Americans require a moderate solution to the healthcare crisis

I read with interest the “Your Voice” contribution by Dr. Craig Wax, “To solve the U.S. healthcare crisis, think small, not big.” My fundamental objection to Dr. Wax’s well-articulated position is that he represents an extreme position on healthcare in the United State, and Americans are (present political discourse notwithstanding) not generally an extreme people. Not recognized by Dr. Wax is the existence of the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986. This statute, passed in keeping with the compassionate nature of the American people, requires hospitals that accept payments from Medicare (i.e. nearly all) to provide at least stabilizing treatment to any patient seeking care on an emergency basis.  Because of EMTALA, some Americans rely on emergency departments for catastrophic care and eschew expensive health insurance altogether. The latter is not in the patients’, the hospitals’, or society’s best interest. 

The right position for the country is, per usual, a middle course that will provide the compassionate safety net, encourage individual responsibility for health and its cost, and assure a sustainable future for the providers of care. Healthcare legislation passed since 1986 has attempted to walk that line. Extreme positions on both ends of the spectrum need to be considered, but compromise and moderation must win the day. 

James P. Nataro, MD, PhD, MBA
Charlottesville, Va.

We must challenge the current healthcare dogma

It is refreshing to read an article that challenges the current dogma of our healthcare system. Promoting individual choice and advocating for diminishing the bureaucracy of our current healthcare system is an effort that is long overdue.

I applaud the perspective of Dr. Craig Wax, as well as your decision to publish his thoughts. This side of medical economics has not been adequately discussed.

Craig Hjemdahl-Monsen, MD
Hawthorne, N.Y.

Articles

Your voice: Americans require a moderate solution to the healthcare crisis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Getting patient data into their EHR is rated as a major problem. So how are doctors getting the patient data they need when they need it? 

Physicians' EHR work-arounds

In the brief span of my medical school and residency training I was exposed to 16 different electronic health records (EHRs), as well as paper charting.

Ironically, I found that the easiest to use, most comfortable, and best experience was the paper record. Everything else felt clunky, unintuitive, and disruptive to the patient-physician encounter. Digitizing health records increases communication, continuity, and long-term tracking of illness. But for this millennial trainee who is facile with technology and has a background in computer networking, the sum of my experiences with EHRs have left me simultaneously overwhelmed and unimpressed.

And here’s the kicker: Starting my first job as an outpatient primary care physician, I was introduced to my 17th EHR.

In my experience, exposure to the EHR during medical school obstructed both my learning and the training environment. Routinely, I would arrive on my first day of a new rotation to find lack of access to the medical record system and patient information. Obtaining access was always coupled with hours or days of formal training on the nuances of the EHR. In the span of a two-or four-week rotation, this represented precious time away from the bedside. Thereafter, I experienced at least a week of fumbling through a foreign system before understanding the processes, anomalous places to click, and complex orders that almost never paralleled other systems. In effect, the impact of the EHR on my training was more a lesson in responding to change and decoding a dysfunctional medical record system than an actual enhancement of clinical experience.

I was in medical training between 2008 and 2015; my hope is that with EHR consolidation, such experiences are less common. Yet I suspect that EHRs remain disruptive to the training environment. Even the most advanced current EHR systems have incongruous inpatient, outpatient, surgical, and imaging interfaces. Month by month, trainees are still left to contend with the challenge of understanding the computer interface before patient care.

Frustration with EHRs is not limited to senior physicians. It is transgenerational and extends from misapplication of outmoded technology. I have yet to meet a young physician colleague or trainee who has displayed any emotion greater than lackluster contentment with their medical record system.

I envision three major themes for EHR improvement: advancement of usability, care enhancement capability, and supportive infrastructure. The first requires updating technology, revolutionizing interfaces, and easing data entry and extraction. The second theme is already underway in some settings, and involves enhancing digital interaction to extend beyond the documentation of episodic encounters.

Such capability would include integration of population management, digital and remote monitoring of patient data, and real time updating of clinical information and guidelines.

The third major theme involves the systems, people, and processes that are built around EHRs. This supportive infrastructure is responsive to changes in payment, policy, regulation and documentation requirements that are layered into the healthcare system.

One major, yet necessary, fix depends upon  coordinating interoperability between systems. In my free time outside of my busy medical practice, I can instantaneously video chat a friend across the globe easily, for little cost, and with good fidelity. Yet I am frequently foiled in efforts to garner even simple notation on care from the walk-in clinic across the street from my practice.

Such fragmented communication remains far too commonplace. It cripples continuity, leads to soaring costs and duplicative work, and engenders uncertainty in physician decision making and patient care. I fully appreciate the complexity and challenge in meeting the goals of interoperability, not to mention the cost, but a sane healthcare system demands it.

I anticipate that we will see a disruptive innovator-the kind that has arrived in almost every other industry- that will be able to provide a better EHR product, at a far more reasonable price and improved ease of use. In terms of the current market, there have been so few new players on the scene, and those that do exist charge kingly prices to implement and maintain their systems. I anticipate we will see an Uber of EHR, given the expansive marketplace, financial possibilities, and creative genius of Silicon Valley and elsewhere. Many should be eager to take advantage of an uninspiring and frequently frustrating healthcare environment.

On the horizon, physicians should anticipate the implementation of voice recognition software with smart learning and artificial intelligence (AI). This will allow audio recording of an entire encounter, with construction of relevant history points, physical exam notations, and assessment and plan into a digestible, structured, and cohesive document.

Imagine immediate creation of a patient handout at the conclusion of any encounter that summarizes and condenses salient points and plans as they are vocally conveyed to the patient in real time. A similarly generated documented summary of the visit in written form can be reviewed by the physician prior to finalizing and signing.

At this very moment Amazon’s Alexa software can instantaneously tell me the score from the 1960 NFL championship game, and provide details of the date, hour and place of the game in the span of a heartbeat. Yet, after nearly 40 hours of personalized voice recognition training, my current clinical dictation software routinely falters and employs essentially no artificial intelligence or capability beyond that of a transcribing Dictaphone.

The future of EHRs should look to replace typing and clicking with the ability to simply say: “What was Mrs. S’s most recent hemoglobin A1c?” or respond to the request, “Show me Mr. D’s hospital discharge summary.” Beyond this, imagine the comfort of voice activated ordering: “For Mrs. R, I would like to order a chest x-ray, CBC, CMP, and urinalysis.”

This will eliminate the need for multiple clicks, multitasking, and the current fatigue and mental strain associated with scattered rapid eye movement required to navigate uncoordinated ordering systems. It is my belief that voice recognition software complemented by AI will have the greatest impact on breaking the shackles of the current EHR chains that weigh so many of us down.

I hope my next system, my 18th EHR, will be approachable, intuitive, and connected enough to not require a 19th.

A young physician’s view on EHRs

When Delos “Toby” Cosgrove, MD, stepped down from the helm of Cleveland Clinic, where he had served as chief executive officer since 2004, few thought he was ready to exit the healthcare industry altogether.

Still, many were surprised when Gregory Moore, MD, vice president at Google Cloud, announced in a July 19, 2018 blog post that Cosgrove would be joining the company as executive advisor to the Google Cloud Healthcare and Life Sciences team. But in an email to Medical Economics, Cosgrove says Google Cloud’s mission to make healthcare information “accessible, useful, and secure” appealed to him.

“This team is making huge inroads in helping to balance the advances in digital health with the impact on those who provide care,” Cosgrove writes. “I’m thrilled to join them and look forward to continuing Google Cloud’s mission to improve provider efficiency and patient care through the use of technology.”

Cosgrove’s move follows other high-profile moves of individuals prominent in the healthcare industry into technology-related positions. Thomas Insel, MD, left the ­National Institutes of Mental Health in 2015 to join Google’s Verily, and recently left there to create his own healthcare technology start-up.

Meanwhile, famed surgeon and author Atul Gawande, MD, has taken command of the new Amazon-Berkshire-JPMorgan Chase healthcare partnership. But while these healthcare “defections” make headlines, it’s often unclear what such illustrious physicians have to offer these technology companies. What is the potential impact of Cosgrove’s new role with Google Cloud on the healthcare field-and the company’s position in it?

As noted in a recent IDC Health Insights Survey, among the biggest barriers to cloud adoption in healthcare are concerns over the privacy and security of patient data.

Vince Vickers, MBA, a principal at KPMG Healthcare and Life Sciences, who has conducted cloud migrations for several healthcare systems, says that many organizations may have preconceived notions about Google as a secure cloud provider. Vickers says Google’s success in consumer data mining might make some wary of using them to help secure patient health ­information.

“Bringing in someone like Dr. Cosgrove, who is an icon in the industry-someone who has been successful as a physician and as a businessman in the healthcare space and really understands the challenges in this space-goes a long way to building that trust,” he says. “It can help make healthcare providers more comfortable with the idea of Google, and what Google Cloud might be able to offer to assist them.”

Such an eminent hire, Vickers says, can help healthcare organizations believe that Google Cloud is trustworthy-and can provide the tools to keep patient health information private.

Reconciling the push and pull of cloud adoption

Lynne Dunbrack, MS, MBA, vice president of research at IDC Health Insights, says that many healthcare organizations have conflicting feelings about cloud adoption.

IDC’s 2018 Cloud Adoption Trends survey suggests that security remains a top concern for healthcare organizations considering cloud adoption-yet those same organizations also understand that cloud solutions can help make their organizations more secure. Dunbrack says this seemingly contradictory finding is due to many organizations’ lack of experience with cloud solution technologies. This ambivalence remains a bit a conundrum for the industry-and one that could use the right leadership to resolve.

Dunbrack says that many organizations feel overwhelmed by cloud offerings-but Cosgrove’s hire, and the resulting education and outreach efforts, may help healthcare organizations better balance their worries concerning cloud adoption and find the solutions that will work best for them.

“Cosgrove’s reputation in the industry speaks volumes. The fact that he’s getting behind these initiatives and lending his professional talent and expertise speaks to Google’s commitment to understanding the specific needs involved with healthcare and the needs involved with healthcare cloud in particular. It puts Cosgrove, and Google Cloud, in a really good position to guide others,” says Dunbrack.

Cosgrove writes that’s why one of his principal efforts at Google Cloud will be to educate healthcare professionals regarding the benefits of moving to the cloud.

“Google Cloud believes it is important to work with partners across the ecosystem-patients, providers, insurers, and researchers-to unlock important data and deliver it to where it is needed most,” Cosgrove explains.

Cosgrove says that his mission at Google Cloud will be to help healthcare organizations simultaneously improve clinician workflow and the quality of patient care using innovative technologies.

“As the executive advisor, my goal is to use expertise to help the Google Cloud Healthcare and Life Sciences team educate healthcare professionals on the benefits of moving to the cloud and how it can improve not only the work experience of clinicians and staff but also patient experiences,” he says. 

Both Vickers and Dunbrack believe he is in a unique position to do so. Vickers says that Cosgrove’s experience will be a boon to Google Cloud as they extend their reach in the healthcare industry.

“This is a guy with an amazing background who really understands the nuances of healthcare,” says Vickers. “I think Google Cloud having someone like Cosgrove on board, someone who understands the needs and the challenges, is going to be a big benefit for them-and for cloud adoption in general.”

Dunbrack agrees. “There are a lot of benefits to being in the cloud, especially with regards to becoming more agile and bringing new systems online,” she says. “Having a high profile executive like Toby Cosgrove on board is certainly going to be very helpful to Google Health as they move forward and demonstrate their commitment to working in healthcare.”

What does his move mean for digital healthcare?

Toby Cosgrove heads to Google

Nearly 70 percent of physicians find themselves stuck with EHRs they can’t quit for reasons ranging from cost to lack of better options, according to the 

 2018 EHR Report. About 57 percent said they wouldn’t recommend these systems to their peers due to administrative frustrations, lack of interoperability and how they distract from patient care. We spoke to five of the physicians who answered the survey about the EHRs they say they are stuck with. 

 A common reason physicians remain stuck in an EHR they don’t like is a sense of limited options. Keith Aldinger, MD, an internist with a large group practice, Living Well Health Center, in Houston, Texas, says, “It’s pick your poison.” He’s particularly frustrated with the lack of interoperability, which he says was supposed to be the whole point of the original RAND Corporation study that suggested EHRs would improve health benefits and reduce costs.  “They’re not interoperable and the government hasn’t brought pressure to bear on IT vendors to do that, yet they levy penalties against physicians if they haven’t demonstrated meaningful use of the tool,” he says. While acknowledging that he and his fellow physicians could put pressure on the medical group to change to a different EHR, he says, “I don’t see anything out there worth putting pressure on to change to.” Aldinger, who was in independent practice before he joined Living Well in January, 2018, has used two different EHRs and says, “I don’t find any of them helpful when you’re entering the room clinically.”  “You spend a heck of a lot more time with the computer than with the patient,” he says. “I don’t think a computer possesses any of the characteristics that help you interview or interact with people better.”  He doesn’t want to bring in a scribe, as some physicians have done, because he feels that having another person in the room can interfere with the patient’s sense of safety or confidence. “It would just be another presence that made the patient uncomfortable in fully discussing what they want to say,” Aldinger says. Not only does entering data into the EHR distract from communicating with his patients, he dislikes having to sort through what he calls “digital debris”-far more information than he needs-to get to what he’s looking for, particularly when the emergency department sends records. The records are very lengthy, even for simple clinical encounters. “Someone comes in just for a cold and it’s three to five pages due to these pre-populated things they want you to do,” he says. The only improvement he is hopeful about is a possible shift to voice dictation. An affiliated hospital uses a system called Nuance, which Aldinger has tested with success. He envisions this technology replacing manual template box clicking with simple voice commands. 

 Edwin Schmidt, MD, a primary care doctor with SSM Medical Group in St. Louis, Mo., feels constrained by his EHR.“We don’t have any choice in it. It’s corporate medicine. Whoever is on top picks our medical record,” he says. 

He dislikes that his EHR adds complexity to once-simple tasks. He says that he and the five other physicians in his office have all adopted different ways of doing the exact same process in their EHR because it’s just not straightforward. 

“Even if [IT] corrects the problem later, it’s not worth the time to learn how to do it when you’ve already jury-rigged your own system,” he says.

Despite his frustration, and the extra hour of work it adds to his schedule at the end of each day, he won’t be changing EHRs before his planned retirement in 2020.

Nor is he hopeful that there’s a better option. “The big [vendors] say they have physician input, but those are physician administrators who are more interested in the administrative component than practicing medicine,” he says.
If he had his way, Schmidt says he’d go back to paper “in an instant.”

Scott McLeod, MD, an independent primary care physician in Woodstock, Va., looks longingly back to the time two years ago, when he was using an EHR that he found pretty user-friendly.

But in order to keep up with the shift to quality reporting measures as an independent practice, he joined Privia Health, a practice management and population health company that required him to switch to a different EHR.

“It was a downgrade in terms of ease of use,” McLeod says. Before, he had unlimited templates, which allowed him freedom to customize them as needed. Now he has only  173, and can’t change them easily, he says.

The transition between EHRs was so intensive that he acquired tennis elbow and carpel tunnel syndrome from what he describes as “endless clicking” and felt burned  out to the point that he had to take two weeks off during which he did not look at a computer.

But he feels that this EHR is the price of staying independent. As a result, he’s had to reduce his patient load by 20 percent to keep up with all of the administrative work, and his income has decreased.

Having now used the system for two years, he is as comfortable with it as he can get. “I know its ins and outs. I can make it do whatever it can do, but I’m also very aware of its limitations,” he says.

Steven Ames, MD, a primary care doctor with Thurston Medical Clinic, in Springfield, Ore., left independent practice to join a medical group to stay in business.

His previous EHR did not interface easily with the new one, and he couldn’t find anyone to help him adapt to the new system because none of the data was standardized. “It was sort of like going from VHS to DVD, so there really wasn’t a way to input data,” he says. As a result, he had to manually transfer data for every patient.

What’s more, information from other sources has to be entered separately. “I call it a bunch of islands instead of anything being integrated,” he says.

He uses a scribe because “It keeps my head out of the computer” but it doesn’t solve all of his problems.

He’s frustrated by how EHRs areprimarily “based on how to get reimbursement, how to create a database that then proves to the government what we did and what our value is.”

Ames would like to see a healthcare system where patient information is centralized, not siloed. Patients would have a data card containing everything pertinent: address, birth date, health insurance information as well as doctor visits.

“You’d have one repository of past medical history,” he says.

Of course, he’s aware that this is something of a pipe dream at present. At best, he says, “They just need to develop some interoperability standards so that each system can talk to one another. Right now, it’s like some [EHRs] are on a railroad track, some are on a highway and some are on a dirt road.”

A hospital merger between Scarsdale Medical Group and White Plains Hospital in Harrison, N.Y., brought with it a forced change of EHR for internist and gastroenterologist Malcolm Schoen, MD. Schoen thought his previous EHR was less than perfect, but he calls the new one “a horror show.”

He’s frustrated by how it complicates simple processes. “You can’t just get a spreadsheet of vital signs. You have to go to each individual visit and look it up,” he says.

Additionally, the only way he can enter medications into the patient’s record is if he knows the name of the pharmacy the patient uses. And there are medications missing from the database that he has to call in to the pharmacy himself.

Following the merger, patient information did not transfer to his new EHR and he’s had to come in as much as twohours early to do pre-charting. The added burdens are taking a toll on him. “I’m losing sleep and extremely stressed, but all the doctors in my fifty-doctor group are,” he says.

Still, he hangs a small amount of hope on the possibility that the medical group will consider a better product. “I’m anxious to see what else is out there. They can’t all be like this,” he says. 
 

Five physicians discuss how the performance of their systems affects their workload, careers, and ability to treat patients.

Trapped in an EHR

Robert Lending, MD, describes himself as a “computer dinosaur.” The Tucson, Ariz., internist and clinical lipidologist gets cash from bank tellers rather than ATMs. He doesn’t make online purchases or use social media. And he doesn’t use electronic health records.

Lending, 65, calls EHRs “the most dangerous, ridiculous piece of equipment I could ever have conceived of,” adding that his colleagues envy him for the peace of mind and extra time he enjoys from using paper charts.

“You can’t believe how angry they are at computers, at the whole system,” he says.

Lending is far from alone. True, physicians’ use of EHRs has soared in recent years, due in part to the financial incentives the government provided through its Meaningful Use program. According to the most recent data from the Office of the National Coordinator for Health Information Technology, 87 percent of office-based physicians were using some form of EHRs in 2015, up from 24 percent a decade ­earlier.

Still, that leaves a lot of doctors who aren’t using EHRs, despite pressures from the government, payers, and sometimes their own colleagues to do so. Medical Economics spoke with some of them to find out why.

Since beginning practice in the early 1980s Lending has watched as EHRs have spread throughout the healthcare system.

Now he is among a handful of providers at his large, multispecialty practice who continue to use paper charts. While conceding that EHRs offer some benefits, such as data mining and e-prescribing, for the most part he has not liked what the technology has done to physicians or the profession.

“Most of my colleagues are spending an extra one to two hours per day just doing their records, often at ridiculous times,” he says. “Like they’ll see a patient on Tuesday afternoon and finish the note [for that patient] on the weekend.”
Lending dictates his notes on an iPad during the patient visit, in part because he values the level of detail and accuracy it allows.

“When you’re doing a note four days later it’s hard to remember if it was the second left proximal knuckle or the third left distal knuckle,” he says. “My ability to create a useful, accurate note lessens even a day later.” He e-mails the dictated note in audio format to a medical transcription service.

Lending estimates that the government docks him the equivalent of 2 percent to 3 percent of his Medicare reimbursements for not using EHRs. “But I’m willing to give that money up so I’ll have all my charts done before I leave the office, every script is taken care of, and my desk is clean,” he says. 

Similarly, he misses out on a portion of bonuses the practice receives tied to quality data gleaned from providers’ EHRs. “But that’s another thing I’m willing to give away so that I can just do my thing and be a doctor,” he says.

Lending says that if he were younger and had more years of practice ahead he would probably have gone digital by now because “Who knows, ten years from now it may be illegal even to use paper.” As it is, EHR use now is a requirement for any new provider  joining the practice. But he is determined to hold out.

“Why would I want to take the smooth, efficient machine I have in my office and throw this kind of junk [EHRs] in just to be able to be current?” he says. “If my group forced me, that’s when I would quit.”

For Washington, D.C. internist Ashesh Patel, MD, using paper charts rather than EHRs was more a legacy than a conscious decision. But having started down the paper trail, so to speak, he’s reluctant to turn back.

Patel, 46, began his career in 2000 by partnering with an older physician who didn’t use EHRs. Patel followed his example and continued with paper charts even after his partner retired six years later.

“It was more economically feasible to continue than to convert all those paper charts I inherited into electronic form, especially starting off as a solo practitioner,” he explains.

Since taking over the practice Patel has sometimes considered using EHRs for new patients while continuing on paper with existing patients but has found he likes the simplicity and direct patient contact paper charting affords.

“When I see a patient there’s no computer in front of me so I’m always face to face with that patient,” he says. “I write the note in front of the patient and they like seeing me write what they’re saying and knowing they’re being listened to,” he says.

Patel’s day begins around 7:30 a.m. and most days he’s finished charting by 4 p.m. “So I’m not in the position of many doctors I know who are still charting on their computers for an hour or two after their day is over, which leaves me time to focus on tasks like refills,” he says.

Like Lending, Patel incurs a financial penalty from Medicare for not using EHRs. But since only 20 percent of his patients are on Medicare, it’s a price he’s willing to pay for not spending additional hours completing patient charts.

An unexpected benefit of paper charting, he adds, has been the response of the medical students who rotate through his practice.

“I’m the only place they go that has paper charts, and at first they’re a little shocked,” he says. “But once they realize that charting is simple, and they can come here and participate in patient care right off the bat without having to learn a new [EHR] system and password and all that, they really seem to appreciate it.”

His students are also reassured, Patel says, by the fact that he has computers in his office for other purposes, such as scheduling and getting patients’ lab results. “I’m not totally averse to computers, I grew up playing with them,” he says. “It’s just that I’ve gotten used to paper charting and I like it.”

When Boise, Idaho internists Ann Cordum and Kristen Fiorentino began planning to open their own practice in 2015, one of the first questions they debated was whether to use EHRs. Both had used them previously and knew the technology’s advantages and drawbacks. Eventually they chose not to, though the decision was not easy.

“There’s a lot of pressure in medicine to use a formal EHR. But so far we have not felt that the pros outweigh the cons,” Cordum says.

In part, their decision was driven by a desire to keep their practice small and personal and operate it on a direct-pay model, which requires minimizing overhead expenses. And the costs of buying and maintaining an EHR system and keeping its software updated can easily run into tens of thousands of dollars.

“So if I can cut out that piece it allows me to see fewer patients per day and spend more time with them, which was our goal when we started this practice,” Cordum explains.

Moreover, she adds, EHRs require physicians to spend a portion of each patient visit entering often-irrelevant data such as when the patient last had an eye exam or dental checkup. “And the more time spent on all that, the less time the practitioner has to address the patient’s immediate concern,” she says.

In place of an EHR, Cordum has developed her own patient charting system, either creating a traditional SOAP note in Microsoft Word or dictating the note and sending it to a transcription service. She stores printouts of notes in her office and in digital form encrypted on her computer. Except when the patient grants permission, the only other person who can see the data is Fiorentino, when she’s covering for Cordum.

When Cordum needs to exchange patient data with another provider or institution  she does it the same way the other party does even if they have an EHR: by fax.

“It’s the irony of electronic health records that none of these systems talk to each other,” she says. “So even if I were totally electronic, I’d still be relying a lot on paper.”

Despite their shortcomings, Cordum says she’s not philosophically opposed to using EHRs. “If it’s a tool that will help my patient get better care, I will use it,” she says. “But if it’s cumbersome and not really helping the care, then it just doesn’t work for me and my patient.”

Some physicians have resisted electronic health records systems and still rely on paper.

The paper chart holdouts

In what some are calling a major technological breakthrough for EHR interoperability, Carequality and CommonWell are set to launch a health information exchange that will include all major EHR vendors.

Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative, sat down with Medical Economics to answer questions about what to expect, how to cope with the additional data, and what lies ahead.

Medical Economics: When will this be available to U.S. physicians and how do they get on board?

 We already have some provider organizations in initial production connected via Cerner, Greenway, and Epic, so some physicians are already using this.

By early October, it will be opened up completely to all CommonWell and Carequality vendors. The bridge is built, now we just need vendors to make it available to their customers. We expect that in eighteen months to two years, most vendors will have implemented it with their customers.

ME: How many US physicians will be able to make use of this?

The EHR vendors in Carequality and CommonWell represent about 75 percent to 80 percent of U.S. physicians. I suspect and hope! that as word gets out, physicians will be banging on the door, asking their vendors: “When do I get this?”

ME: More interoperability means more data for physicians to digest. Won’t physicians be flooded with data?

This is one of the challenges of interoperability, but it’s the problem we wanted to have.

I’d rather that people complain about the data they’re getting than get no data at all. However, I realize that physicians can be inundated by too much info, which presents workflow and safety issues as well. Vendors are working with their customers to integrate all this data into their workflow-what fields doctors need to be able to access from which screen, what data they can do without, and so on.

But in order to make this work for you, there is no better channel than loud and frequent feedback to vendors. The more focused feedback you provide, the more they respond.

ME: Is there something that physicians can do on their end to help them sort through the tsunami?

 Physicians need to think: “How I am going to use this data? What data do I really need?”

The practice manager, physician manager, or care teams need to look at this in a thoughtful way, see how they can make the best use of it, and set up processes and routines for managing the day-to-day flow It’s no different than what they’ve already put in place with their postal mail, courier packages, and faxes – it’s just another medium.

ME: What types of information will doctors be able to access beyond Continuity of Care Documents?

 Right now all you get is the Continuity of Care Document, which has 22 data elements required by Medicare and Medicaid.

Physicians say, “The CCD! You’re giving me more of the stuff I hate!” For many physicians CCDs seem like 10-15 pages of cut and pasted information with one small piece that they need hiding in there somewhere. I’m sympathetic to these concerns, but once this data is in their system, they can figure out how they want to integrate it into their workflow.

Most physicians can tell you the three or four other clinicians or specialty groups they need information from regularly, and usually three or four types of info they need. They should communicate with their main referral partners to get and set expectations of what they will send and receive through their EHR systems. They can say establish workflows for handling information from their main referral partners, which will account for most of their activity, and a triage process for managing the less frequent, ad hoc information that dribbles in less frequently.

Again, they already do this with their paper processes, they just need to apply that same attention on process to their electronic processes.

 Over the next few years we should see more functions based on FHIR standards which will provide the ability for more useful interoperability because the data will be more manageable.

The CCD is a document-level standard, meaning that you get the entire medical document with each exchange, not just the specific information (like medications) that you were looking for. FHIR is a data-level standard, meaning that you can ask for and receive specific information (like medications) and just get that back. It’s basically the same technical approach that Amazon and other modern platform companies use today.

Here’s an analogy. Way back in 1998, Sears had a shopping website, but in order to use it you had to download the whole Sears catalog, page through on your computer it to find what you want to buy, and type the information into a box on the Sears website. Now you go to Sears or Amazon and type “21-inch gasoline lawnmower,” and it gives you back just the information that you asked for, not their entire catalog.

ME: So now we’re at the 1998 Sears website stage?

: Right. Is it perfect and elegant? Absolutely not. But we have to start somewhere. We’ll look back in ten years and see that this was the first step toward nationwide interoperability-like the old online Sears catalog. But by then we’ll hopefully have something more like Amazon.

A new health information exchange will include all major EHR vendors. 

An interoperability breakthrough?

A whopping 83 percent of physician practices report that they have experienced some form of a cyber-attack, including phishing, hacking, and even employee theft of electronic protected health information (ePHI), according to a study from the AMA and Accenture.

Practices typically focus on technological tools and interventions to prevent these incidents. While antivirus software and firewalls do play a critical role in cybersecurity, the human element should not be overlooked, says Uday Ali Pabrai, chief executive officer of ecfirst, a cyber-defense company.

“The journey starts with knowledge acquisition,” he says. Most organizations have not done enough to improve individuals’ cyber-literacy, thus weakening practices’ readiness overall, he says.

It’s important for physicians to gain staff buy-in on cybersecurity, as it can affect the future of the practice and their jobs.

October 25, 2018 edition

Your voice: Americans require a moderate solution to the healthcare crisis

Physicians' EHR work-arounds

A young physician’s view on EHRs

Toby Cosgrove heads to Google

Trapped in an EHR

The paper chart holdouts

An interoperability breakthrough?

Four tips for successful cybersecurity training

She doesn't have a door

12 things doctors should consider before a major tech investment

2018 EHR Report Card