Physicians' EHR work-arounds

In early August, CMS Administrator Seema Verma called for an end to physicians using faxes to transmit patient data by 2020. While those outside of medicine wondered why she would want to ban a seemingly obsolete piece of office equipment, many physicians wondered how they would access patient records without it.

Yul Ejnes, MD, MACP, an internist in Cranston, R.I., uses his fax machine, EHR, secure email, or whatever it takes to get data on his patients. “The ideal scenario is all the EHR and other data sources would be interoperable and all the data would be accessible with a couple of clicks,” he says. “The reality is, depending on where else the patient has been seen determines how we go about getting information that is not generated in my office.”

A fact of life for many doctors is that, despite its inefficiencies, the fax machine is a vital part of getting the information needed to provide quality care. Other doctors may have some level of interoperability through their EHR, which connects them to physicians using the same software, and in some cases, to those using different EHRs. In states with robust Health Information Exchanges (HIEs), doctors may be able to get patient data from a variety of sources-as long as they participate in the system. But for the vast majority of physicians, the fax machine still plays an important role in obtaining patient information.

Getting patient data into their EHR is rated as a major problem by respondents to the 2018 Medical Economics EHR survey. When asked about importing data into their system, 61 percent of doctors rated their software as a five or less on a scale of zero to 10, with 10 being excellent; 14 percent rated theirs a zero.

Even for those fortunate enough to have access to most or all data their patients generate at hospitals, specialist visits or labs, challenges remain. “Not all data is created equal,” says Robert Tennant, MA, director of health information technology policy at the Medical Group Management Association. “If all the information looks the same, you can have trouble discerning what’s critical. Does an emergency room doctor have time to read 500 pages of data created from over a decade of the patient seeing different doctors? No.”

So how are doctors getting the patient data they need when they need it? Medical Economics talked to doctors on the front lines-as well as those working on the technology meant to help them-to find out.

Here are their stories.

Yul Ejnes, MD || Internal Medicine, Cranston, R.I.

For one large health system, Ejnes can access the hospital notes through its EHR, even though it’s not the same one his office uses. But for other area hospital systems, he has to rely on someone to fax him the notes on a patient.

“Some labs and diagnostic imaging can be accessed through the statewide HIE, and in Rhode Island, we have a pretty good one,” he says. “All the labs share data through the exchange.” But he notes that this manual retrieval takes time.
“It’s a matter of opening a browser, logging in with a password, and getting the info,” he adds. “It then has to be printed out and scanned into our records. Even when the data is electronic, you have to use multiple portals and passwords.”

Ejnes estimates 70 to 80 percent of the information he needs can be accessed through his EHR, but the remaining data doesn’t get to his office on its own and requires checking portals or making phone calls to track it down. “There’s a lot of old-world stuff that goes on to get the information we need,” he says.

Finding the data consumes hours of his staff’s time each day, and if the office doesn’t know about a patient’s ED visit, for instance, they won’t even know to look. “Often, we don’t know something happened until a patient tells us,” says Ejnes.

While he’s hopeful that interoperability improves, he says it’s also important not to forget the human factor. “It has to be embedded in our DNA as physicians to share information with those who need it,” he says. “This has to be of importance to the doctor, hospital, specialist, or urgent care or it won’t happen.”

Darren Sommer, DO || Internal medicine, Jonesboro, Ark.

Sommer provides telemedicine services to hospitals, and many are not on the same EHR he uses. Accessing the data he needs may require some searching. “Even within the same health system, a patient may have disparate records,” he says. He focuses on trying to obtain the most relevant information in whatever system it resides, which may require converting data to a PDF format or having someone print out the information and transmit it by fax.

And even if he can locate the appropriate patient record, finding the specific information he needs is often frustrating. “There is so much data and a limited amount of time,” says Sommer. “I might need EKG results and have to search in the cardio tab in one EHR, but now it’s in the procedures tab or some other location in another EHR. Even in one system it can be difficult to gather the information you need.”

Despite the challenges of EHRs, he says that using paper charts wasn’t ideal either. For a patient with complex conditions, a doctor might only have the most recent record and not the whole picture, while today there is a better chance that the attending physician can access either the entire record or the relevant parts of it. But much work still needs to be done to make the software more useful.

“A lot of these systems were created 10 years ago,” he says. “A lot of the systems sold to practices today have had marginal improvements, and I’m not sure we’ll see a dramatic change in the way they are accessed or used.”

Linda Delo, DO || Family medicine, Port St. Lucie, Fla.

The goal may be to eliminate the fax by 2020, but unfortunately I don’t think we are even close to that,” says Linda Delo, DO, a primary care physician in Port St. Lucie, Fla., who says getting patient records from specialists via fax is commonplace.

Delo has had a mixed experience withlocal hospitals in tracking the care herpatients have received. With one hospital, communication of patient data is relatively seamless. “Every time a patient visits the ED, the details are downloaded into our system,” she says. “When they are in the hospital, I get daily notes so I know when to dofollow-up and we really have excellent continuity of care.”

One of the reasons she chose her EHR was based on the local hospital’s use of the same system, which helps her stay updated on her patients’ status. The same can’t be said of her experience with another local hospital. “It’s horrible-I’ve had patients come out of there and I cannot get the ­records.”

Her solution is to talk to the hospital administrator when necessary but also to ask her patients to have any outside providers  send their records back to her.

A third hospital has a portal she can access for updates, but doing so takes a lot of time. The data isn’t “pushed” to the doctor; the doctor has to search for it. “For me to remember which person went to that hospital isn’t realistic, and I would have to go into the system each day to see which new test results are out. It’s very cumbersome,” she says.

Florida has an HIE, but Delo hasn’t used it because it has the same limitations as the hospital portal and would require too much time. Overall, she hasn’t seen much progress on interoperability in recent years.

“In some areas of the country, where everyone is probably on the same system, interoperability is probably great,” she says. “In areas where people are on different systems, the communication is probably poor and difficult.”

Cole Zanetti, DO || Family medicine, Arvada, Colo.

Zanetti sees the challenge of getting patient data from both the practice and the IT side thanks to his work with the informatics arm of the American Osteopathic Association. “The idea of interoperability is frustrating for providers,” he says. “It seems like it would be so easy to lift the veil and share information, but privacy and security are legitimate concerns that make it difficult to do.”

And because of this difficulty, the fax machine still rules the day. “I’ve seen organizations struggle when their fax machine isn’t working. Maybe it’s missing toner or needs maintenance because the volume on the receiving end is so high, but it’s absurd that this is what we need to be concerned about.” Beyond faxing, he says much of the burden falls on the patient to make sure their records get transmitted to their primary care physician.

One of the drawbacks to EHR printouts is that older patients’ records might include as many as a thousand pages. “If someone drops some pages or doesn’t include them, is anyone even going to notice?” says Zanetti. “I wish I could say there is a portal that we could have on every EHR that is national and you could just click a button and request information.”

But even if such a system existed, that thousand-page record presents a new challenge: No one has time to read it all to find the relevant pieces. “AI programs are being developed to read records, but if we don’t have a way to process the data, we certainly don’t have time to read it all. It’s a wicked problem.”

Bruce Bullock, MD || Family medicine, Rutland, VT. 

Bullock gets some patient data from his EHR, but he doesn’t get all the notes from specialists or the local hospital, leaving him with an incomplete picture of his patients’ care. “With everyone moving to the electronic world for data, interoperability has not kept up,” he says. “As a primary care physician, I still can’t get my hands on the information that is out there.”

And while Vermont has an HIE with a portal, he has to go into the system and look up the information. “You have to know what you are looking for and go get it instead of the information coming to me,” says Bullock. “I feel like we have benefited a great deal from electronic records, but the information in the system is not complete nor is it going to be complete anytime soon.”

To fill in the gaps, his staff faxes requests to specialists his patients have seen, but this can require multiple steps and authorizations before the records are finally released, and they actually need to know the patient received care outside the practice. “When you have to ask the patient, it doesn’t make you look informed, it doesn’t make the institution you are asking about look good and it doesn’t build confidence in the system. It’s inefficient.”

Daniel Kendrick, MD, MPH, FACP || Internal medicine, Tulsa, Okla.

Kendrick is the CEO of MyHealth Access, a nonprofit health information network focused on ensuring every Oklahoman’s health record is available to those who need it. “On average in Oklahoma, only 30 percent of patients have all their data in one place, and 70 percent have it in two or more,” he says. “When I’m seeing patients, that means I have a 70 percent chance of missing important information if I’m not connected.”

Prior to MyHealth Kendrick, like many doctors, would find out from his patients about an ED visit, often with little detail. “They knew they got medicine, but couldn’t remember what it was,” he says. “We would have the patient sign a release and fax it over to the hospital, wait a couple of weeks for the information, then the patient would get care. If the issue was acute, then I would have to guess and treat them, possibly repeating tests.”

The HIE, which includes about 5,000 doctors and 70 percent of the hospital activity in the state, pushes most data out to the primary care physicians’ EHRs when someone is hospitalized. Kendrick recognizes that doctors need the data delivered to them and shouldn’t have to go looking for it, but not all EHR vendors cooperate in that regard.

“The data should be teed up in the doctor’s workflow,” says Kendrick, but the EHR has to allow data to be downloaded from the HIE, which doesn’t always happen. “I consider that inbound data blocking,” Kendrick says.

While he says tremendous progress has been made toward interoperability across the nation, more work remains, including training doctors to know how to find the information that’s available to them. But regardless, doctors need to be leading the process. “As clinicians, we need to drive the conversation and be clear on what we want and how it should look and vendors should be held to that,” says Kendrick.

Daniel Carey, MD || Cardiologist and secretary of health and human resources for Virginia

Carey is charged with overseeing ConnectVirginia, the HIE system linking all the EDs statewide. The initiative started as a way to track frequent users of EDs to reduce duplicative services and provide ED doctors with all the background information they needed to effectively treat the patient. As the program proved successful, it has expanded.

“Why not move the information downstream to providers that allow a whole community of care where they are being seen, allowing them to address any red flags there?” says Carey, noting this is exactly what Virginia has done.

The HIE integrates an alert into the EHR, so doctors are notified about ED visits as part of their normal workflow, and all emergency departments are required by law to participate. Carey says the ease of use is why the system has proven so popular. “It is getting the information to the clinician using it, right there when they need it,” he says. “It’s right there, and that’s the key.”

He also credits a design that was focused on the needs of doctors in the ED. “If you design it right, you don’t have to sell the concept to doctors. People will be asking you how to expand it,” he says.

Melissa Kotrys, MPH || CEO, Health Current, Pheoniz, Ariz.

Kotrys says before Health Current, Arizona’s HIE, health records were being exchanged primarily by fax and phone. But as more providers moved to EHRs, the need for connectivity increased. Today, the system has over 500 healthcare organizations participating, representing 95 percent of inpatient discharges in the state.

“Without the information available through the HIE, doctors may not know that certain tests were done in different organizations,” says Kotrys. “From a care coordination standpoint, just knowing their patient is in the hospital or a high-risk patient is visiting the emergency department has allowed doctors to intervene to get them to a more appropriate care setting.”

Health Current uses a combination of alerts that are pushed out to doctors’ EHRs as well as a portal where more detailed information is available.

“In Arizona, we have had a lot of success in bringing together organizations that compete in other aspects, but recognize they shouldn’t compete when it comes to sharing information,” she says. “Sharing improves safety and care and we have a lot of support from the community.”

Teresa Rivera, MBA || CEO, UHIN, Salt Lake City, Utah

UHIN is Utah’s HIE, and connects 92 percent of hospitals in the state to primary care practices, skilled nursing facilities, and even therapists and paramedics. Rivera says the goal of the organization is to get the information providers need with a minimal of effort on their part.

“Where we can connect with their EHR, we want to push the data through that,” says Rivera. “Ideally, when a patient comes to a clinic and registers, their system will call our system and we can push them a summary of all the information we have.”

Before the system, she says fax was the primary method of data exchange. “Trying to get doctors to take the fax out of their workflow is one of the things we work hard on,” she says.

Part of the challenge is that early on, the system didn’t have as many participants as it does today, so physicians may have tried it eight years ago and dismissed it as not meeting their needs. “Because we are adding new data sources every week, it is an education process with them,” she adds.

Rivera recognizes the challenge doctors face with receiving too much data, so they are working on the best way to filter the most relevant data out of a larger health record. “It’s a matter of all data versus important data,” Rivera says. “How can we filter so that it is the right amount of data needed for the physician to treat the patient?”