For more than 6 years, the federal government has rewarded physicians and hospitals who use electronic health record systems. Pressure to use such systems will only increase - officials have called for "full interoperability" by 2024. But few doctors have fully embraced EHRs, according to data released by the CDC's National Center for Health Statistics. While four out of five physician offices have EHR systems, the survey showed, fewer than 9% of physicians reported using all the major capabilities over the course of 2015.
Sending and receiving patient health information with other providers via EHR was the most common use case, with 38% of doctors reporting one or the other. Some 30% said they had imported patient information from another source into their EHR system. Perhaps most surprising, only about one-third said they ever searched for health information online when seeing a new patient or referral. From state to state, this use of digital technology varied considerably. More than 60% of doctors in Oregon searched for health information online, which led the nation. At the other end was Washington, D.C., where the rate was just 15%.
The map below shows the percentage of physicians in each state who reported "electronically search[ing] for patient health information from sources outside [their] medical organization." Click on a state to see more detail.
Now that the digitization of healthcare information has evolved from a preference to a mandate, healthcare providers face the need to make ""Meaningful Use of EHRs or lose existing Medicaid and Medicare reimbursement levels. At the same time, healthcare entities must choose the right EHR platform — a seemingly overwhelming decision because of the number of choices, the ever-changing identities of vendors and the limited interoperability with third-party systems.
In light of the inevitable downsides of digital — server outages, dropouts, potential data loss, manual data entry, and more— having the proper knowhow to manage and negotiate a relationship with vendors is more important than ever. Many providers are finally dipping their toes into the digital age or experiencing a system change, presenting a prime opportunity to reevaluate their contract. But first, there are a few points to consider.
Who's in Charge?
At the start, you need to decide who will be representing you in the contract negotiation. Many delegate the process to practice administrators or managers. However, the right team should include tech-savvy individuals experienced with digital medical records who have a vested interest in the well-being and security of your practice. An attorney does not always have to be involved in the early stages of EHR contract negotiations, but the sooner you consult a legal advisor, the better. Choose a decision maker with relevant skillsets and knowledge who you can also trust.
Old or New?
After you decide who will take the lead, the next step is to identify whether to modify your existing contract or switch to a new provider altogether. While it is tempting to start afresh, remember your EHR vendor controls invaluable patient information. If your first contract was not negotiated well, it may contain vague, vendor-friendly rules dictating how your patient data is returned to you.
Retrieving data from a vendor can be similar to negotiating a hostage situation —especially in financial disputes where a vendor may be expecting payment withheld due to unmet expectations. In these scenarios, it is difficult — if not impossible — to ensure data is returned in a useable format.
Therefore, even if you stay with your current vendor, consider reviewing your contract and amending it with verbiage which will work in your favor when switching vendors in the future. Be sure to clarify how a data conversion should be handled. If a vendor will not incur additional costs, they should agree to your conditions.
Below are two examples of contract language detailing data conversation requirements. The first example is "vendor-friendly," while the second is notably more "client-friendly."
#1: Upon termination, Vendor shall deliver to Client, after full payment of all fees owed Vendor, a download of the Client Data in a commercially reasonable electronic format determined by Vendor. Additional programming costs associated with such download shall be set at Vendor's then-current list price.
#2: Upon termination, Vendor shall deliver to Client a final CD in ASCII Format (or mutually agreed upon alternative format) with fixed length data elements or comma delimited data elements (or mutually agreed upon common file delimiter.) Notwithstanding the foregoing, Client may request that any Client-related information be provided by Vendor to Client in other commercially reasonable formats selected by Client. If Vendor can provide the requested information in such other formats without having to incur additional material costs, then Vendor shall comply with such requests. If Vendor cannot provide the requested information in such other formats without Vendor having to incur additional material costs, Vendor shall notify Client of such costs (using its lowest available rates) and only be required to provide the requested information in such other formats upon Client's payment of same.
Even with the best contract language in place, it's ultimately unclear what will be needed in five years' time. This is why it's always a good idea to build flexibility into a contract's language. Additionally, you can negotiate on the front-end to receive periodic downloads of your data in a user-friendly format.
Effectively Managing Costs
When negotiating contracts, don't accept fees without fully understanding what services those fees include. Take the chance to understand and tailor your vendor's fees and services to your specific needs. Common types of fees include:
For instance, a vendor's consulting fee may only cover a few hours of communication. If you anticipate needing more consultation time, consider negotiating to increase the hours or services covered. Additionally, your practice will likely experience workflow interruptions when migrating to a new vendor so consider negotiating a fee for productivity lost. This line of thinking also applies to network errors and downtime. If a practice cannot function due to a vendor's error, the vendor should be responsible for reimbursement.
It is also possible to limit vendor fee increases by setting percentage/CPI caps or limiting frequency of increases. Increases are often related to system upgrades, add-ons, new equipment and staffing needs. Also, review whether your contract stipulates your provider will automatically update software in compliance with changes in law at no cost to you. Know where your risks are and limit them with the help of an attorney.
Use Your Knowledge
Negotiating a beneficial EHR contract can be a tricky process, and healthcare attorneys understand better than anyone how frequently the legal environment can change. However, if you take your contract process step-by-step with careful attention to detail, you should be able to create a relationship with your EHR provider that fairly and fully services you and — most importantly— your patients.
As more physician practices merge or consolidate the question of how to integrate electronic medical records becomes increasingly important."You've heard the three lies. The check's in the mail. I'll respect you in the morning. And this EHR merger will be seamless," said Jacqueline Fincher, M.D.
When Fincher and her husband joined her father-in-law's solo physician practice McDuffie Medical Associates in Thomson, GA, in 1988, there was no electronic medical record. Her father-in-law used 5x7 patient card files to document individual medical records. The practice graduated to 8x11 cards soon after her arrival, then to templated notes a decade later. Finally in 2006, they invested in an electronic health record from a Top 5 vendor. In April 2015, when the "mom and pop" four-physician practice merged with a physician-owned group of 30 other clinicians, they anticipated integrating their EHRs would be easy. The two groups shared not only the same EHR vendor, but had the same version with the same update.But when Fincher's practice contacted the vendor, it didn't have a procedure to support such a merger. Fincher was dumbstruck. The vendor connect them with a third party that could build an interface to connect "their EHR to their EHR," she said, stressing the absurdity of the situation. The new physician group and its IT staff said it would deal with the vendor directly. "We were told, 'We will handle it. Y'all just work.' Wrong."
When the "go live" date came in June 2015, it was chaos. The EHR for all nine clinics slowed down and would sometimes freeze. The printers would disconnect from the system, attachments wouldn't open, and forms for the most common visit types were missing or difficult to find. In addition, every document received would appear to be new, as though I had never been signed off, which on top of the wasted time, was a liability for the practice. "Every problem [list], every medicine since 2006 came over as active," she said, meaning that it appeared patients were actively taking every medication they had ever been prescribed. "And just the frosting on the cake. They came over in Z to A order. "It took 2 and a half months and 10 different interfaces before their system was functioning smoothly. "The bottom line is, moving data is very difficult," she said, and it's expensive.
While Fincher's practice did not have to pay for new licensing agreements from a new vendor, because the other practice used the same vendor, the merger still cost $55,000 in new hardware (such as network cabling and interfaces), another $35,000 for new servers to increase capacity, and $100,000 in personnel time - and excluding the cost in physician productivity, which dropped by about half in the first month.The experience taught her some useful lessons in switching or merging EHRs, she told ACP meeting attendees. If a small practice decides to convert most of its clinical data it should leave at least 6 months to plan, Fincher said. And participating in the transition is critical. She advised physicians to form a "merger team" that incorporates management, administration, clinical staff, and physicians. Fincher suggested setting aside time each week for planning. Creating a to-do-list at each meeting and assigning tasks will ensure the most important planning activities get done.
Fincher outlined some key questions small practices must ask before any merger or switch.
In addition to carefully indexing all patient records with a master list, one of the most crucial aspect of merging EHRS is managing work flow, Fincher said. "Every single office has a different work flow for every type of encounter ... and you have to understand the differences," Fincher said. Similarly, it's important for the IT team to fully understand these differences in work flow either in a new EHR or in a new practice, she noted.
One seemingly minor difference between Fincher's practice and the new practice was the issue of when to order laboratory tests.Fincher's practice ordered lab tests several weeks in advance while the physician owned group ordered them the day of a patient's visit. In Fincher's practice these pre-ordered tests were marked "on administrative hold," while the new practice categorized their tests as 'in processing." The end result of these inconsistencies was that labs "on administrative hold" defaulted to "in processing" with a date at some point in the future, which confused the billing department.
For other practices planning an EHR merger, Fincher advised a site visit including all staff, so that members can see another practice's administrative, clinical and electronic work flows, and identify differences. Representatives of both practices should meet and determine the best work flow practices for the group. Once these decisions have been made, Fincher recommended, data migration should be tested on at least 50 charts of different sizes and complexities, and ensure that a clinician is viewing the results. She also recommends leaving the old system in place for at least a year for a practice to reference.
Implementation of the new ICD-10 coding system has been easier than most expected, but there have been a few hiccups, according to healthcare business consultants. For Chris Zaenger, of Z Management Group, in Elgin, Ill. and president of the National Society of Certified Healthcare Business Consultants, Y2K seems an apt metaphor for the initial concern over ICD-10 before it was implemented. "Y2K" is short for the year 2000, and in 1999, many in the computing world were concerned that computers across the globe - which often dealt with computer programs that only allowed "19xx" as a date variable - would malfunction when the year 2000 arrived. That concern turned out to be largely unfounded.
"We haven't really run into a lot of issues," said Zaenger, and he isn't seeing more claims rejected after ICD-10 than he would have expected, he said. However, there are a few minor problems, such as difficulty finding the codes within the software. Sometimes the answer is a software add-on. Other missing codes require a mental re-set.Physicians lost some of the nomenclature built into ICD-9, he said -for instance, the term "blackberry thumb" was used as a factor contributing to carpal tunnel syndrome.
David Zetter, of Healthcare Management Consultants in Mechanicsburg, Pa., said he has seen medical documentation reviews becoming "a little more frequent." While Medicare contractors said they would be flexible, at least initially, if a code is in the proper family, other payers have not been as forgiving, he said. "If you think of it from a payer's standpoint, their job is to keep their money." When a code isn't accurate, they can deny payment or "make you jump through more hoops" until you get it right, he added. Physicians and other staff do sometimes struggle to find the right codes, Zetter noted. In the past, his company has placed laminated sheets in every room of a facility with the most common codes used by one set of physicians, because that's simpler than scrolling through a bottomless drop-down menu.
Robert Tennant, of the Medical Group Management Association (MGMA) here, highlighted productivity concerns. When physicians have to spend their time looking for the appropriate code, "That's time away from seeing other patients."But there have been positive, unintended consequences of ICD-10 too, he said. "Clinical documentation itself has improved." To find out about ICD-10's affects in the hospital world, Seth Avery, JD, of AppRev, a healthcare business consultancy in Temple, Texas, surveyed 40 hospitals to assess the financial impact of the new coding system on denial rates and other metrics. The survey, which is still ongoing, matched data from the final ICD-9 period, which began in July, to the first ICD-10 claims period, which began Oct. 1.
The results showed little variation in the amount of cash on hand, and the number of patients whose claims were slowed by the transition. Or in claims speak, the "discharged not final billed" number revealed a "small spike" in October that dropped to pre ICD-10 levels by December. Changes in authorizations denials were similarly negligible. However, medical necessity denials increased for all 40 hospitals surveyed, and in a few cases doubled. These are claims submitted to show the reason for a service or procedure - i.e., a chest x-ray for a patient diagnosed with tuberculosis. While Avery did not share the exact number or rejected claims pre- and post- ICD-10, he said "We're talking about thousands" of rejections. Errors in Medicare's national coverage determinations which have since been corrected, and problems with some local coverage determinations, may be partially responsible for the rise in some rejected medical necessity claims, but not all, he noted. Tennant, of MGMA, said he had also noticed earlier a spike in denials from Medicare contractors, but added that the problem appeared to have been fixed.
Avery credits the overall positive picture - the absence of any significant slowdown in production or shortage of cash on hand for hospitals - to time spent preparing for the transition by increasing staffing, training, and for some hospitals, securing lines of credit. The idea of comparing concerns over ICD-10 to Y2K irks Avery. Instead, he said, "It wasn't an issue because of all the work we did."Overall, the fury over ICD-10 seems to have been replaced by begrudging acceptance. One doctor told Zaenger, "We're just manning up to it." Zaenger added, "They understand it's not going away and they're trying to work their way through it."
The CMS has made it easier for providers to opt out of meaningful use requirements in the federal electronic health record program. In December, a new federal law authorized the CMS to batch process hardship applications by categories instead of the case-by-case method previously used. To comply with the law, the CME has posted a new streamlined hardship application, reducing the amount of information that providers must submit to apply for an exception. The CMS has also made it easier for whole groups of providers to waive out by allowing them to apply for hardship exception on a single application.
Interoperability remains a key issue for increasing use of
electronic health records, according to several experts who testified
before a Senate committee.
"The current health information technology ecosystem continues to be
challenging for healthcare providers due to lack of interoperability
among various health IT systems," Craig D. Richardville, MBA,
senior vice president and chief information officer at the Carolinas
HealthCare System in Charlotte, N.C., told the Senate Health, Education,
Labor and Pensions Committee at a hearing Wednesday on health information exchange. "The cost to build, test, and maintain integration and interfaces is significant."
co-founder and CEO of Cerner, a large health IT company in Kansas City,
Mo., said that his wife Jeanne was diagnosed with stage 4 cancer in
2007, "and my version of [her medical records] are bags and bags. I
think it is a failure of all of us [that] in 2015 ... Jeanne carries
bags to doctor's appointments where she is going to see new doctors or
specialists. Interoperability is high on my list, both professionally
and personally, to fix."
One in a Series
Wednesday's hearing is part of a series of health IT hearings that
the HELP committee is holding to try to spur more use of health IT,
especially electronic health records (EHRs). The government's Meaningful
Use program -- which was launched in 2009 to financially reward
doctors and hospitals that make "meaningful use" of EHRs -- has
resulted in 456,000 physicians receiving some sort of incentive payment,
noted committee chair Sen. Lamar Alexander (R-Tenn.).
However, "the [Meaningful Use] Stage 2 requirements are so complex that
only about 11% of physicians have been able to comply so far," he said
in his opening statement. And because of the penalties imposed on those
providers who don't comply with Meaningful Use requirements, "this
year... 257,000 physicians who serve Medicare and Medicaid patients have
already begun losing 1% of [their] reimbursement, and 200 hospitals may
lose more than that."
"So we're trying to identify five or six steps we could take, working
with the [Obama] administration, to improve EHRs," he continued. "The
technology has great promise, but through bad policy and bad incentives,
it has run off the track."
Sen. Patty Murray (D-Wash.),
the committee's ranking member, said she knows that physicians have
been very frustrated with the Meaningful Use requirement. "We need to do
more to both set high standards and to ensure that providers have the
support and flexibility they need to reach them," Murray said. "We
should make sure systems developed by different vendors ... are able to
speak to each other [so] providers will have quick, easy access to
information about patients' unique medical needs."
"We also need to continue supporting the development of a network of
networks so providers will have many options for trustworthy information
sharing and don't have to reinvent the wheel every time they have to
exchange info with new facilities," she said. "We should look for ways
for providers to shop for EHR systems and vote with their feet if one is
not working. Finally ... we need to look for ways to ensure security
that stands up to our 21st-century challenges."
Hearing witnesses outlined other steps Congress and federal
regulators could take to increase providers' EHR use. "Relatively simple
steps could be taken to improve documentation requirements, such as
encouraging regulatory guidance that clearly delineates who is and is
not eligible to enter documents into the record for compliance and
reimbursement purposes," said Thomas Payne, MD, medical director for IT services at the University of Washington School of Medicine, in Seattle.
"Longer-term, Congress should develop policies requiring CMS [the
Centers for Medicare and Medicaid Services] to revisit the entire
billing and coding system that drives documentation for reimbursement
and compliance purposes," he continued. Congress should also continue to
promote the broad adoption of alternative payment models such as
value-based purchasing, so reimbursement is contingent on
outcome-oriented measures supported by less prescriptive requirements
Christine Bechtel, MA,
president of Bechtel Health, a consulting firm in Olney, Md., that
specializes in consumer healthcare issues, said that Congress could
start by helping to "rais[e] consumer and provider awareness about
[patients'] rights to their EHR ... We could also use a federal EHR
certification program to create the capacity of EHRs to receive
consumer-generated data, and make it easy for providers to analyze and
act on it."
Bechtel argued against a proposal by CMS to relax the Meaningful Use
requirement that a certain percentage of a physician's patients use a
practice's online access portal at least once. "The CMS proposal to drop
this threshold to a single patient will completely undermine efforts to
make consumer access to healthcare data the norm," she said.
Industry Cooperation Needed
In terms of making EHR data more interoperable, one problem is that not all EHR vendors are cooperating, noted Sen. Bill Cassidy, MD (R-La.).
He singled out one EHR vendor, Epic, in particular. "I feel like Epic
is the elephant in the room," Cassidy said, noting that the company
seems to feel "that a business practice which does not allow sharing
somehow furthers their business model, so if you want to share data with
another hospital that has Epic, you have to have Epic too, and they
have such market share that people will migrate [to them]."
Patterson confirmed that Epic did seem to use exclusivity as its
business model; however, he added that he is hoping Epic will join CommonWell Health Alliance, an industry group aimed at promoting interoperability, "and that we will work together as an industry."
Sen. Elizabeth Warren (D-Mass.) raised concerns about patient mismatches that could occur if EHRs become more interoperable. She quoted a 2008 RAND Corporation study
estimating that even with data management software and personnel
dedicated to solving the problem, hospitals still mismatch patient
information about 8% of the time.
Richardville said his healthcare system solved the problem by using a
biometric palm vein scanning system to identify patients. "We've had
that for many years, and since then, our medical record error rate is
0.11%, so at least within our system we've been able to mitigate that
As the hearing drew to a close, Sen. Alexander sounded amenable to the
idea of delaying implementation of some Meaningful Use rules that
physicians might find onerous.
"There's probably some downside to that, but something that seems to
have as much resistance right now, human nature tells me it may be
better to step back a little bit on at least some parts of rules, and
work with physicians and vendors and hospitals, take advice on how to
improve things, and once they're better accepted, go forward," he said.
"We don't want to lose the impulse to cause people to do this, but the
more important thing is to make sure to get it done in a way to cause
patients, doctors, and hospitals to look forward to the experience of
this system rather than to dread it."
Proposed changes to patient engagement requirements under the
federal government's Meaningful Use program are drawing praise from
physician groups but are disappointing patient advocates.
"Meaningful use" refers to provisions in the 2009 Health Information
Technology for Economic and Clinical Health (HITECH) Act, which
authorized incentive payments through Medicare and Medicaid to
clinicians and hospitals that use electronic health records (EHRs) in a
meaningful way to significantly improve clinical care.
Under the three-stage program, the current Stage 2 requirements call for
physician practices to show that more than 5% of all their patients
view, download, or transmit to a third party their health information
during a 1-year reporting period. Providers also must demonstrate that
more than 5% of their patients used the EHR's electronic messaging
function to send the provider an email message.
Challenges for Physicians
These requirements have proven challenging for many physician practices. At a hearing held in March by the Senate Health, Education, Labor and Pensions Committee, Robert Wergin, MD,
president of the American Academy of Family Physicians, gave the
example of how, with 2 hours left to meet a Meaningful Use deadline, his
staff discovered that he hadn't fulfilled the requirement involving
patients' use of email communication.
"I stopped what I was doing, called two patients and asked them,
'Could you send me a question about your labs?'" Wergin said. "I met
[the deadline] by the skin of my teeth. If they had not [participated] I
would not have met meaningful use -- it was 100% or 0%."
The requirements are particularly difficult for specialty practices, Robert Tennant, senior policy adviser with the Medical Group Management Association (MGMA) said, "If you're a primary care physician and you have an ongoing relationship
with patients, you could at least try to convince them to use your
portal," he said. But if you're a surgeon, "you're only seeing the
patient for 15 minutes and that's it -- you'll never see them again.
It's extremely difficult to convince them after the visit to log in,
create a username and password, and use one of the functions that count
toward meaningful use."
As a result of feedback it has been getting, the Centers for Medicare and Medicaid Services (CMS) has proposed relaxing those Stage 2 requirements. For the requirement relating to viewing, downloading, or transmitting medical records, the proposed rule
would require that at least one patient seen by the provider during the
EHR reporting period views, downloads, or transmits his or her health
information to a third party.
"This would demonstrate the capability is fully enabled and workflows
to support the action have been established by the provider," CMS noted
in the proposed rule.
For the secure messaging component, the proposed rule would "convert
the measure for the ... Secure Electronic Messaging objective from the
5% threshold to a yes/no attestation to the statement: 'The capability
for patients to send and receive a secure electronic message was enabled
during the EHR reporting period.'"
"These changes are intended to allow providers to work toward
meaningful patient engagement through health IT [information technology]
using the methods best suited to their practice and their patient
population," the agency added.
Providers, Patient Advocates at Odds
Those changes would be very welcome, said Tennant. "You can't force
patients with some sort of large stick to get on these portals," he
said. In terms of wanting patients to be able to access records and
communicate with providers, "Their hearts are in the right place [at
CMS], but I don't think the industry is quite caught up to where the
industry should be."
MD, director of the Alliance for eHealth Innovation at the American
Academy of Family Physicians, in Leawood, Kan., also praised the
proposed changes. "We think it's wonderful for the patient to email the
physician, but after you have an initial visit with your doctor, how
many times do you need to do a follow-up email with them?"
And, he added, "If you think about a rural area that doesn't have
full penetration of broadband ... say, even if just half your patients
have access to the Internet [so] they could send a message, and how many
of them come in and see you, and of those how many are interested in
sending a message, and of those how many have the need to send a
message? We have found that for many of our doctors, getting to 5% is a
However, while physician groups are happy with the proposed changes, patient advocates are not.
"The proposed modification to Meaningful Use ... is a startling and
unwelcome departure from the administration's commitment to healthcare
transformation that produces higher value, more patient- and
family-centered care," Debra Ness, president of the National Partnership for Women and Families here, said in a statement issued April 13.
"All of us who care about achieving the 'Triple Aim' -- better
care, better health and lower costs -- know that success depends on
patients being equal and engaged partners, true co-creators, of their
health and their care. This rule signals a turn in precisely the wrong
The changes to the rules for secure messaging and patients access to
medical records "would undermine the momentum to give patients tools
that would improve their ability to understand and manage their care,
communicate effectively with providers, and participate in efforts to
enhance coordination of care across settings and providers -- which is
essential to improving health and our healthcare system," Ness added.
What Practices Can Do
Patient advocate Jan Oldenburg
said in an interview that she understands the difficulties providers
have had in meeting these requirements, "but it's important to know this
isn't as much outside -- not just the physician's ability, but the
whole staff's ability -- to impact as it may originally seem."
"We have seen lots of evidence that the biggest predictor
of portal and email use is the physician's direct invitation to the
patient," said Oldenburg, a senior manager at Ernst and Young in Boise,
Idaho, who spoke while a public relations person was present. "It really
does ask you as a physician, as a nurse, as an organization, to look at
'What are the ways I could do more to encourage this? How could I
change workflows? Change scripts so everybody knows they've got a
"I know organizations that have done things like 'Surf the Web
Fridays,' where everyone wears Hawaiian gear and makes an effort to
encourage patients to register, or contests in clinics within a whole
system to see who can get the most people registered ... So it's a
combination of making it fun, making it an organizational initiative,
and how you want to support that with internal incentives and internal
Oldenburg also pointed out that CMS has written an amendment to
Meaningful Use that helps specialists and others who have difficulty
getting patients to register for online access; the exemption applies to
specialists and other physicians who contribute records to any sort of
health information exchange or any sort of community database.
"I'm Physician A, I contribute my records and Physician B does as
well. Then [my patient, who also sees Physician B] goes to look at their
record with Physician B, and I get the 'halo effect' of that."
The amendment "not only encourages the interoperability effort, but
also reduces the burden on the individual physician who feels they have
to make it all by themselves," she said.
Tennant noted that even if CMS does lighten up Stage 2
requirements, the proposed requirements for Stage 3 call for even more
engagement -- for example, the provider "must communicate with the
patient (or the patient's authorized representatives), through secure
electronic messaging for more than 35% of the unique patients seen by
the provider during the EHR reporting period," according to the proposed
For accessing the health records, the proposed Stage 3 rule
requires that 25% of patients or their authorized representatives "have
viewed online, downloaded, or transmitted to a third party the
patient's health information."
So between the proposed Stage 2 and Stage 3 requirements, "One hand giveth and one hand taketh away," said Tennant.
The AAFP's Waldren pointed out that the proposed secure messaging
requirement for Stage 3 is a little less onerous because it also counts
email messages that providers send to patients, not just those patients
send to providers. "I still think it's a challenge for doctors, but it's
not exactly the same," he said.
"Which electronic health record system should I select?" Among
physicians and managers in small-group practices today, there is no more
common question. And lately, another vexing question has emerged:
Whether to purchase or lease electronic health record (EHR) software and
install it on servers in your office, or subscribe to an Internet-based
system maintained in "the cloud."
What is 'The Cloud'?
When EHR vendors began
offering their products via the cloud, many physician practices may have
been puzzled. Some think that the cloud is simply technology parlance
for the Internet. In fact, it refers to a method of computing whereby
the critical applications are hosted remotely and accessed by end users
via the Internet.
Practices have long been accustomed to hosting critical software
applications on servers in their offices. After all, that is how they
have accessed their practice management systems - the IT backbone of
medical practices - for 20 years.
But a cloud-based EHR, where all the practice's data is hosted remotely,
raises questions about data access and security. To understand how a
cloud-based EHR works, consider how much you are already doing in the
cloud. Many people conduct much of their banking via secure websites
that allow them to access all of their private financial information,
transfer funds, check investment accounts, and pay bills. Millions have
used Web-based e-mail systems such as Gmail for all manner of personal
and professional correspondence for many years.
These services are offered up in the cloud. You do not have any software loaded and running on your computer to use these tools.
The cloud is really just a giant client-server model: a distributed
application structure that partitions tasks between the providers of a
service (called servers) and the clients. A client (a user workstation
or PC) initiates communication sessions with the server by requesting a
service function. In the cloud, the server providing the service -
for example, EHR service - is hosted remotely. Your Web browser is
Why the Cloud Is Gaining Popularity
computing is a paradigm shift in information technology (IT) management.
The cloud makes it possible for you to grow and expand rapidly and
generate efficiencies and cost savings by paying as you go for the
services you use. Cloud-based EHR services are typically offered as
complete software packages provided over the Internet, eliminating the
need to install and run an application on your own computers and
simplifying maintenance and support. Sometimes this is referred to as
"software as a service," or SaaS.
For many practices the cloud-based solution is a common choice for several reasons:
Fear of losing control over critical data is often a stumbling block in
cloud adoption. Cloud computing can give you even more control over your
data than you get with a client-server EHR. Cloud providers offer a
plethora of options for protecting the data entrusted to them - often
more than your in-house IT staff or budget could make possible. In all
situations, however, data sovereignty should belong to you.
An encrypted high-speed Internet connection provides your practice with
access to data and applications without having to manage software
changes or invest in server hardware. Updates are automatic and managed
by the vendor so you won't need staff to work over a weekend to install
software, migrate files, or test data conversions. And you'll always be
on the most current version, without requiring additional infrastructure
Although there are start-up costs, there is no up-front software license
to purchase or lease with the SaaS cloud model. While you won't be
paying a software maintenance or upgrade fee, you will be paying a
monthly subscription or service fee.
For organizations that have the wherewithal and staff to maintain a data
center (multiple servers, perform regular data backups, manage software
upgrades, and attend to the details of technical troubleshooting) a
client-server model is a viable choice, but may still be
cost-prohibitive. Practices that find start-up investment in a data
center daunting, or do not have adequate IT support, will find clarity
in the cloud.
An international survey of primary care physicians in 10 countries
finds progress in use of electronic medical records (EMRs) - particularly
in the United States, though the U.S. still lags several countries where
EMR adoption is near-universal. U.S. doctors report their patients
continue to have problems paying for health care, with well over half
saying patients often cannot afford care. In each nation, physicians
contend with communication and care coordination challenges.
In high-income countries, policymakers have pursued reforms in
primary care to meet the needs of aging populations and better manage
chronic conditions like diabetes and heart disease. To learn about
physicians’ experiences in the midst of health reform efforts, a team
led by Commonwealth Fund researchers surveyed primary care doctors in 10
countries on such issues as patient access, health information
technology, communication, overall views of the health system, and job
Addressing the Problem
policies - including those related to insurance design, support for
primary care practices, and HIT - make a difference, the authors write.
For instance, all of the study countries, except the U.S. and Canada,
have policies for ensuring patient access to primary care outside of
regular office hours; these range from the establishment of walk-in
centers and national help lines in the U.K., to physician payment
incentives in Australia. As the low rates reported by Canadian and U.S
physicians indicate, depending on the actions of individual practices
may not yield good results. “In general,” the authors conclude, “U.S.
primary care physicians’ views and experiences endorse the need for
reform, including enhanced access.” The Affordable Care Act, whose major
insurance expansions occur in 2014, can lower barriers to access.
About the Study
The authors surveyed primary care physicians in 10 countries:
Australia, Canada, France, Germany, the Netherlands, New Zealand,
Norway, Switzerland, the U.K., and the U.S. The 2012 survey builds on
The Commonwealth Fund’s 2009 survey of primary care physicians, which
included these same countries, except Switzerland. Physicians were
interviewed by a combination of mail and telephone between March and
The Bottom Line
The United States has made considerable strides in physician use of
electronic medical records but performs poorly, compared with other
high-income countries, on access to care. The experiences of U.S.
physicians support the need for reform, including enhanced access to
C. Schoen, R. Osborn, D. Squires, M. M. Doty, P. Rasmussen, R.
Pierson, and S. Applebaum, "A Survey of Primary Care Doctors in Ten
Countries Shows Progress in Use of Health Information Technology, Less
in Other Areas," Health Affairs Web First, published online Nov. 15, 2012.
As health records move from being paper-based to totally electronic,
concerns around the security of patient information are growing in the
health information technology (IT) world. A person's health information is worth 15 to 20 times more than
financial information, said Robert Wah, MD, president-elect of the
American Medical Association and chief medical officer for CSC, a health IT company in Falls Church, Va. A
stolen credit card can be cancelled, but a medical record contains much
more rich data and information about a person -- family history,
financial information, of course, medical history. "It's easier for identity theft to take place from a medical record
that's not secure than it is from a financial record because they tend
to be locked down a little better," Lisa Gallagher, who heads up privacy and security at HIMSS, said. "Hackers and other perpetrators have moved to trying to get it from the medical record."
Here are four things physicians should be aware of as the debate continues about the security of digital health information.
1. The Opportunity for Theft Is Growing
"We have medical devices on the network that have operating systems that are getting hacked," Gallagher said "We have the use of mobile to access data or transmit data which is an insecure way to do things." The security threat associated with health IT is growing. Meanwhile,
there is a lot of regulatory pull from other directions on providers,
so resources and attention to focus on this are scarce. For example, a survey of hospital and large physician practices showed that organizations
continue to spend just 3% of their overall IT budgets on security. That's an area of concern for Gallagher as it's low relative to other industries.
2. Your Employees Are Your Own Worst Enemy
The survey found that organizations' biggest concern was
about their own employees accessing patient information they shouldn't
be. Such inappropriate employee access is considered a breach by federal regulators. "Implementation
is such that you can't segment a nurse on the floor from only looking
at her patients' data," Gallagher said. "They have access and are able
to look at someone else's record." Providers hear this is a problem but have trouble preventing it.
3. Violators Must 'Fess Up
law requires providers who violate patient privacy and security to
notify each individual that such a violation has occurred. That might
damage the physician-patient relationship. HHS posts the names of providers whose security breaches top 500 individuals. The list is dubbed the "Wall of Shame" and is now available in a searchable format. Nearly 900 providers and organizations currently reside on the "Wall of Shame."
4. An Insurance ID Is a Valuable Thing
the cost of healthcare continues to rise and the need to obtain
coverage becomes greater, Gallagher said perpetrators of identity theft
are more likely to use someone's personal identity and coverage
information as a way to pay for healthcare. Gallagher shared the
story of a friend whose wallet was stolen, her health insurance card
with it. A couple of months later, someone showed up at the emergency
room and used her friend's identity to get care for a child. The hospital didn't detect the fraud, and Gallagher's friend was billed for the emergency visit that wasn't hers. "Now
you have data being put into someone's record that is there for someone
else, and they've compromised the integrity of the medical record,"
Gallagher said. "There's no process to fix it. Their policy is you don't
extract data from a medical record because it's a legal record."
Karl Sandberg, MD, says he's ready to throw in the towel. A
primary care physician in rural Arkansas, Sandberg said he is feed up
with electronic health records (EHRs) - among other bureaucratic
headaches - getting in the way of his treating patients. A MedPage Today story reporting on comments from Karen DeSalvo, MD, MPH,
the new national coordinator for health information technology,
resonated with Sandberg. DeSalvo noted how EHRs need to be more
doctor-friendly to encourage physicians to use them. The 62-year-old left a long comment to the story, clearly frustrated with his own experience with EHRs. Here are some excerpts from Sandberg's post.
"[EHRs are] an inefficient tool for documenting patient care. It
fractionates the chart into lots of boxes and categories that are only a
click or two away, but each click takes time and you have to remember
where everything is.And the whole time you are struggling with
that, the patient is going on about three other problems he has. By the
time you've finished documenting the first one, you're behind the
eight-ball and you stay there," he wrote." And God forbid that the
Internet should ever go down, or the program glitch, which happens.
Then you basically get to treat your patient from memory. And,
even if the computer happens to work correctly, all the verbiage it
encourages you to add only makes it harder to find the important stuff
when you look back over it," he stated.
Sandberg, 62, said he had planned to practice into his 70s, but
retirement might come sooner, which would be especially problematic
because of a rural physician shortage in the state. He recently went to
work for a satellite clinic of a local hospital."The main reason
I'm still here is that the hospital hasn't been able to find anyone to
cover the practice, and - let's face it - I still love the people
I'm treating even though I hate the hassle of treating them. But the
hassle is weighing on me more and more." He goes on to question "meaningful use" policies that penalize providers for not using EHRs in certain ways. "I
have gone from comfortably seeing 30 to 40 patients in an 8-hour day to
rushing like a madman in order to see 20 to 25 patients in a 9-hour day
(takes me an hour after everyone is gone to catch up on all my computer
tasks)," he explained.
"How demented is that for a national policy? We already have a rural
primary care doctor shortage, so we frustrate the doctors we have left
by markedly diminishing their efficiency with mandatory [EHRs]. There
certainly seems to be a screw loose here. There should have been
widespread appreciation of the efficiency of [EHRs] by clinicians using
it in actual practice before it became national policy. Doctors are not
technophobes, but we need technology that makes us more efficient, not
less." Do you agree with Sandberg? What are your thoughts and experience with EHRs in clinical practice?
Physicians' effective use of electronic health records will play a
critical role in the development of payment and delivery reforms, the
country's new health information technology (IT) czar said in her first
public comments. The reliance on EHRs and the information they can
provide physicians is why it's critical for federal regulations that
address the development and use of EHRs be tailored to optimize their
potential, Karen DeSalvo, MD, MPH, the new national coordinator for health information technology, said . "The
systems on the front line have to be usable so that doctors actually
want to interact with the electronic health record, or [so that] nurses
or others can access critical information that will eventually not just
save money or improve the quality of care but save lives," DeSalvo said,
speaking at the annual meeting of the Office of the National
DeSalvo, who started her new role last week, spoke more about her past work with EHRs than about her plans for the office.An
internist by training and most recently the health commissioner of New
Orleans, DeSalvo helped move the outpatient clinic of the city's Charity
Hospital to an electronic scheduling system as a young physician. She
also worked at the Veterans Administration while it was adopting a
system-wide EHR.But the bulk of her health IT work came in the
aftermath of Hurricane Katrina, which infamously flooded the city and
destroyed many hospitals' paper records. DeSalvo helped rebuild the
city's health information infrastructure, which was based on electronic
records; that allowed for a transformation of payment and delivery
models, she said.
Improper use of an electronic health record (EHR) may be akin to texting while driving, a couple of physician researchers argue. When
doctors have their eyes focused on a keyboard and computer screen, they
can miss patient signals of depression, disagreement, and lack of
understanding, according to Christine Sinsky, MD, a general internist in private practice in Dubuque, Iowa, and John Beasley, MD, of the University of Wisconsin School of Medicine and Public Health in Madison, said.
"As when driving, physicians also need to be alert to environmental cues and unexpected turns," the two argued Monday in the Annals of Internal Medicine.
"Multitasking can undermine the core activities of observation,
communication, problem solving, and developing trusting relationships."
"As when driving, physicians also need to be alert to environmental cues and unexpected turns," the two argued Monday in the Annals of Internal Medicine.
"Multitasking can undermine the core activities of observation,
communication, problem solving, and developing trusting relationships."
The crux of the problem comes in the form of stage 2 "meaningful use" criteria for EHR incentive payments
from Medicare and Medicaid. Those criteria require clinicians to type
in orders so that clinical support tools can offer reminders in real
time. However, Sinsky and Beasley found that less than 0.1% of
tests ordered in a primary care setting could benefit from point-of-care
decision support tools. "We are concerned about the hazards of applying
a work burden to 100% of orders when less than 0.1% might benefit,"
they wrote. Sinsky and Beasley believe they have an answer:
Team-based models of care where physicians and support staff work at the
top of their license.
"In those models, physicians give their patients undivided attention
while other team members perform clerical and routine clinical
functions, such as data acquisition, visit note documentation, and order
entry," they wrote. The workflow mandates such office policies as
team logins to allow collaborative documentation, team signatures to
allow staff to sign off on much of the practice's paperwork, and polices
that allow nonclinical staff to fully support care.
"Practices using these new models report greater patient access,
better staff and physician satisfaction, and higher-quality metrics,"
the authors said.Sinsky and Beasley found that up to 3 hours per
week are lost for physicians when they perform order entry rather than
allowing staff to do it. Something needs to change, they said.
Texting while driving is linked to a 23-fold increase in risk of
crashing. But multitasking for physicians is also dangerous to the
doctor-patient relationship. "Reducing texting while doctoring
will decrease the hazards of distracted physicians making perceptual and
cognitive errors during the medical encounter," they wrote.
The cumbersome nature of electronic health records (EHRs) interferes
with patient care and causes much professional dissatisfaction among
physicians, a report from RAND Health found.Overall, physicians
rated their ability to deliver high-quality patient care as a major
determinant of satisfaction, according to Mark Friedberg, MD, a natural scientist at RAND Corporation, in Boston, and colleagues. However,
their daily interaction with clunky EHR systems appears to have taken
its toll, as physicians blame the technology for lowering the quality of
care they can deliver to patients, according to the study, which was
commissioned by the American Medical Association and is available on the
Overall, physicians approved of EHRs in concept, noting they allow
remote access of patient information, improve some aspects of quality,
and allow for better communication within a practice. In fact, only 20%
of physicians expressed a desire to return to paper.But the
current crop of EHR systems does not seem to offer a sufficient level of
intuitive, user-friendly operation that would make workflow easier and
less time-consuming, thereby allowing more time with patients, according
to the report.
Some of the complaints by physicians gathered by the authors include:
The results of the study indicate that the problem is one that will
not abate as physicians become more familiar with EHRs, researchers
said. They found no association with EHR dissatisfaction and the length
of time an EHR had been installed."The issue is about the
fundamental state of interoperability with the technology and not one of
familiarity," Friedberg said. "We weren't really surprised that physicians were unhappy with EHRs," said co-author Francis J. Crosson, MD,
vice president for professional satisfaction, care delivery, and
payment for the AMA, during the briefing. "What really surprised us was
the breadth and depth of that dissatisfaction. "Physician
dissatisfaction for perceived suboptimal patient care might actually be a
signal of a larger problem that can be addressed, Friedberg and
"Aside from viewing better patient care as a potential 'downstream'
benefit of better physician professional satisfaction, it may be useful
to view physician dissatisfaction, when it is caused by perceived
quality problems, as an indicator of potential delivery system
dysfunction," they wrote. Knowing reasons for dissatisfaction can lead to targeted interventions, they said. The
AMA had concerns about physician satisfaction because of several
current challenges including healthcare delivery and payment reform,
care integration, and the need for new skills and resources, according
to the report. Between January and August 2013, researchers
collected data from 30 physician practices in six states: Colorado,
Massachusetts, North Carolina, Texas, Washington, and Wisconsin.
The number of physicians in each practice ranged from fewer than nine
to more than 50 and the practices included single and multispecialty,
as well as primary care. Nineteen practices were physician-owned or
partnerships; 11 were hospital-owned or some other type of ownership. In
addition to surveying physicians, researchers visited each practice to
conduct in-depth interviews with 220 physicians, medical administrators,
and allied health professionals to better understand the issues that
drive doctors' satisfaction with their work lives.
Other findings from the study include:
Friedberg and colleagues pointed out that physician professional
satisfaction is based on many factors common to other professionals,
such as fair treatment, responsive leadership, attention to work
quality, and pace - and that these can be targeted by policymakers
and healthcare delivery systems. "This may seem an obvious
conclusion, but considering the typical tools used to influence
physician behavior (regulations, payment rules, financial incentives,
public reporting, and the threat of legal action), refocusing attention
on the targets identified in this study may actually represent a
substantial change of orientation for many participants in the U.S.
healthcare system," they wrote.
The use of electronic health records has the capacity to cut down on
the number of emergency department (ED) visits and hospitalizations, and
also to improve early diagnosis in primary care, two studies suggested.In
one U.S. study of patients with diabetes, implementation of electronic
health records in a large integrated health system was associated with
28.80 (95% CI 20.28-37.32) fewer ED visits and 13.10 (7.37-18.82) fewer
hospital admissions per 1,000 patients each year, according to Mary Reed, DrPH, of Kaiser Permanente Northern California in Oakland, and colleagues.
And in a second 12-month study conducted in Finland, use of an
automated growth monitoring system integrated into primary care
electronic health records was associated with a diagnostic yield of
growth disorders of 0.9 (95% CI 0.6-1.2) per 1,000 children screened
compared with only 0.1 (95% CI 0-0.3, P<0.001) per 1,000 in previous years, reported Leon Dunkel, MD, PhD, of Queen Mary University in London. Both studies were published in the Sept. 11 Journal of the American Medical Association. "Electronic
health records increase access to timely and complete patient
information at the point of care, with potential to improve the quality
and efficiency of care delivered, including improved care coordination,"
wrote Reed and colleagues.
As emphasis on electronic health records has increased in recent
years, questions have been raised about the implications for care and
utilization for costly chronic diseases such as diabetes.To address this, Reed's group examined the records for all individuals enrolled in the Kaiser Permanente Northern California diabetes registry between 2004 and 2009. Beginning
in 2005, the health system gradually implemented electronic health
records in a staggered fashion across its 45 outpatient facilities. In
the time period before implementation, there were 100,510 hospital
admissions, 211,623 trips to the ED, and 2,574,472 office visits.After implementation, there were 96,684 hospitalizations, 194,486 visits to the ED, and 2,412,882 office consultations. Implementation
was followed by a 5.21% decline in hospital admissions, from an
expected 251.60 per 1,000 patients each year to 238.50. Use of the
electronic records also led to a 5.54% decrease in ED visits, from an
expected 519.12 per 1,000 patients each year to 490.32. When the
researchers looked at the specific types of hospitalizations, they found
10.92 (95% CI 6.48-15.48) fewer nonelective admissions per 1,000
patients yearly, which represented a 6.14% decrease. And for
hospitalizations for potentially preventable, ambulatory care-sensitive
conditions, there were 7.08 (95% CI 4.44-9.60) per 1,000 fewer each
year, for a 10.50% decline. There were no differences in
hospitalizations for diabetes-related or cardiovascular conditions,
which may have reflected the relative rarity of these specific events,
and rates of office visits remained unchanged.
The effects of the electronic health record implementation were "modest" but "consistent," according to the researchers. "Because
a complete [electronic health record] system like the one we studied
can be used in numerous ways to manage patients with diabetes, including
many with multiple conditions, we believe that our finding of reduced
ED visits and hospitalizations may represent not just improvements in
diabetes care but also the cumulative effect of the [electronic health
record] across many different care pathways and conditions," Reed and
colleagues stated.They noted that their study was observational, so the possibility of unmeasured confounding exists.
The Finnish study, which was published as a letter, prospectively
evaluated a yearlong primary care intervention to identify children with
growth disorders, which are often recognized late. In
Finland, almost all children undergo routine growth screenings through
age 12. With the automated growth monitoring program, any abnormal
growth measurements were automatically sent to a pediatric
endocrinologist, who then advised the primary care physician on
referral. During the 3 years before the intervention, with 33,029
children being screened annually, a mean of four cases of a primary or
secondary growth disorder were diagnosed. In contrast, during the intervention year, when 32,404 children were screened, 28 cases were identified. Half
of those children had at least one abnormal measurement in the previous
3 years, and the median delay in diagnosis for those children was 1.79
years, Dunkel and colleagues noted. Significant increases also were seen in the number of children referred for specialist treatment of their growth disorders. During
the years prior to the intervention, a mean of 72.7 referrals took
place annually, which was 0.22% (95% CI 0.18-0.28) of children screened. But during the intervention year, there were 209 referrals, or 0.64% (95% CI 0.56-0.74, P<0.001) of children screened. The researchers concluded that the automated growth monitoring program successfully increased detection and referral rates.
"We identified prevalent cases who were missed by the [standard
growth monitoring] in preceding years, which may partly explain the
exceptionally good results of the 1-year [automated growth monitoring]
intervention," they explained. They acknowledged that it's uncertain if the results would be generalizable to other countries and settings.
Using electronic health records (EHRs) saved a little more than 3% in
ambulatory health costs 18 months after adoption but didn't reduce
overall inpatient costs, a large comparative study of EHR use found.With
that rate of savings, it would take 7 years to recoup the projected
5-year adoption costs for an EHR, according to the study, which was
published in July 16 issue of Annals of Internal Medicine.
"Reducing health spending by the magnitude that we observed would result
in substantial savings if sustained over several years," Julia
Adler-Milstein, PhD, of the University of Michigan in Ann Arbor, and
colleagues wrote. "Larger savings are possible if providers have
incentives to deliver more efficient care."
Researchers analyzed data from the Massachusetts eHealth
Collaborative, a 2006 project that helped three communities widely adopt
ambulatory EHRs. They compared health costs for patients who received
most of their care from providers who adopted EHRs to costs in matched
control communities.Monthly costs were examined in commercial
payers from 15 months before implementation to 18 months after
implementation, with a total of 48,000 patients in the EHR group and
130,000 in the control group. Practices involved were mostly small and a
mixture of primary care and specialty.Providers with the EHRs
saved an average of $5.14 per member per month over the 18 months after
implementation, representing a 3.40% savings. Ambulatory cost savings
accounted for $4.69 of that amount.
But health costs still managed to increase for the EHR and control
groups -- just not as fast for those with EHRs. Total costs increased
an average of 0.78 absolute percentage points in the intervention group
and 1.09 absolute percentage points in the control groups (P=0.135).
"Our failure to find a statistically significant reduction in total cost
may be explained by providers not using EHRs in more advanced ways that
would improve patient health status, thereby avoiding hospitalizations
and other high-cost episodes," the authors wrote. "The disruption caused
by EHR adoption could have made it difficult for providers to learn how
to use EHRs to monitor population health, better coordinate care, or
engage in more sophisticated use."
Providers with EHRs most commonly reported using them to view lab and
radiology test results -- the latter probably explaining why the
service showed the largest overall drop in costs (P<0.001). Health
policymakers see EHRs as a way to lower health costs. Providers can
reduce unnecessary tests and office visits and access previous
diagnostic test results. But as Adler-Milstein noted, available evidence
has yet to resolve the debate over whether EHRs can save money for
individual physicians. A report she published in Health Affairs this spring found more than a quarter of physicians lose money on EHRs because they don't have operational changes to realize the benefits of EHRs.
Rainu Kaushal, MD, of the Weill Cornell Medical College in New York
City, noted in an accompanying editorial that EHRs are needed for other
infrastructure changes that will bring true cost savings."Without
electronic clinical data, these new transformative models of healthcare
cannot be implemented," Kaushal said. "Financial savings in the
healthcare system will be driven by these new models rather than by
EHRs. "Furthermore, physicians should not forget about quality and value in delivery reform efforts. "Understanding
costs in the absence of concurrent assessment of quality and safety
changes limits our ability to effectively understand how to optimize
healthcare delivery," Kaushal said. "Driving down costs at the sacrifice
of quality is not a desirable outcome."
Adler-Milstein's study had several limitations, including the fact
that pilot communities in Massachusetts were selected because of their
strong likelihood of successful adoption. Certain factors may not have
been well controlled for in the studied practices.Also, the study didn't include Medicare and Medicaid, which Adler-Milstein said could have had a larger effect size.Mark
Frisse, MD, of Vanderbilt University in Nashville, Tenn., noted these
findings were from March 2006 to January 2008, when EHR use was really
just getting off the ground. "These data are really from a very
early stage in three communities, so they're kind of reflective of where
you're going to be just when you're starting out trying to install an
electronic health record," Frisse said.
Everyone expects a hospital to be ready to jump into action when
disaster strikes. But what about when the disaster devastates the
Turns out, it helps a lot to have an electronic medical record system in place.
At least that was the case at Moore Medical Center in Oklahoma, a small hospital right in the path of the tornado
that ripped through the suburbs of Oklahoma City. Three hundred people
-- staff, patients, and community members -- hunkered down in the
cafeteria, stairwells, and chapel as 200-miles-per-hour winds demolished
the building around them.
One patient in labor stayed on the second floor with two nurses, where they could continue to monitor the fetal heartbeat.
Amazingly, everyone survived. Within an hour, 30 patients had been
transferred to the two other hospitals that are part of the Norman
Regional Health System. And every one of them arrived with their medical
histories fully intact. The woman in labor even delivered a healthy
baby later that evening.
"The transfer was totally seamless," says John Meharg, director of health information technology at Norman, which has had an electronic health record system for the past 5 years. "We're very fortunate that we're a little ahead of the game," he said.
If the hospital system had still been using paper, Norman explains,
"the first thing we would have had to do was find their records. And
with all of the hustle and bustle of a disaster, they can easily get
lost." As for any records left behind in files, he continues, "if the
tornado doesn't get them, the subsequent rain would ruin them. The
roof's gone, the walls are gone, and the windows are gone."
Instead, physicians at the two transfer hospitals were able to pick
up care for the Moore patients where their home physicians left off.
Even if the patients had been taken to hospitals outside of the Norman
system, their records would still have gone along with them. That's
because Oklahoma City has a regional health information exchange that
allows the various hospital systems in the area to access all patient
records, says Meharg.
"I'm very happy," he adds, breathing a sigh of relief. "The systems
never missed a beat. It would really have been a mess if we weren't
Almost 17% of physicians will at least consider switching electronic
health record vendors this year, but the problem may not be in the
system, according to an EHR physician consultant.
To cure their dissatisfaction with their EHR, doctors may need to see
if their expectations are unrealistic or change their implementation
strategy, Cephus Daniel Vincent Allin, M.D., of EHR software vendor
NextGen in Horsham, PA., said.
Organization problems cause more failed implementations than
technology, he said, adding that the staff who use the EHR need good
training on a system -- more than just having an instruction manual
thrown at them.
Practices may need to change their work flow or the way they chart,
assess, and bill patients to maximize the EHR system, Allin advised.
"It's easier to change your work flow or way of thinking than it is
to change the silicon," Allin said, referring to the material computer
software is made of.
A big point Allin made was making sure office staff are doing the
most they can with the system. For example, the doctor doesn't need to
take a history of a patient. They can allow the staff to still do that
and review their notes, which takes less time.
"I'm actually going to do exactly what was suggested today, go back,
regroup, look at your work flow, sort of see if we need to retrain
people," Yogesh Trehan, M.D., of Brentwood, CA, said.
Allin also suggested planning and budgeting for an EHR update every
year. He said every vendor has a team of developers constantly working
"The first thing they do is fix defects," Allin said. "The second thing they do is keep up with the regulatory environment."
Physicians looking to receive "meaningful use" bonuses from the
federal government should be aware of increased reporting requirements
under Stage 2, health information technology experts said at a separate
One notable difference is that 5% of patients should be using a
patient portal, said Michael Zaroukian, M.D., Ph.D., chief medical
information officer for the Michigan State University HealthTeam in East
Lansing. This means practices can't just passively make patients aware
that a portal exists, but should push them toward using it.
To encourage usage, physicians can consider secure messaging to
patients through the portal rather than via phone calls, Zaroukian said.
Send certain results and clinic notes through the portal.
"Meaningful use" refers to provisions in the 2009 Health Information
Technology for Economic and Clinical Health (HITECH) Act, which
authorized incentive payments through Medicare and Medicaid to
clinicians and hospitals that use electronic health records in a
meaningful way that significantly improves clinical care.
Providers who show "meaningful use" of certified EHRs can receive up
to $44,000 in extra payments from Medicare and $64,000 from Medicaid,
but eligible professionals who don't meet such requirements are subject
to penalties starting in 2015.
"There's very little meaningful use in Stage 1 that's required by the
doc," said Peter Basch, M.D., medical director for ambulatory EHR and
health IT policy at MedStar Health in Columbia, MD.
Stage 1 of meaningful use focuses on capturing and sharing data, while Stage 2 aims for improved clinical outcomes.
As an example of how MedStar used its EHR to try to improve outcomes,
Basch said, every primary care provider receives electronic prompts to
remind patients about ways to lower blood pressure, cholesterol, and
The result was better use of tools to manage those conditions. For
example, Basch said the use of smoking cessation tools jumped from 23%
in 2012 to 70% in one year.
Electronic health records (EHRs), although they may be frustrating now,
will become more than just legible medical records and will provide
more robust tools for improving patient care, predicts an information
technology expert. "Improvements in the documentation process hold
promise for more than simply efficient data entry and legible notes,"
wrote James J. Cimino, MD, in a Viewpoint article published online in
the Journal of American Medical Association. "If impressions
and plans can be captured within EHRs as explicit data elements, using
standard terminology rather than being buried in the narrative text of a
note, clinicians could use this information to better support clinical
workflow. "Furthermore, a "problem or diagnosis entered in this
way could allow an EHR to provide a suggested list of appropriate tests
and treatments, based on best available evidence," wrote Cimino, chief
of Laboratory for Informatics Development at the National Institutes of
Health Clinical Center in Bethesda, MD.
Although three out of four physicians report using EHRs, many
complain that patients' records are riddled with "note bloat" that
obscures the patient's condition, according to Cimino. "The
lineage of many commercial EHRs can be traced to billing systems in
which clinical data functions (such as review of laboratory results)
were tacked on," he said. "Clinical documentations functions were a
similar afterthought, added more in support of billing than patient
care."EHRs often ask clinicians first about a specific encounter
or level of service rather than going straight to patient data, wrote
Cimino. Additionally, instead of making record-taking and record-keeping
easier, computerized records have required more time and effort with
less flexibility, Cimino said. "When the time required for the task exceeds the time available, appropriate completeness is bound to decline," he wrote.In
fact, he said, some attempts to make EHR functions more efficient can
backfire. Checkboxes and boilerplate paragraphs that may be quickly
copied and pasted also may fail to capture the nuances of patient
Those and "note bloat" are symptoms of bad EHRs that obscure the
decision-making behind diagnosis and treatment. Excessive pertinent
negatives captured in EHRs, wrote Cimino, hide more essential
information.Cimino suggested that EHRs which allow doctors to annotate previous notes -- instead of blanket copy and paste -- would alleviate cumbersome narrative.
Instead of daily summaries of hospitalization, which can become
needlessly redundant, EHRs should capture the doctor's current thoughts
and observations as they arise, and make retrieval of earlier
information more facile. "Summaries could be produced dynamically,
reflecting the present state of the clinician's thinking (or the state
at some previous time point, if necessary)," he wrote. "This more fluid
approach could help make it possible for any clinician to view an EHR
and immediately understand the thought processes of other clinicians who
have been involved in the patient's care."
In a nod to the idea that EHRs have brought some good things along
with the bad, Cimino pointed to a Columbia University suggestion that
EHRs include a print prescription function.
When added to EHRs, the print option "substantially increased
compliance with medication list documentation and medication
reconciliation." Studies show that the functionality and user
experience of an EHR program affect the way a physician takes notes,
Cimino continued. On paper, a physician typically constructs a
comprehensive note in one sitting, he said. Electronically, physicians
can make notes several times in a day. Yet, EHRs usually are not
designed to support this approach, leaving users to devise "inefficient
workarounds." An EHR program able to notice keywords and phrasing
typical for doctor's notes about patients could offer appropriate
medical responses. Subsequently, the EHR program could offer automated
medical orders that could be dispatched efficiently. Appropriate
follow-up would be born from those orders, and EHR monitoring could
reveal the need for alternative responses to treatment. "These
computer-based functions have already been developed; they are merely on
hold for the necessary improvements in clinician documentation to be
implemented," Cimino wrote.
Don't give up hope, Cimino wrote."EHRs
had to start someplace," he wrote. "Rather than complain about the
challenges they have introduced, clinicians should recognize that
current EHRs are illuminating the opportunities for the next generation
of systems that will support clinicians as active partners across the
spectrum of healthcare settings and tasks."
The average physician lost nearly $44,000 over 5 years implementing
an electronic health record system, a large pilot study found, but the
technology itself was just part of the reason.
Just 27% of practices achieved a positive 5-year return on investment
-- a number that would rise to 41% with the addition of federal
incentives to use EHRs, the study in the March issue of Health Affairs stated.
But the vast majority of practices lost money because they failed to
make operational changes to realize the benefits of EHRs such as
ditching paper medical records after adoption, Julia Adler-Milstein,
PhD, of the University of Michigan in Ann Arbor, and colleagues wrote.
"Practices with a positive return on investment realized savings by
eliminating paper medical records, as well as dictation and billing
services and positions of, or hours worked by, staff members who were
performing services no longer required after EHR adoption," the authors
wrote. "Practices may therefore need encouragement and assistance in
changing the way they operate so they can benefit from EHR adoption."
The researchers surveyed practices adopting EHRs through the
Massachusetts eHealth Collaborative, a pilot program to help more than
80 ambulatory care practices in three communities in the state. The
program was supported by the Massachusetts Medical Society and American
College of Physicians and funded in part by $50 million from Blue Cross
Blue Shield of Massachusetts. EHRs were implemented between March 2006
and December 2007.
The Health Affairs study sought pre- and post-adoption
financial cost/benefit data from practices such as total revenue, total
operating costs, and total labor costs. Researchers also asked for
information on areas that were impacted by EHRs such as the cost of
paper medical records, dictation services, and billing services.
The authors tried to calculate how EHRs impacted the practices'
bottom line. "Our aim was to decrease potential over attribution that
could result from asking practices to focus exclusively on EHR
adoption," they wrote.
Adler-Milstein and co-authors admitted it was difficult to attribute
certain savings to EHR adoption. For example, if a practice's revenue
increased by $100,000 after EHR adoption, how much of it was because of
EHRs? So the authors reported results as sensitivity analyses.
"Factors such as practice attitudes toward the EHR system may have
systematically biased attribution in ways that we were unable to
address," the authors noted.
Their results showed that the average physician lost $43,743 over 5 years. Primary care practices fared better than specialists.
Practices that saw a positive return on EHR investment increased
revenue by more than $114,000 per physician over 5 years, results
showed. In comparison, practices with a negative return on EHR
investment saw revenue increase by an average of only $9,200 per
physician in 5 years.
Even when adding federal incentives to use EHRs, the majority of doctors would have lost money.
With the additional $44,000 from "meaningful use" incentives, more
than half of primary care practices would have realized a positive
return on investment, compared with a third of specialists, the study
found. Doubling the incentive would cause 59% of practices to break
even. Tripling it to $132,000 would result in 67% of practices breaking
"Meaningful use" refers to provisions in the 2009 Health Information
Technology for Economic and Clinical Health (HITECH) Act, which
authorized incentive payments through Medicare and Medicaid to
clinicians and hospitals that use electronic health records in a
meaningful way that significantly improves clinical care. However,
recent reports have shown a small minority of physicians qualify for the bonuses from Medicare and Medicaid.
Other results from the study include:
Wide usage of EHRs was supposed to help doctors increase revenue
through improved billing and efficiency gains that would allow them to
see more patients per day. However, doctors have complained that EHRs
are cumbersome and cause physicians to spend more time documenting patient visits.
"Whether the meaningful-use incentive is sufficient to ensure that
practices at least break even probably depends on both the practice
setting and the decisions made by practices to organize and deliver care
differently after EHR adoption," the authors wrote. "Understanding how
to help all practices benefit from adoption is crucial to the success of
HITECH and represents an important area for future research."
About 30% of physicians in the Department of Veterans Affairs (VA)
health system participating in a survey said they had failed to notice
important test results, sent via the VA's electronic records system, on
at least one occasion. The survey's authors, most of whom worked in the Michael DeBakey VA
Medical Center in Houston, blamed "information overload" related to
electronic health records (EHR) systems for the findings.
"Because this was a cross-sectional survey, we cannot determine
causation," wrote Hardeep Singh, MD, MPH, and colleagues online in a JAMA Internal Medicine
research letter. "Nevertheless, our findings suggest that missed
results in EHRs might be related to information overload from alert
notifications, electronic handoffs in care, and practitioner perceptions
of poor EHR usability."
The researchers invited 5,001 primary care physicians in the VA system
to participate in the survey, which asked several questions about the
respondents' attitudes toward EHRs, and whether they had ever personally
"missed abnormal lab or imaging test results that led to delayed
patient care." The response rate was 51.8%. About 56% of respondents indicated that the VA's EHR system made it "possible for practitioners to miss test results." Large majorities also said they thought the number of alerts sent
through the system was excessive and that the volume was more than they
could manage effectively. The median number of alerts per day reported by respondents was 63.
Singh and colleagues also analyzed their data for factors predicting
increased or decreased likelihood of reporting having missed test
Respondents who said they found the EHR system easy to use were much
less likely to say they had missed results (odds ratio 0.64, 95% CI 0.43
to 0.96).Other factors associated with significantly decreased
likelihood of missing test results included affirmation that respondents
consistently notify patients of abnormal results and that they always
follow up on alerts in the VA EHR system. Additionally, respondents
indicating that their native language was not English were significantly
less likely to report missing test results. On the other hand,
physicians who said they thought the number of alerts was unmanageably
high and those who said they worried about alerts routed to other
practitioners in handoff situations -- indicating concern about care
coordination, Singh and colleagues wrote -- were significantly more
likely to say they had missed test results.
Negative attitudes toward the EHR system were also associated with
increased probability that respondents would say it creates potential
for missed test results."Interventions to improve safety of test result follow-up in EHRs must address these factors," the researchers concluded.
Doctors who view electronic health records (EHRs) as time-draining
and a waste of resources should take a larger view of their use within
the practice, EHR advocates said. Physicians should view
EHRs as more of a shared care plan of a patient's health, not just a
billing mechanism under a fee-for-service model, experts said at the
AcademyHealth National Health Policy Conference here. Practices can use
EHRs to help better patient outcomes. "It still may take time, but
the end result is far better," said Paul Tang, MD, of the Palo Alto
Medical Foundation in Los Altos, Calif.
Most estimates peg physicians' EHR use at around 70% -- almost double what it was 3 or 4 years ago. But the complaint from doctors still is that most EHRs are cumbersome and time-consuming. "What
we hear from the docs in the front lines is that it is actually
reducing productivity in our arcane system of billing and practice
because it takes longer to document," Norman Vinn, DO, president-elect
of the American Osteopathic Association, said at the panel on health
information technology (IT). Instead, physicians need to have a
three-way conversation among themselves, the patient, and other readers
of a record, according to Farzad Mostashari, MD, national coordinator of
health IT at the Department of Health and Human Services. Information
needs to be clinically relevant to allow multiple providers to read a
patient's record -- and save time and clinical costs -- later down
the road."It's not a waste of time if it's communication and shared decision-making," Mostashari said.
If doctors view an EHR more as a tool they and patients can use as
they go from one provider to another, the time spent can be viewed less
as a waste of time, Mostashari and others said. David Blumenthal,
MD, president of the Commonwealth Fund, acknowledged that physician
documentation requirements are increasing and taking up more time. But
he notes that the healthcare system isn't going back to paper
documentation or giving up on EHRs."You can find testimony to the
time-saving value of electronic health records, as well as the
time-consuming," Blumenthal, an expert on health IT, said.
Vinn said it takes providers a great deal of time trying to obey
health privacy laws, and noted that EHRs are easily shared among
providers. He called on policymakers to better outline how physicians
can share patient information without violating privacy."We need to create some very defined exceptions to portability among silos of information," Vinn said after the panel discussion. Also, the designers of EHRs could design programs that are more productive and user-friendly for providers, he added.
Meanwhile, stage 2 of HHS' EHR Meaningful Use incentive program, which takes effect in 2014 for providers, intends to lay the foundation for further interoperability. "Meaningful
use" refers to provisions in the 2009 Health Information Technology for
Economic and Clinical Health (HITECH) Act, which authorized incentive
payments through Medicare and Medicaid to clinicians and hospitals that
use EHRs in a meaningful way that significantly improves clinical care. Mostashari
said vendors will be working hard over the next 10 months to meet the
stage 2 meaningful use goals of interoperability. He shared his agency's three goals for creating better interoperability among providers for EHRs:
"There have to be standards that you can reach or that the different
vendors can agree to for being able to exchange complex information,"
Mostashari said. He noted that delivery models are becoming more reliant
on better coordinating care and sharing information.
More than two-thirds of family doctors now use electronic health
records, and the percentage doing so doubled between 2005 and 2011, a
new study finds.If the trend continues, 80 percent of family
doctors -- the largest group of primary care physicians -- will be using
electronic records by 2013, the researchers predicted.
The findings provide "some encouragement that we have passed a
critical threshold," said study author Dr. Andrew Bazemore, director of
the Robert Graham Center for Policy Studies in Primary Care, in
Washington, D.C. "The significant majority of primary care practitioners
appear to be using digital medical records in some form or fashion. "The
promises of electronic record-keeping include improved medical care and
long-term savings. However, many doctors were slow to adopt these
records because of the high cost and the complexity of converting paper
files. There were also privacy concerns. "We are not there yet," Bazemore added. "More work is needed, including better information from all of the states."
The Obama administration has offered incentives to doctors who adopt
electronic health records, and penalties to those who do not.
the study, researchers mined two national data sets to see how many
family doctors were using electronic health records, how this number
changed over time, and how it compared to use by specialists. Their
findings appear in the January-February issue of the Annals of Family Medicine. Nationally,
68 percent of family doctors were using electronic health records in
2011, they found. Rates varied by state, with a low of about 47 percent
in North Dakota and a high of nearly 95 percent in Utah.
Dr. Michael Oppenheim, vice president and chief medical information
officer for North Shore Long Island Jewish Health System in Great Neck,
N.Y., said electronic record-keeping streamlines medical care. These
records "eliminate handwriting errors, and help with planning and
caring for patients with chronic medical problems," Oppenheim said.
Plus, the files can be accessed by a doctor when the initial provider is
unavailable, he said.Electronic health records also save money
in the long term, he noted. "If a patient has a complaint and just had a
blood test, and then shows up at the ER (emergency room) with the same
complaint, the ER doctor can access the record and not reorder the same
test," he said.
Oppenheim said medical penalties are driving adoption of e-records,
but there is still some hesitancy. "Doctors are nervous about the cost
and worried about how it will affect their practice," he said. "The
conversion process is complex. "Doctors can do it themselves or outsource the system. "You pay in productivity or dollars," he said.Electronic
health records are good news for all involved, agreed Dr. Adam
Szerencsy, an internist at New York University Medical Center in New
York City and the Epic Medical Director there. Epic is NYU's electronic
health record system. When the concept first surfaced, many
patients were concerned about their privacy. Today's electronic health
records are secure and often have protocols attached to make sure that
they don't fall into the wrong hands, he explained.
A key reason that family doctors are leading the transition is that
government incentives make it a little more lucrative for family
practitioners than specialists, he said.Also, "primary care
doctors manage patients over time, while subspecialists usually don't,"
Szerencsy said. For example, a surgeon may treat appendicitis, and then
the case is closed.The Holy Grail is thought to be a universal
health record where doctors everywhere can access patient records. "We
are getting closer," Szerencsy said. "Within the next couple of years,
electronic health records will explode across the board."
Electronic medical records arrived with a fanfare in 2005, promising
huge cost savings, better accuracy and efficiency - most health care
professionals and authorities have been disappointed, stating that
systems overall are not user-friendly and badly integrated, says a new
report issued by the Rand Corporation, a non-profit organization.
The authors of the new report state that the potential of health
information technology to reduce spending as well as improve patient
care will never materialize if health care providers do not reengineer
their processes to focus on the benefits that could be achieved.
Dr. Art Kellermann, senior author, and Paul O'Neill Alcoa, Chair in Policy Analyziz at Rand, said jointly:
"The failure of health information technology to quickly deliver on its
promise is not caused by its lack of potential, but rather because of
the shortcomings in the design of the IT systems that are currently in
A team of IT experts from Rand Corporation in 2005 published an analysis
that predicted "widespread adoption of health information technology"
that would eventually save America over $81 billion in better delivery
and efficiency of health care annually.
Co-author Spencer S. Jones, and Kellerman concluded that a much more
compelling vision is required to attract funding into health information
technology. They offer the following suggestions:
Several media reports mention that a significant number of
healthcare providers would rather bypass the incentive checks and even
pay up the eventual penalty fees than have to deal with the bother of
implementing electronic health record systems. If this is occurring in a
big scale across the USA, something needs to be done urgently to make
the implementation and everyday usage of these systems more practicable.
Learn from other countries, say some experts
Some say that the
USA should liaise with other countries which have successfully created
and implemented electronic health care records systems in a big way
nationally, such as the United Kingdom.
Professor David Blumenthal of Harvard University, and Dr. Jenniffer
Dixon, of the Nuffield Trust, UK, stress that in technology,
organization and financing, the two nations could learn a a lot from
each other. They said "Comparing health reforms in the USA and England
seems to be an unlikely project: many people in both countries view the
other as having a pariah health system that is not to be copied in any
circumstance. But both countries are under pressure to get more value
out of health care spending and reduce growth in expenditure to
sustainable levels, and are consequently experimenting with new ways to
encourage clinicians, patients, and institutions to help achieve this."
Several studies have looked at the benefits of electronic health records, with mixed results:
As electronic health record systems become more interconnected,
errors may propagate much farther than under old paper-based systems, a
recent study suggested. According to a review by the Pennsylvania Patient Safety Authority,
mistakes and near misses involving electronic health records were
analogous to those made with paper-based records with one caveat: those
made with EHRs tend to be amplified and can affect a larger group of
The Authority's study looked at 3,099 reports from
Pennsylvania hospitals detailing 3,946 problems. More than 2,700
incidents involved near misses and 15 involved temporary harm to
patients. The study focused on incidents from 2004 to 2012 in
which electronic health records were the root cause in the event, as
opposed to being incidental.Electronic health records are
designed to be more efficient than paper-based records, but the two
systems have one thing in common: they're developed and maintained by
people. The most common source of problems identified in the study
rested with data entry and, to a much lesser extent, with technical
glitches.Medication errors accounted for about 80% of the cases, or 2,516 reports. Many of the remainder involved lab tests.About half of the drug errors involved the wrong medication, with underdosing the problem in about 30%.One
problem is EHRs are connected to other systems like a hospital
pharmacy, and they will only get more connected as EHR information is
transmitted using health information exchanges. That means that any
incorrect information entered in the record is widely distributed.Another
complication is that the deadlines established by the federal
government in the 2009 economic stimulus package led to some providers
rushing to set up an EHR system without adequate staff training in
The study noted that one big problem is several
institutions are trying to use paper-based and electronic records in
tandem, which creates incomplete information in one source or the other.
This issue has led to overmedication in some cases and underdosing in
others.Wrong medication was the No. 1 source of mix-ups, just as
with paper-based records. Talking to reporters in a webinar about the
study, William Marella, program director for the Patient Safety
Authority, said, "There's no question in my mind that EHR is the smart
way to go, but in the short term we are seeing safety issues."He added that the scale of the problem has changed, so you can have a single problem that can cascade.Marella
recalled one incident discovered in the review in which a technical
glitch caused medication orders to randomly appear on some electronic
medical records. The problem was not noticed until a request for an
erectile dysfunction drug appeared on a female patient's record. In a
separate incident, a note that a patient was allergic to penicillin was
made in the free notes section of an EHR rather than in the section
addressing allergies. The patient was subsequently given ampicillin,
which sparked an allergic reaction.
One way to address the current
issues with electronic health records is to make systems smarter,
particularly with natural language processing. Such a system could catch
information even if it's not entered in the right place.The
study highlighted the need for tracking the number of near misses and
mistakes caused by electronic health records. It pointed out that an Institute of Medicine report
called attention to the lack of hazard and risk reporting data on
health information technology as a hindering factor in building safer
In a new study, Northwestern Medicine researchers found that patients at
high risk for cardiovascular disease (CVD) are more likely to receive a
prescription for cholesterol-lowering medication, and to achieve lower
long-term cholesterol levels, when doctors use electronic health records (EHRs) to deliver personalized risk assessments via mail.
The paper was published in the Journal of General Internal Medicine.
"It is important to get high priority preventive care messages to
patients in a variety of ways," said Stephen Persell, MD, assistant
professor of general internal medicine and geriatrics at Feinberg, and
first author on the paper. "Sending a mailed message that depicts one's
actual cardiovascular risk may lead some patients to action even though
talking about treating cholesterol with their physician did not."
CVD remains the number one cause of death globally, and is the leading
cause of death for both men and women in the United States. High blood pressure, high LDL cholesterol and smoking are well-known key risk factors for heart disease, and about half of Americans (49 percent) have at least one of these three risk factors.
However, according to the study's authors, risk assessment is not
performed often in primary care, and doctors may have inaccurate
perceptions of patients' risks.
Persell and the Northwestern team believed the use of EHRs to
automatically identify candidates for risk-reducing interventions would
result in better care delivered directly to patients. They enrolled 29
physicians and 435 eligible patients in the study, and assigned 14
physicians with 218 eligible patients to the test, or intervention,
"This is the first study that took a population-wide approach to
identifying all patients who might benefit from this kind of an
intervention in a primary care setting," said Persell. "Prior studies
have only tried this kind of approach with select groups of patients."
Working with the Northwestern Medical Enterprise Data Warehouse, a
sophisticated EHR data repository developed jointly by Northwestern
University, Northwestern Memorial Hospital, and the Northwestern
Memorial Faculty Foundation, researchers identified a pool of at-risk
patients who were not being treated with cholesterol-lowering drugs.
Physicians in the test group received automated notification of these
high-risk patients, who were then mailed personalized risk assessments.
The assessments encouraged them to discuss risk-lowering options with
Ultimately, those in the test group were twice as likely as the control
group to receive a prescription for lipid-lowering medication, and after
extended follow-up 18 months later, 22 percent had lowered their
cholesterol significantly (by 30 mg/dl or more) vs. 16.1 percent of
Though these tactics improved results compared to usual care with no
follow-up messages, Persell believes there is still room for
"Many patients who had increased cardiovascular risk and got the risk
message sent to them still did not get their cholesterol lowered. Future
studies can examine if repeated exposure to these messages leads to
bigger changes over time," he said.
Persell said an ongoing study is currently testing whether a similar
approach combined with telephone outreach can help patients in federally
qualified community health centers control their cardiovascular disease
A new study by Weill Cornell Medical College researchers, published in the Journal of General Internal Medicine, provides compelling evidence that electronic health records (EHRs) enhance the quality of patient care in a community-based setting with multiple payers, which is representative of how medicine is generally practiced across the United States.
The use of EHRs is on the rise, in part because the federal government has invested up to $29 billion in incentives promoting the meaningful use of these systems, with the aim of tracking and improving patient outcomes. Previous studies have provided conflicting evidence about the impact of EHRs, and until now it had been not clear whether they improved the quality of patient care, particularly in typical communities that use commercially available systems. "The previous studies on the effects of electronic health records in the outpatient setting have been mixed," says the study's lead investigator, Dr. Lisa M. Kern, associate professor of public health and medicine at Weill Cornell Medical College. "This is one of the first studies to find a positive association between the use of EHRs and quality of care in a typical community-based setting, using an off-the-shelf electronic health record that has not been extensively tailored and refined. This increases the generalizability of these findings."
"This study starts to grow the evidence that the use of these systems can systematically improve the quality of care, although their maximum value likely lies in their ability to support new health care delivery models," says the study's senior investigator Dr. Rainu Kaushal, director of the Center for Healthcare Informatics and Policy and the Frances and John L. Loeb Professor of Medical Informatics at Weill Cornell Medical College. "The findings of this study lend support to the very significant investments in health information technology that are being made by the federal government, states, and health care providers."
This study was conducted with the Health Information Technology Evaluation Collaborative (HITEC) - a multi-institutional effort directed by Drs. Kaushal and Kern and funded by New York State, in order to evaluate and assess the impact of New York's health information technology strategy. In 2008, the researchers collected data about the quality of patient care across nine measures from nearly 500 physicians and 75,000 patients in ambulatory practices in the Hudson Valley region of New York, where there has been a concerted effort to implement EHRs. They gathered data from five different health plans, including two national commercial plans, two regional commercial plans and one regional Medicaid health maintenance organization.
"This study reflects data from five different health plans, which is another strength of the study and which is critical for understanding the experiences of patients in the community," says Dr. Kern. "If you only have one health plan, then you will not be seeing the whole picture."
The team found that the 56 percent of physicians who used commercially available EHRs provided significantly better quality of care than physicians using paper records for four measures, including hemoglobin A1c testing in diabetes, breast cancer screening, chlamydia screening and colorectal cancer screening. EHRs typically provide reminders about these clinical tests. Moreover, the combined score across all nine measures indicated that EHRs led to better patient care than paper records.
"EHRs may improve the quality of care by making information more accessible to physicians, providing medical decision-making support in real time and allowing patients and providers to communicate regularly and securely," says Dr. Kaushal. "However, the real value of these systems is their ability to organize data and to allow transformative models of health care delivery, such as the patient-centered medical home, to be layered on top."
To follow up on this study, the researchers plan to determine how the effects of EHRs on patient care vary over time and across different locations in New York, to examine the effects EHRs on the cost of patient care and to work on improving ways to measure the quality of patient care.
Switching over to electronic health records (EHRs) appears to
dramatically cut malpractice suits, according to a small study of
insurance claims. The adjusted rate of malpractice claims fell six-fold among physicians
in practices that adopted computerized records, Steven R. Simon, MD,
MPH, of the VA Boston Healthcare System and Brigham and Women's
Hospital, and colleagues found. The shift reflected a reduction in the number of all closed claims,
rather than just in payouts, the group reported in a research letter
published online in the Archives of Internal Medicine. Thus,
"our findings suggest that a reduction in errors is likely responsible
for at least a component of this association, since the absolute rate of
claims was lower post-EHR adoption," they wrote.
Federal incentives under the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act pay out bonuses through Medicare and Medicaid for "meaningful use" of EHRs to improve care, although only a fraction of physicians appear to have qualified so far." The
reduction in claims seen in this study among physicians who adopted
EHRs lends support to the push for widespread implementation of health
information technology," Simon and colleagues noted.
Electronic records may cut down on risk factors for errors and
resultant malpractice claims, such as poor communication among
providers, difficulty getting patient information in a timely manner,
unsafe prescribing practices, and poor adherence to clinical guidelines,
they explained. The documentation in EHRs may also improve the likelihood of successful defense against suits, they added. Their
study examined closed malpractice claims among Harvard-affiliated
physicians by using data from the Massachusetts malpractice insurer
Controlled Risk Insurance Company/Risk Management Foundation and from a
survey on EHR implementation from a random sample of physicians in the
Overall, 33 of the 275 physicians included in both databases in
either 2005 or 2007 were named in at least one malpractice claim. Of
the 51 claims, 49 were related to events before adoption of EHRs. While
27% of the pre-EHR claims resulted in a payout, neither of the two
claims related to events after EHR adoption resulted in payment.After
accounting for duration of coverage by the malpractice insurer and of
EHR use, the use of electronic health records was associated with an
estimated relative risk of 0.16 for malpractice claims (95% CI 0.04 to
0.71). The researchers cautioned that other unmeasured factors
could have at least partially accounted for this apparent protective
"For example, physicians who were early adopters of EHRs may exhibit
practice patterns that make them less likely to have malpractice claims,
independent of EHR adoption; these early adopters contribute a
disproportionate amount of time in our analyses, favoring an effect of
EHRs on reducing malpractice claims," the group explained. Centers may also have implemented other practice changes around the time of EHR adoption as well, they noted.
Other limitations were the fact that data from a single group of
physicians in one state covered by one malpractice insurer may have had
an impact on generalizability and that it covered a relatively short
period after EHR adoption, which may have precluded looking at the
influence on missed or delayed diagnosis-type claims. "While this
study includes only a small number of post-EHR claims, it suggests that
implementation of EHRs may reduce malpractice claims and, at the least,
appears not to increase claims as providers adapt to using EHRs," the
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