesn’t use or store at least some patient information electronically. On the whole, however, there’s a long road ahead for many organizations to reach the nirvana of a fully integrated electronic health record that incorporates both clinical and billing information, allows information to be exchanged between providers and organizations, and makes the fullest use of technology to enhance care.

It prompts the question: Why?

Because adoption of an electronic health record system is neither simple, straightforward nor cheap, that’s why. It demands a major commitment from health care organizations – a commitment, moreover, that tends to be mostly invisible to patients and the public and may not offer an immediate payback.

The challenges of EHR implementation emerged in the details I learned while talking to staff at Rice Memorial Hospital here in Willmar about the hospital’s conversion to Epic last year.

Going live with the new system, which replaced six disparate health information systems across the hospital, involved a $4 million investment, a full year of planning and countless hours of training before flipping the switch on Feb. 1, 2012. One year later, Rice still has lots of work ahead to optimize the system and reach additional milestones that will qualify the hospital for the next stage in federal meaningful use criteria.

The hospital is starting to see some of the benefits – no more chasing down of paper charts, for one. But it’s not hard to realize why many health care organizations would hesitate to dive into EHR adoption when they know how time-consuming and resource-intensive it’s going to be.

Indeed, clinicians and health care leaders are often ambivalent over whether the EHR is an enhancement to patient care or an invention of Satan.

Consider the responses to a recent blog entry by Dr. Robert Wachter, one of the leading voices in the U.S. for patient safety, about the federal HITECH program to promote the use of information technology in health care.

Doctors used words such as “tedious” and “akin to torture” to describe their experiences with the EHR.

“My role anymore is about 50% practicing medicine and the rest being a data entry clerk,” one commenter complained. “It has overall decreased my efficiency rather than increased it. I really like some aspects of it such as drug interaction warnings and clinical reminders. There’s a lot I don’t like.”

From someone else: “Most of American medicine is not done in large clinics or hospitals with their own in-house IT staff and the burden on the rest of us has been near intolerable.”

Earlier this year the American Medical Association sounded an alarm over the federal push toward higher and higher levels of meaningful use, warning that it may be too much, too fast for many providers, especially in view of issues with software design and usability that haven’t been fully resolved yet.

There’s emerging evidence that although some aspects of the EHR are safer, such as replacing handwritten physician orders with computerized physician order entry, the technology also has introduced new potential for other types of errors. Although patient portals are part of the meaningful use requirements and are meant to encourage more engagement by patients, they tend to contain limited information, and organizations are beginning to find that the mere presence of an online portal does not mean patients will actually use it.

So what’s the good side?

A growing body of research confirms the benefits of information technology in making health care safer and creating new opportunities for mining health data to improve care. A survey last year of physicians found that the majority had few complaints about using an EHR and most also felt it helped make their practice more efficient.

Here’s what Dr. Wachter has to say to the critics:

Let’s pause to ask a few questions: Does anyone honestly believe that computerizing American healthcare is wrongheaded? Or that the correct strategy was to continue toe-tapping, waiting for “the market” to promote IT adoption when, in 2009, only 16 percent of US hospitals and doctors’ offices had functioning clinical IT systems? Or that they would like to be a patient, or a clinician, in a paper-and-pencil hospital?

I didn’t think so.

Love it or hate it, the electronic health record is clearly on its way to becoming a permanent part of the health care landscape. The challenge, it would seem, lies in constructively addressing the vulnerabilities of the EHR, supporting organizations through the transition, using feedback from clinicians to make EHR systems better, and trying to eliminate some of the pain inherent in the process so the electronic health record can begin to deliver all that its supporters have promised.

Does online patient access = better care?

When patients have online access to their medical record and the ability to email their doctor, does it lead to better care?

In theory, patient portals are supposed to improve communication between patients and clinicians and encourage patients to become more engaged in their care, thereby producing better outcomes. There has also been a belief that if patients can view test results online and have non-urgent concerns resolved via email, it would help cut down on in-person use of health care services and allow the system to function more efficiently.

But a new study, carried out by Kaiser Permanente and published last month in the Journal of the American Medical Association, has found that the case for efficiency might be wishful thinking.

Previous studies that have examined patient use of health information technology have mostly been small. This study was a large one, involving about 44,000 Kaiser Colorado members who had online access to their medical record and 44,000 who did not. Both groups were followed before and after the introduction of an online patient portal.

The results were surprising. Contrary to what the researchers expected, patient use of the portal was associated with more, rather than fewer, office visits and telephone calls. The researchers found an 8 percent increase in the volume of phone calls from these patients and a 16 percent increase in office visits.

Patients who had access to the online portal also made more visits to the clinic after hours, went to the emergency room more often and were hospitalized more often than those who weren’t signed up for the portal.

Is there a connection between online access to medical information and care-seeking behavior by patients? The study wasn’t designed to explore this, although Dr. Ted Palen, the lead author, speculated in an accompanying audio interview that patients who anticipated needing more care may have been more likely to sign up for the portal in the first place.

It’s an intriguing study because there’s still much that isn’t clear about how health information technology is shaping patient behavior and the impact this has on the delivery of health care. Which patients are more likely to use online access to their doctor and their medical record? Do patient portals foster more engagement? Are outcomes better for these patients? When a medical practice decides to offer an online patient portal, does it promote more efficient communication or does it create an extra burden?

This last point is important. An 8 percent increase in phone calls or a 16 percent increase in office visits might not sound like much, but when it’s applied across a system  with thousands of patients, it can add up to a significant impact, Dr. Palen points out.

Health systems considering the use of patient portals need to ask themselves whether they have the capacity to absorb a potential increase in utilization, he said. “You’d better plan for that.”

The findings from the study could further dampen the enthusiasm for online patient portals, which the health care system has been slow to adopt anyway. What we don’t know, however, is whether the additional office visits and phone calls were actually beneficial in some way to patient health, or whether there was a fundamental difference between the patients who signed up for the portal and those who didn’t.

The increased utilization may in fact have been “a good thing” if it led to better outcomes and health status in the long run, Dr. Palen said. But it seems far more study and analysis are needed to truly sort out the impact of patient-centered information technology and how to use it wisely, appropriately and effectively.

Demolishing assumptions about patients and the PHR

When a medical practice in Florida decided to survey its patients about whether they’d be willing to use a personal health record offered by the practice, the doctors figured those most likely to say yes would be younger, well-educated and higher-income. They also hypothesized that the likely users would be more health-literate.

As it turned out, they were right – but only by half.

Income and schooling made no difference and neither did age. What seemed to matter most was the patient’s health literacy (or, to be more accurate, the patient’s perception of his or her level of health literacy). Among the patients in the survey who said they were willing to use a personal health record, 65 percent self-reported high health literacy. For those who weren’t willing to use a PHR, only 38 percent estimated their health literacy as high.

Overall, three out of four who responded to the survey said they’d be willing to adopt a personal health record if the medical practice made this service available to them.

The results of the survey appear in a recent edition of the Perspectives in Health Information Management journal, and they raise some interesting questions about the assumptions that often are made regarding patients and information technology – e.g. that older adults don’t go online or less-educated individuals aren’t very interested in a personal health record.

Even the researchers were a bit taken aback by their findings. Alice Noblin, Ph.D., an assistant professor and program director for the Health Informatics and Information Management Program at the University of Central Florida, told the AMA’s Medical News Today, “I knew going in that it was a high Medicaid population, so the demographics didn’t surprise me. But how they felt about the PHRs, yes, I thought they would be a lot more unwilling to get involved with it, but definitely, most of them were interested.”

To be sure, this was a small survey, involving only 562 patients at just one medical practice. Nor was it able to predict whether these patients would translate their willingness into action if an online personal health record became available to them.

One of the lessons, however, seems to be that the medical community shouldn’t take for granted that most of their patients are indifferent to technology – and they shouldn’t underestimate patient interest in PHRs either.

A couple of the more intriguing findings from the survey: More than half of the patients who participated in the survey had a high school education or less, yet 71 percent in this group said they were willing to use a personal health record. And although nearly 60 percent of the respondents were in the lowest income category ($20,000 a year or less), three-fourths of them were interested in using a PHR. Most of the survey participants also were middle-aged and older.

Now for another statistic: Nationally, use of personal health records has been placed at around 7 percent of the total patient population – a very low figure when you consider the extent to which people are using information technology in other areas of their lives.

It’s not clear why there hasn’t been more uptake. Some of this can be traced to people’s concerns about privacy and security; unlike the electronic medical records maintained by hospitals and medical practices, the personal health record is maintained by patients themselves. Some of it could be due to the amount of hunting and gathering often required for consumers to create a PHR that’s complete and accurate. Actual use also somewhat depends on the PHR’s design and whether it’s easy or cumbersome.

But much of it simply might be a result of a general lack of awareness and patient education. Would it help if medical practices took a greater lead in discussing and promoting the PHR with their patients?

This particular survey was commissioned by a medical practice that wanted to offer a PHR and wanted to gather some data before making a final decision. Although many health care professionals remain ambivalent about how much information should be placed in the hands of patients, this small study suggests patients are more receptive than providers might think – and furthermore, that patient interest cuts across the demographics of age, income and education. It remains to be seen how the gap between what patients say they want and what providers assume they want can somehow be narrowed.

Make room for the scribe

In some exam rooms and hospital rooms, there’s a third person these days – a scribe whose task is to record all the notes for the visit between patient and physician.

The use of medical scribes isn’t particularly widespread. But as the paper trail for patient care becomes increasingly complex, some health care practices are bringing scribes on board to handle all the note-taking and documentation. And there’s a chance this trend could grow with the adoption of electronic medical record systems.

What does a scribe do, anyway? He or she might take the patient’s medical history, document the exam and any procedures that are done, transcribe orders for tests or prescription drugs, and record the patient’s diagnosis, followup instructions and other pertinent information dictated by the physician. Although medical scribes work in a clinical setting, they generally don’t do any hands-on patient care.

A rather detailed article from the Physicians Practice journal explains how an emergency practice in Fresno, Calif., benefited from hiring scribes:

With clerical duties relegated to dedicated “apprentices” rather than clinically trained, overworked medical personnel, workplace satisfaction has gone up across the entire staff. A scribe’s full concentration on creating a complete chart results in improved compliance, more accurate (read: higher) coding, and, therefore, increased reimbursements – both on a per-patient basis (less under-coding) and a patient load basis (more patients seen per day).

From the patient’s point of view, the presence of a scribe also can mean the physician is free to concentrate on patient care and having a two-way conversation vs. spending part of the visit taking notes.

The introduction of the electronic medical record seems to be upping the ante. I think it’s safe to say the medical community has found it challenging to enter the digital age. Many practices are struggling with how to incorporate the EMR at the bedside or in the exam room in a way that’s seamless rather than clunky. The transition can take time, and productivity can drop while frustration rises.

Bringing in scribes is one way that some practices are managing this transition, as this article, which appeared last fall in USA Today, makes clear:

Instead of pens, scribes… use laptops as they trail doctors from bed to bed, taking detailed notes that will form part of each patient’s electronic medical record. Experts say the scribes’ peculiar role – with one foot in 2009 and one in 2000 B.C. – illustrates hospitals’ often bumpy transition from clipboards and closets of paper charts to digital records.

Uberblogger Dr. Kevin Pho published a guest post just this week that illustrates how awkward it can be to manage a patient encounter while simultaneously trying to document for an EMR:

It’s relatively easy to write with pen and paper while listening and explaining. It’s far harder to keep two hands on a keyboard, a third hand on the mouse, one eye on the screen and another eye on the patient and his family. And the fact that most EMRs and user interfaces are designed by computer geeks with no knowledge of clinical care or workflow certainly doesn’t help matters.

I suspect there’s another factor at work as well: Many doctors aren’t good typists. I learned these basic skills in Mrs. Perry’s ninth-grade typing class (back then it was called “typing”; nowadays I suppose it would be called “keyboarding”) and they’ve been seriously honed by years of daily use. This isn’t necessarily the case for other people, though, whose keyboard experience might have focused more on the Internet and e-mail. It takes time to build up proficiency, and time is what busy medical practices simply don’t have.

This is the up side to medical scribes. The down side? There’s an added cost to hiring scribes. Presumably it can be offset by improved reimbursement and increased productivity, but the introduction of another category of employee can be rather challenging for a medical practice to manage and the payoff might not be immediate. There doesn’t yet appear to be any standard training or qualifications for becoming a medical scribe, so quality is at risk of being hit-or-miss. Adding this third layer to the doctor-patient encounter also can increase the possibility of errors and miscommunication in the record and differing interpretations of what happened in the exam room.

So far, I’ve heard little of the patient perspective regarding scribes. One of the commenters at Kevin MD took a rather dim view of the concept, calling it “creepy.” More than a few patients might find it inhibiting to have a scribe in the room, especially if they’re already stressed about their doctor visit or if they need to have a conversation about something that’s awkward or sensitive. From a practical standpoint, many exam rooms aren’t very large and a third party can make for rather crowded quarters. The constant clickety-click-click of a laptop keyboard also can be unnerving for patients.

If a patient really didn’t want to have the scribe in the room for part of the visit, could they ask to have the scribe step out into the hall? Would providers be willing to accommodate this, or would it brand the patient as uncooperative? If the scribe isn’t physically present in the room but is observing the encounter through a two-way monitor or some other means, are patients made aware of this fact?

There seems to be a lot to sort out yet about the best way to incorporate scribes in clinical care. In the meantime, consumers shouldn’t be too surprised if one of these days their appointment with the doctor also includes a scribe.

The third wheel in the exam room

There’s a third presence in the doctor’s exam room these days, and it’s not always comfortable. In fact, at times it can be downright intrusive.

I’m talking about the hardware associated with the electronic medical record, aka the computer. As paper charts are slowly but inevitably phased out in favor of new-fangled technology, it’s not enough for doctors to learn how to navigate through the software of the EMR. They also have to figure out how to incorporate a computer’s physical presence in the doctor-patient encounter, preferably in a way that’s as effective and seamless as possible.

And it hasn’t been easy. Dr. Pauline Chen, who writes the “Doctor and Patient” column for the New York Times, recently described her first experience of using a computer in the exam room. Despite plenty of advance training on the new electronic charting system, she realized as she entered the room that she had “no idea where to sit.”

The new computer was perched atop a desk in one corner of the room; the patient sat on the exam table on the other side of the room. In order to use the computer, I had to turn my back to the patient as I spoke to him. I tried to compensate by sitting on a rolling stool but soon found myself spending more time spinning and wheeling back and forth between patient and computer than I did sitting still and listening. And when my patient did talk, his story came only in spurts because every time I turned my back to him to type, the room fell silent.

My vision of an interaction marked by the seamless flow of conversation and capture of information vanished. Instead, I was spinning my wheels. Literally.

It’s a lament that’s being heard with increasing frequency. Doctors don’t like being forced to deal with a keyboard and monitor instead of concentrating on the patient. Patients don’t like looking at the doctor’s back while he or she busily types away.

Sometimes what you get is this situation, described by Lisa Gualtieri at The Health Care Blog:

While waiting in Peets, a coffee shop in Lexington Center, I watched the friendly discussions between the baristas and customers. I then went to a doctor’s appointment, where a nurse stood typing at a laptop asking me a series of questions, including “Are you in pain?” and “Do you feel safe at home?”

She didn’t look at me once as she read and typed.

Not that this never happens with older-style paper charts, of course. Doctors can spend just as much time with a paper chart – leafing through pages, scribbling down handwritten notes while the patient sits there and waits – as they do on the electronic version. I’m not sure anyone really anticipated, though, that computers in the exam room could become such a physical presence.

An issue brief, published last month by the Center for Studying Health System Change, outlines some of the challenges. Many of the most substantial issues have to do with the management of the EMR itself. It’s not a substitute for face-to-face communication, nor does it automatically make charting faster or more accurate. But there’s no getting around the fact that the introduction of a computer in the exam room can affect doctor-patient communication in subtle ways. From the report:

Use of an EMR has been noted in some studies to result in less face-to-face engagement with patients, making it more difficult for clinicians to focus their attention on particular aspects of patient-centered communication, such as outlining the patient’s agenda, exploring psychosocial and emotional issues, discussing how health problems affect a patient’s life, and ascertaining the timing of events needed to assess patients’ problems.

The report also makes this important point: “How computers are used in the exam room may depend on a clinician’s baseline patient-communication skills before EMR adoption.” In other words, if a physician wasn’t a great communicator with a paper chart, an electronic medical records system won’t necessarily bring about a miraculous change for the better.

The question, though, is whether the physical mechanics of the computer can help or hinder this process. When Affiliated Community Medical Centers began phasing in an electronic medical records system some years ago, a really smart approach was taken. First of all, it was implemented in stages rather than all at once, allowing the staff and physicians time to get comfortable with the technology. And second, before computers were introduced in exam rooms, ACMC undertook a pilot project to determine which would be best, desktop computers or electronic notebooks. The electronic notebooks ultimately won out for a number of reasons, not the least of which is that they can be physically handled in ways similar to a paper chart.

The IT industry unfortunately has lagged when it comes to health care applications. Many of the early systems were cumbersome and didn’t meet the needs of clinicians. The industry is finally starting to catch up but I‘m still not sure whether there’s a true understanding of how computers actually are used in the exam room. Is the machine simply plunked onto the most convenient desktop? Is there due consideration for the work flow and the uniqueness of the doctor-patient encounter? Have physicians and staff had enough training to help them be comfortable with the technology? It’s a mistake to assume these things aren’t important. They are; and when they aren’t done well, it’s frustrating and counterproductive for everyone involved.

When electronic medical records systems are implemented thoughtfully, though, they can be more or less seamless, at least from the patient’s point of view. My own experience has been that the EMR isn’t an intrusion in the exam room at all.

I think what we’re seeing here is a transition. There’s a lot to learn yet about how to implement the technology effectively and use it to its fullest potential. Mistakes have been made; some organizations have learned things the hard way. Designers and vendors still have some way to go before they’re fully responsive to the needs of the health care industry.

Transitions are always difficult and uncomfortable, but industries manage to navigate them all the time. Ten years from now, I suspect the presence of a computer in the exam room will be so unremarkable as to hardly even be noticed.

West Central Tribune file photo by Bill Zimmer

In pursuit of the EMR

Maybe bonus payments will do it – speed the transition to electronic medical records, that is. Last week the Centers for Medicare and Medicaid Services announced plans to distribute billions of dollars’ worth of stimulus payments to doctors and hospitals who make the switch from paper to digital medical records. Standards are in the process of being developed and are currently open for public comment. Once the standards are finalized, eligible hospitals could start receiving incentive payments by October. Other eligible providers, such as physicians, could get their bonus payments starting next January.

The money itself was authorized as part of the American Recovery and Reinvestment Act of 2009, which allocated $19 billion in stimulus funds to spur the adoption of electronic medical record technology.

Despite all the technologic advancements in medicine, the industry as a whole has lagged far behind everyone else when it comes to information technology. By some estimates, fewer than 20 percent of physician clinics use electronic charting for their patients; all the rest still rely on old-fashioned paper records.

There are a lot of reasons why health care hasn’t rushed to the forefront to embrace information technology in patient care. For one thing, health care is complex, so it’s no easy matter to develop workable – and affordable – software programs that can do everything that’s needed. What a hospital emergency room or radiology department might require, for instance, vs. what a physician office practice might need can be two very different things.

Well-designed programs have been slow to be developed, although the pace has been quickening in just the past few years. A frequent complaint has been the use of electronic templates which, depending on your point of view, can either help streamline and standardize the charting process or can get in the way of adequate, thorough documentation. Another issue is compatibility with other programs so hospitals and clinics can electronically “talk” to each other and share patient records.

Cumbersome hardware has been one of the barriers as well. If you run a physician office practice, do you go to the expense of installing a computer in every exam room? If you’re a hospital, should you have a computer at every bedside? Or do you lug a laptop or electronic notebook or some other portable gizmo from one patient to the next?

There’s no getting around the fact that the EMR is an expensive investment for health care organizations. On top of the money they’re spending, they also have to consider the cost of training and the inevitable headaches and lost productivity associated with implementing an EMR system and working through the glitches.

And let’s face it, plenty of physicians are unhappy with their experiences so far with the electronic medical record. At least one recent study suggests the EMR hasn’t lived up to its promise of offering better patient care at a lower cost – although the study’s authors also believe many organizations simply aren’t using their EMR systems to their full potential. A recent online gripe session at Kevin, MD, made it clear how some physicians feel about the push toward the electronic medical record. “If these were good products, they would sell themselves without incentives and such,” one physician wrote. “It is becoming clear that the EMR emperor is wearing no clothes. The current sales pitch can be translated, ‘Yes, we know they’re lousy products, but the government is going to require them, so you better buy one now.’”

In spite of all the challenges and drawbacks, plenty of health care organizations have already forged ahead with the EMR. One of the earliest adopters was Family Practice Medical Center here in Willmar. Affiliated Community Medical Centers also has been making the transition, starting a few years ago with electronic prescribing and expanding in stages. Ditto at Rice Memorial Hospital, where a new EMR system in the emergency room and electronic charting at the patient’s bedside were both implemented within just the past couple of years.

It hasn’t been easy. It has taken a lot of work and a lot of planning, not to mention the commitment that this is the direction in which these organizations want to go. It’s also still a work in progress, with problems yet to solve and new applications yet to learn.

To be sure, Minnesota is farther ahead than many other states in implementing the EMR. A year from now, a new e-prescribing mandate will take effect, requiring all prescriptions to be ordered, filled and paid for electronically. The state’s so-called e-health initiative also requires all Minnesota providers to adopt an electronic medical records system by 2015. The goal, laid out by the public-private collaborative that’s leading the e-health initiative, is “to accelerate the adoption and use of health information technology in order to improve health care quality, increase patient safety, reduce health care costs and improve public health.”

Will Minnesota get a piece of the action when the federal stimulus funding starts being doled out later this year? Let’s hope so. More to the point, let’s hope local providers will receive some incentive payments for what they’ve already been doing. They’ve been at the forefront, bearing the brunt of the risk and the hard work so that others can follow after them – and this ought to be worth something.

West Central Tribune file photo by Bill Zimmer.