Article

May 20, 2015

EHRs' broken promise

Electronic health records (EHRs) promised to revolutionize healthcare delivery. In some respects, they have. But for physicians deluged by patients, EHRs have yet to fulfill their lofty promises and, in many cases, have added considerable strain to the daily workload of physicians. In this article, physicians discuss with Medical Economics how EHRs should-and must-improve to reach their potential.

Electronic health records (EHRs) promised to revolutionize healthcare delivery. In some respects, they have. But for physicians deluged by patients, EHRs have yet to fulfill their lofty promises and, in many cases, have added considerable strain to the daily workload of physicians. In this article, physicians discuss with Medical Economics how EHRs should-and must-improve to reach their potential.

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Jeffrey Pearson, DO, a family physician practicing in a 70-doctor group in the San Diego area, regards himself as a tech “geek.” He has used two different EHRs over a period of six years, and he says he received adequate training on his current system. Yet he is frustrated because, except in the simplest encounters, he can’t finish his EHR documentation by the end of each visit.

“I saw patients all morning, and some were fairly complicated, and with an EHR there’s no time to do your full charting when you’re in the room,” he says. “All the patients get backed up if you do. So I’ll probably take two or three hours at home to get caught up on charting, and that certainly isn’t reimbursed.”

Many other doctors are similarly frustrated. A recent high-profile RAND Corp. survey found that for many physicians, “the current state of EHR technology significantly worsened professional satisfaction in multiple ways.” Among the aspects of EHRs that displeased doctors were “poor usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information, and degradation of clinical documentation.”

On the other hand, only 20% of the survey’s respondents said they wanted to go back to paper charts, and few physicians actually do that, observers say.

“No way would I go back to paper,” declares internist Yul Ejnes, MD, MACP, who belongs to an 80-doctor group in Providence, R.I., and is a former board chair of the American College of Physicians (ACP). “I think EHRs are our future, and we went electronic in 2006, before the feds were paying for it, because we saw value in it. But a lot of our needs have changed, and the current products don’t meet them. The issue of the user interface needs to be addressed.”

“To most doctors, it’s apparent that EHRs are better than paper,” says Robert Wachter, MD, a professor of medicine at the University of California, San Francisco. “But it’s also clear to many doctors that there are losses they’ve seen as they’ve gone digital, and the systems need to be and can be much better.”

Not all of the problems can be traced to poor EHR design, experts and physicians say. Regulatory compliance and billing needs account for some of the difficulties that physicians encounter when they use EHRs. But there’s a general sense that EHR vendors could do more to deliver innovative applications that meet users’ needs and help them improve quality, safety and efficiency.

Many doctors are disappointed that EHRs have not fulfilled more of their promise in these areas. But 54% of physicians believe that their systems have helped them improve quality, according to an exclusive Medical Economics survey, and some studies support that perception.

“There’s some reasonably persuasive evidence that health IT has improved quality and safety-although there certainly are examples of new safety and quality problems that have emerged because of technology,” says Wachter, author of “The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age.”

Where the promise of EHRs has been largely unrealized, he says, is in efficiency. A RAND study conducted in 2005 predicted health IT would save upwards of $80 billion a year, he recalls, “but those savings have been elusive. When you look at studies that ask whether computerization has saved money, the answer mostly is no. And most doctors will tell you they’ve become less efficient in their practice since adopting EHRs.”

Mark Anderson, FHIMSS, a health IT consultant in Montgomery, Texas, points out that most physicians never see more patients than they did before they got EHRs. “The best we’ll get back to is neutral, which would be great. There will never be any productivity gains for the doctors, although there are time savings for nurses.”

Some physicians do find that EHRs make them more efficient. For example, Edward Gold, MD, an internist in Emerson, New Jersey, says his EHR makes it easier to locate patient information and to place and track orders. Ejnes, similarly, says his medication and problem lists are far more up-to-date than they were on paper.

But the general view is that the current EHRs are clunky, cumbersome, and difficult to use, regardless of how tech-savvy their users are. What follows is a dissection of what’s wrong with EHRs and what might be done to improve them.

NEXT: Billing and compliance

Billing and compliance

At the heart of physicians’ complaints about EHRs is their method of documenting visits and services, which is based on “point-and-click” templates. On average, Anderson says, it takes physicians nine times as long to enter data in a template-driven system as it would take them to dictate a note. Of course, physicians who dictate their entire note aren’t putting anything in the EHR’s data fields. But how much structured data do physicians really need to input into their EHR?

Billing and regulatory compliance determine that to a large degree. EHRs were sold to physicians as a way to help them improve their documentation so they could bill at a higher level, Ejnes points out. “That was part of the return on investment.” The increased charges, along with lower labor costs tied to reduced record handling, helped his practice pay for its EHR system within a couple of years.

The improved documentation, however, came at a cost. The Medicare evaluation & management (E&M) coding system, which private payers also use, requires doctors to meet certain requirements known as “bullet points” to justify their E&M codes. To do that in an EHR, physicians have to document encounters in the EHR templates by checking off pull-down boxes. Some of those templates are highly complex and detailed, and thus slow doctors down.

The problem has become sufficiently acute that the ACP, in a recent white paper, asked the Centers for Medicare and Medicaid Services (CMS) to consider revising its E&M coding guidelines. The ACP said the current system distorts documentation by forcing physicians to “backfill” their electronic notes to meet the bullet points rather than focusing on actual clinical issues.

And that’s only the beginning of the external mandates that have been placed on physicians since EHRs started to become widespread. The Meaningful Use incentive program, the Physician Quality Reporting System, the Value-based Modifier program, pay for performance, and accountable care organizations all require structured electronic data. So do quality improvement, care coordination, and health information exchange, all key ingredients of healthcare reform.

“The doctor’s note has become a Christmas tree on which too many ornaments are hanging, because the note has morphed from what used to be a clinical communication to your colleagues or yourself to billing, malpractice prevention, regulatory requirements, and other things,” Wachter says. “It makes the doctor’s work untenable.”

Pearson agrees. “There are things that doctors are doing just because they’re told to. We’ve become professional dialog box openers and closers. You’re not practicing medicine, you’re practicing computer-ese just to bill and get reimbursed,” he says.

Sarah Corley, MD, executive committee vice chair for the HIMSS EHR Association, a leading EHR vendor trade group, argues that outside demands are the major cause of physicians’ difficulties with EHRs.

“What we often see is that the physician ends up with the burden of documenting all of this additional information required for compliance,” Corley says. “That’s why they have longer days, less time to interact with patients, and more unhappiness.”

NEXT: Templates and customization

Templates

But even if physicians had less to document for compliance purposes, they would need some structured data to help them keep track of problems and medications, to alert them to allergies and potential drug interactions, and to provide health maintenance reminders, among other things. Unfortunately, the only reliable way for doctors and other clinicians to create structured data in today’s EHRs is to use point and click templates.

These templates are designed for various symptoms, chronic conditions, and portions of the exam. To some extent, they’re also differentiated by specialty. However, many EHRs are primary care oriented, making the process difficult for other specialties. In orthopedic offices, for example, patients usually get an x-ray upon arrival, Anderson notes. But EHR templates typically require a doctor to examine the patient first, then order the x-ray to rule out or select a particular diagnosis.

Customization

Templates can be modified to match a physician’s practice style, and Ejnes says he has tweaked many templates in his EHR over the years. But depending on the EHR, it may be difficult for physicians to customize templates on their own.

Some of the doctors in Pearson’s group worked together to customize their EHR, and they did a pretty good job, he says. Even so, there’s too much involved in documentation for him to finish during complex encounters with patients. If he clicks on the wrong box, for example, he has to wait for the EHR to perform the action, erase what it did, and then click the right box. That can take a great deal of time.

Also, when Pearson has to document a patient’s depression or some other condition, the questions in the EHR template for that condition may not fit the patient’s case. His EHR provides a box that lets him type in one sentence of personal observations. If that’s not enough, he generates a new reason for the visit and types a free-text paragraph about the patient’s problems.

NEXT: EHR workarounds

Workarounds

These kinds of EHR workarounds are endemic throughout healthcare.

A study published in the Journal of the American Informatics Association on EHR use in primary care clinics found that clinicians used various workarounds to increase efficiency or because certain functions needed to accomplish their work were missing from their EHRs. These ranged from paper reminders to printouts from the EHR to entries designed to shut off annoying alerts.

The study classified the practice of copying and pasting portions of past notes into current ones as a workaround, but this is a method widely used to increase the efficiency of documentation. Although the government has raised questions as to whether some physicians employ “note cloning” to commit billing fraud, doctors view it as a completely legitimate way to cut the amount of time it takes to document a visit.

Gold, for example, sees no reason not to copy a family history, which is unlikely to have changed much. But experts warn doctors to check anything they forward from a previous note carefully to make sure it’s still accurate.

Note bloat

One downside of copy-and-paste is that it increases the amount of documentation in a given note, which can lead to “note bloat.”

Other factors contribute to note bloat, such as templates generating long sections of repetitive text related to normal findings in physical exams. Whatever causes it, this is a characteristic of EHR-generated notes that causes great frustration among doctors. Overlong EHR records, they say, are impossible to read and make finding essential information difficult.

Making things worse, Wachter points out, is that most EHRs have only rudimentary search capabilities.

Some vendors have addressed the problem of note bloat by providing multiple versions of documentation. But some physicians don’t like this idea. While current EHR notes read like the fine print in a credit card application, Ejnes says, it should be possible to create a single, readable note that serves as a clinical record, an audit tool and a medico-legal document.

Corley observes that if some physicians didn’t click all the boxes in their templates, there would be far less note bloat. While EHR vendors try to include 80% of documentation for all visits in their structured fields, she estimates, only 30%-40% of any given visit needs to be documented that way.

Many physicians enter far less structured data. Some of Ejnes’ colleagues enter everything in templates, he says, while others dictate everything and have their staff insert the transcription into their notes. Ejnes uses voice recognition with HPIs and assessments, so those portions of the note look more like his pre-EHR notes. Other physicians have found their own ways to personalize their notes so they don’t all look the same.

NEXT: Natural language processing

Less structured data?

EHR vendors increasingly are addressing the issue of structured data entry, and reconsidering their approaches to product design.

“It’s important and necessary to have structured information for some of the things where we need to collect data or drive decision support,” Corley says, “but there’s always a place and a need for free text, particularly in the HPI, so you can get the context and the flavor of it.

“Vendors and providers are working together to identify the areas where it’s fine to use structured text and where you might have more flexibility to tell the story in prose,” he adds.

Natural language processing

For as long as there have been EHRs, physicians have hoped that someday, they might just dictate their notes and have the EHR convert their speech into structured data. The technology to do that, known as natural language processing (NLP), has advanced quite a bit in recent years. But experts agree that it’s still not ready for use in medicine.

“Natural language processing is promising but not quite ready for widespread adoption,” says Corley, citing safety risks if the program misinterprets the data. Initially, she predicts, the technology will probably be used to extract EHR data for quality reporting, where safety isn’t an issue.

Peter Basch, MD, medical director for ambulatory EHR and health IT policy at MedStar Health in Washington, D.C., and chair of the ACP’s medical informatics committee, agrees that NLP poses a safety risk in its current form. “If I’m busy and distracted and behind, as docs always are,” a data point might go in the wrong field or be the wrong number, he says.

Nevertheless, Gold believes that, in the long run, NLP is the way to go. “If they can get software that recognizes structured data in dictation to work, NLP would overcome a lot of the problems we have with EHRs,” he says.

NEXT: Patient data entry

Patient data entry

Other alternatives are available. For example, physicians could save time on data entry if they enlisted their patients or medical assistants to enter some of the information, says Basch.

If a urologist has to enter data about common issues such as incontinence or BPH, he notes, he or she feels like a data entry clerk. But if a patient answered questions in an online survey, and the physician could just look at the data and interview the patient, it would be better for both doctor and patient, he says.

Computerized surveys for collecting data on family and social histories and the history of present complaints have existed for years. Some applications have tried to interface these with EHRs, but have not yet caught on. “Maybe it was a good idea that was ahead of its time,” Basch says.

But Gold takes a dim view of having patients enter this kind of data ahead of visits, for two reasons. First, he doubts that many patients would do it, and second, he believes that he could get all the pertinent data out from a patient in five minutes of questioning, which would be more efficient than having the patient fill out a survey.

As for having clinical staff enter some of the data, he says that medical assistants can take some of the social history, such as a patient’s smoking or drinking, but they’re not qualified to document a history of a medical problem.

The industry’s alternative to having nurses enter some of the note is to have scribes follow doctors around and input their findings. An estimated 20,000 scribes are working in offices today. But scribes cost money, and a recent JAMA commentary noted that they might impede the further development of EHRs. Says Wachter, “Only in healthcare can we computerize and add full-time equivalents.”

Regardless of how long it takes to make EHRs more useful and usable, there is also agreement that physicians eventually will accept the technology as part of their daily work. It won’t be easy, but it has to happen, if for no other reason than that healthcare reform cannot proceed without EHRs.

“As time goes on, physicians will accept EHRs,” Gold says. “Most of them have done that already. Whether they like the EHR or not, or whether they’re new to it or not, most of them have accepted it.”

NEXT: The top 10 EHR implementation challenges

Physicians identify the top 10 EHR implementation challenges

Excessive physician and staff time to implement

Disruption to practice

Concern with the time it will take to implement and be eligible for meaningful use

Concern with staff skills and ability to implement

Unexpected costs for associated hardware

Unexpected costs to implement the basic system

Concern of system quality

Concern with vendor quality and support

Unexpected costs to customize the system to a practice’s needs and requirements

Unexpected costs to maintain the system and keep it function

Source: Medical Economics EHR Best Practices Study

Tips to improve EHR workflow processes

Once you’ve found and use an electronic health record (EHR) system that disrupts your workflow the least, the next step is to examine workflows most affected by the EHR and establish a plan of action, according to Robert Rowley, MD, a practicing family physician and healthcare information technology consultant.

Identify a workflow process that needs to be adjusted.

Chart the steps in the process, and determine where the pain points exist and possible solutions.

Determine whether to phase in those adjustments to the workflow or implement them simultaneously.

Continue to refine efficiency and workflows based on the accumulating experience with the EHR.

Consult outside experts, but with caution. Your EHR vendor, for example, knows their system better than how your practice works. When it comes to workflow, no one knows your processes better than your staff.

Source: Robert Rowley, MD; Rosemarie Nelson, MS