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More than 1,000 physicians told us what they think about their EHR systems

2019 EHR Scorecard: Physicians rate their EHR systems

The electronic health record (EHR) not only houses patient data, but also is a major source of frustration for doctors. Complaints about them are abundant, ranging from a design that’s focused more on billing than clinical workflow to how the computer and its data-entry tasks create a physical barrier between the physician and the patient.
	
	Even with all their flaws, doctors still see the possibilities within the EHR. “The potential is great to be able to track various pieces of information more efficiently and not have to rifle through papers,” says Robert McLean, MD, FACP, president of the American College of Physicians. “Having the EHR identify people that haven’t had health interventions-something a doctor might forget if they are not on their radar screen-is a great way to houses have control of the health of a population of people.”
	
	All this potential comes with a lot of negative tradeoffs, including poor usability in how information is displayed and lack of interoperability. “One of the big frustrations is that so many EHR systems don’t talk to each other,” says McLean. “Because EHRs evolved from different companies all trying to make successful ventures out of it, there was not really an incentive early on to be interoperable.”
	
	The Office of the National Coordinator for Health IT (ONC) is well aware of the usability and interoperability complaints and has proposed rules that it hopes will change how doctors interact with their EHRs and give patients access to their data to better engage them in their care. The changes focus on a set of standards that will allow apps into the EHR ecosystem, and the hope is that this will enhance the EHR the same way apps dramatically increased the usability and functionality of mobile phones.
	
	


	
	For apps to work in healthcare, or any industry, there needs to be an agreed-upon set of standards on how information is exchanged-commonly known as an application programming interface (API). The API acts as a bridge between applications that allows data to flow seamlessly regardless of how they are constructed or what database they use. Consumer travel sites are an example of how they work: The apps go out to dozens of sites and compare rates for hotels and airlines. They aren’t moving any data, just scanning it and compiling it in a new location.
	
	Once the rules for APIs in healthcare are finalized, Don Rucker, MD, national coordinator for health information technology at ONC, says apps will benefit both doctors and patients. “From the patient point of view, patients are going to have access to their medical records,” says Rucker. “Patients will be empowered to shop for care, and I think all doctors will have to be more concerned with consumer issues. I think increasingly, as patients shop for care, the transparency of the app economy of the price of services will make doctors think about how consumer-friendly they are.”
	
	He also sees physicians benefitting as apps improve EHRs. “I think APIs will make it a lot easier to get information, but maybe more importantly, get the right information within the workflow,” says Rucker. “It might mean getting decent [clinical] decision support when they need it, because most decision supports now are painful alerts and not really perceived as helpful. I think APIs over time will make EHR products a lot more pleasant to use.”
	
	Experts say that APIs are the most efficient way to share information across different platforms, so there is potential for a big boost to interoperability. But having a standard also opens the door for new ways of using EHR data.
	
	Rucker expects a lot of apps to become available to allow just that, including some in categories that no one would think of today. There will be apps that improve the medical record to make it more understandable and apps for management of specific diseases, he says.
	
	One area that may greatly benefit from apps is the prior authorization process. “Doctors may be able to leverage API technology within the practice and access health plans’ prior auth policies and push out the clinical template and make things a lot easier,” says Rob Tennant, MA, director, health information technology policy for the Medical Group Management Association.
	
	App development may start with some small start-ups, but Rucker says he would be stunned if there weren’t some major name brands also entering the space. “EHR vendors will want to be in that space with maybe a vendor-labeled app as well as maybe a white-label app (a generic version) that practices could brand for themselves,” says Rucker. “I could see Apple getting in, and Microsoft, Google and Facebook have been talking about what they might do in healthcare. Amazon publicly announced they want to be in the consumer part of healthcare, so I think you will see lots of entrants into the space.”
	
	


	
	While ONC is pushing hard for apps and promoting the expected positive changes they will bring, industry experts wonder how much promise they really hold for EHRs and healthcare in general. Undoubtedly, some aspects will improve, but APIs may not have the major impact hoped for by the government.
	
	“The jury is still out on how effective API technology and whether the use of third-party apps will move the needle on quality and efficiency in healthcare,” says Tennant, adding that in some cases, there are other technology options to achieve the same goal. For instance, CMS has  proposed a rule that requires admission and discharge information be sent to physicians so they can provide better care coordination to their patients. “API technology may be one of the levers to get that done, but it’s not the only one.”
	
	Giving patients access to medication information, lab results and the like from the EHR has great potential to get them engaged, but it also means practices will have to upgrade their technology to make that possible. “Practices that don’t have the capability may have difficulty attracting newer and younger patients who have much of their life driven through their smart phone,” says Tennant. “All of that engagement is great, but there is some potential concern about cost.”
	
	Large practices have economies of scale and dedicated IT staff to handle the upgrades. Small practices must face not only complicated technology installations, but a new security risk and questions about value. “If they invest the money and the uptick is minimal, that’s concerning,” says Tennant, who adds that if the EHR vendors are the ones developing the apps, he expects them to charge for the added capabilities.
	
	There’s also the challenge of integrating the app into the workflow, which can vary by practice and specialty. “Getting apps working in a physician’s workflow is not a simple problem, and even once you have the API standards established, you are still going to run into that problem,” says Robert Rudin, Ph.D., information scientist and EHR expert at the RAND Corp. “And what is the business model? Who is going to pay for it?”
	
	The CMS proposed rule requires health plans to offer their members access to claims data through apps, something Tennant says many already do with very robust apps available for easy download. Despite this, he says few patients are using them. “The whole ecosystem envisioned by the government rests on the premise that patients actually want this technology. If you are managing the care of a loved one, you might want this technology. For a lot of others, they are happy to have all the records stored and maintained by the practice.”
	
	“For the majority of patients, their simple goal is to be healthier; they trust that doctors do the right things and have access to the data they need,” says Kyle Meadows, founder and president of Chart Lux Consulting, which helps companies navigate healthcare technology and policies. “Data on my phone isn’t where I, the patient, need it. I need to have it in front of the doctor on their screen and have it pre-fetch various activities in the last six months so they have a more complete picture of me in the 15 minutes I have with them.”
	
	Meadows says in the short-term, once the rules are finalized, he expects to see some apps that do interesting things that help physicians, but is skeptical of their total impact. “EHRs have a large amount of data that is not curated real well,” he says. “Apps using APIs can curate that and get to the stuff you are looking for, but I don’t see them moving the needle significantly.”
	
	


	
	Sharing data among EHR systems via APIs may be a big boost to interoperability, but it also creates security concerns, says David Finn, executive vice president, strategic innovation, for CynergisTek, a healthcare cybersecurity firm. “APIs usually have a code to a specific site or system, and those are supposed to be secret and kept for developers,” says Finn. “We don’t have defined standards in how to protect the codes and who’s trying to use them.”
	
	Finn says there needs to be more defined security standards and less reliance on developers and vendors to do it on their own. He says when the final HIPAA security rule rolled out in 2003, developers used the cheapest and fastest methods possible to comply with vague security standards put forth by the government. Without clear guidelines, he expects the same thing to happen with API technology.
	
	“Providers want to provide better care; consumers have the ability to care more about their health and they want access to the same data and have it updated in a more timely fashion,” says Finn. “These are all good things, but we have to make sure we do it the right way.”
	
	A related concern is privacy. Once patients agree to the terms of the app-and most consumers don’t read the legalese in the signup agreements-and information flows from the EHR to the app, experts say the data may be used for a wide variety of purposes. “One concern is vendors will monetize the data, because it won’t be covered by HIPAA or bound by any federal privacy laws,” says Tennant. “A large employer could offer a health app, and go to the physicians and download all the health records of their employees. Who’s to say the employer wouldn’t look through the records looking for substance abuse, pregnancy or cancer? I hope it never happens, but the way the rule is structured, there is no prohibition against that.”
	
	The Office of Civil Rights has issued guidance that says physicians are not responsible for patient data once the patient requests it, but Tennant worries that doctors will be blamed if data is misused or if the app provider suffers a security breach. “Patients might ask, ‘Why didn’t you warn me?’ It erodes the doctor-patient relationship.”
	
	Finn says patient education needs to be a major part of bringing apps into the healthcare system. “Patients have to understand what sharing data means and which data they are comfortable sharing. I think government and the industry itself for too long has excluded the patient from the processes.”
	
	ONC, for its part, says patients understand what’s at stake. “Patients are going to understand that this is their medical record that is being downloaded, and they will treat it the same way they are careful with other personal information-they are not just doing their banking with anyone, for example,” says Rucker. “There will be some consumer branding and trust on these things.”
	
	Tennant says a developer certification process is needed, and it should include a commitment to privacy and security along with clear statements of what the developer plans on doing with data collected from EHRs. “If appropriate steps are taken, this could work well for all sides, but if they are not, you could see catastrophic data breaches.”
	
	Experts say slow, incremental improvements in usability and interoperability are more likely the end result of API standards despite the hype around them. “In healthcare, it’s very rare to have something come out of the blue and spread virally the way we sometimes see in the consumer market,” says Rudin. “There might be some specific applications that take off, but in terms of a major overhaul, I don’t see it happening in the next few years. There is still more foundational work we need to do.”
	
	“Almost anything you can think of, API could step into the picture and really help,” says Tennant. “It’s early yet, and all this excitement comes with a price tag, and for independent practices, they will have to have true ROI to move to the new technology. But the long-term potential is tremendous.”

Articles

Fixing EHRs

A “bold proposal” to reduce the documentation burden on physicians was released as part of CMS’s 2019 proposed Medicare Physician Fee Schedule (PFS). This seemed to have begun as an effort to listen to stakeholders and address the problems of out-of-date guidelines, cloning, EHR misuse, and problems that have evolved since the inception of the documentation guidelines.
	
	However, this proposal introduces a wholly self-serving and uninvited component of a change to payment rates and methodology that no one asked for.


	
	The catchy tagline of “Patients over Paperwork” implies a quality issue caused in part by administrative overkill, but let’s not forget that these are the federal guidelines that have been enthusiastically enforced for more than 20 years by this same CMS.
	
	Last year, when CMS sought input from stakeholders about the need to reduce the documentation burden caused by “administratively burdensome and outdated” guidelines-their own words-the decision was hailed within the industry.
	
	CMS had said, “We are … specifically seeking comment on whether it would be appropriate to remove our documentation requirements for the history and physical exam for all E/M visits at all levels.” The agency went on to say that, “We believe medical decision-making and time are the more significant factors in distinguishing visit levels and that the need for extended histories and exams is being replaced by population-based screening and intervention, at least for some specialties.”
	
	No argument there. Physicians have been looking forward to the results of the comment period and hoping for some regulatory relief.
	
	CMS didn’t say, “While we’re at it, let’s change the way providers are paid. Let’s find a way to pay providers less, particularly for the most complex patients.” But that’s exactly what they’ve done with this new proposal.
	
	In July, CMS administrators and physician leadership from the offices of Health Information Technology and Center for Medicare and Medicaid Innovation (CMMI) gathered for a telecast promoting “Patients over Paperwork,” or their E/M coding reform.
	
	Touting their heartfelt desire to reduce documentation burdens and save individual physicians 51 hours a year in documentation time (roughly an hour a week), these former practicing physicians went on to give some real examples of how the current documentation guidelines don’t work well in the EHR environment.
	
	It’s true that it’s difficult to find the real information in an over-templated note, and this could be a danger to patients. It’s a little less true that docs can’t write real notes. Docs don’t-or won’t is more like it-but some EHRs don’t make it easy, either. 


	
	The first part of the proposal is directed at the real issue: the documentation burden.
	
	The proposal states, “We propose to apply a minimum documentation standard where, for the purposes of PFS payment for an office/outpatient E/M visit, practitioners would only need to meet documentation requirements currently associated with a level 2 visit for history, exam and/or medical decision-making (except when using time to document the service).”
	
	The proposed rule doesn’t specify what level 2, new or established, but let’s assume established since most visits are established. That’s a surprising choice since the documentation burden is so low-no reviews of system (ROS), one exam element, and subacute decision-making.
	
	A 99213 is the most widely reported E/M code and is generally recognized to represent one unit of provider work, an acute uncomplicated problem, or a stable chronic illness. It is somewhat surprising to see, then, that the documentation level wasn’t set there, since it is still very easy to achieve without “note bloat.” But perhaps that is intended as more of the bait, because here comes the switch.
	
	CMS writes: ‘‘We believe our proposed documentation changes for E/M visits are intrinsically related to our proposal to alter PFS payment for E/M visits. … We are proposing to create a single rate under the PFS that would be paid for services billed using the current CPT codes for level 2 through 5 E/M visits. It would not be material to Medicare’s payment decision which CPT code (of levels 2 through 5) is reported on the claim.”
	
	Now that we have reduced the documentation burden for all E/M levels within a code category to a level well below what most codes report and require, it doesn’t matter what code you pick. CMS will pay you the same amount.
	
	Somehow, documentation reduction has now introduced payment consolidation and in many, if not most cases, payment reduction for some providers. This is not an unintended consequence. This is calculated and deliberate.


	
	The rest of the proposal dealing with E/M goes on to say that you can use a time basis to select your code, MDM, or even the old 1995 and 1997 guidelines as the basis for your code selection. The point is, it no longer matters what codes you choose because you get paid the same.
	
	CMS will likely find that physicians lose interest pretty quickly in coding and documentation once it is uncoupled from payment. What they had been complaining about, justifiably, was the time it took to document, not to code.
	
	Were this proposal to be passed as is, it could result in some real unintended consequences. The first provider to comment on this to me said, “Fine, if you make all the visit and payments the same, I’ll just fire all my complex patients.” There’s a consequence. It’s probably not the majority view, but it’s one that CMS should have considered.
	
	Perhaps CMS should just do what it said it set out to do: reduce the documentation burden that they created. Make it a little easier to use the EHR that they mandated, and don’t disguise a budget initiative as a regulation reduction. The sound bite of “Patients over Paperwork” doesn’t disguise the money grab.

Bill Dacey, MBA, CPC is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, billing, documentation, and compliance for physicians.

Is it ‘patients over paperwork’ or a bait and switch?

E/M coding changes 

Prescription drug prices are on the rise. Data from the Centers for Medicare and Medicaid Services reveals that on average, Americans spend approximately $1,200 a year on prescription medications, numbers that have gone up due to rising prices.
	
	In fact, a recent study by the Kaiser Family Foundation showed that nearly one-third of patients say they’re skipping prescription medicine because of the cost. That same study noted four out of five Americans believe the cost of prescription drugs is unreasonable.
	
	Viquar Mundozie, MD, FAAFP, a family physician at Mercyhealth Harvard South in Harvard, Ill., says he often sees patients having to choose between fulfilling daily necessities versus taking medications.
	
	“Many Medicare patients are desperate for help affording meds,” he says. “As primary care providers, the burden of inflated drug prices comes as urgency and we need to be proactive in speaking up and advocating for our patients. This not only helps our patients but entire communities and our nation.”
	
	David Belk, MD, an internist in Alameda, Calif., says it’s important to understand that the rising cost of prescription drugs usually applies to brand name medications. He’s seen studies showing that apprpoximately 87 percent of prescriptions filled in the U.S. in the last two years were for generic medications, and since pharmacies purchase most generic medications for pennies a pill, this is one way costs can be lowered.
	
	“People really need to know this because the cash price for many of these prescriptions can often be less than the insurance copay for the same medication,” he says.
	
	For example, Atorvastatin 20 mg (generic Lipitor) can be purchased for a cash price of about $16 for 100 pills. But that same 100 pills of Lipitor will costs more than $1,400. According to CMS, pharmacies in the U.S. paid an average of 9 cents a pill for Atorvastatin and just over $14 a pill for branded Lipitor.
	
	Another thing that can help alleviate some cost is contacting the pharmaceutical company and asking for discounts for copays. This is a method that Belk has seen work for his patients.
	
	


	
	As of July  2019, more than 3,400 drugs have increased in price, a 17 percent increase compared with the nearly 2,900 drug price hikes at the same time in 2018, according to a new analysis by Rx Savings Solutions, which provides pharmaceutical advice to health plans and employers.
	
	“We need lawmaker to implement legislation that puts a cap on price inflation by drug companies,” Mundozie says.
	
	He notes there are some resources that can help, including assistance programs to those eligible offered by pharmaceutical companies, nonprofit groups or state governments.
	
	To get the assistance process started, he says, patients need to fill out an application with the drug manufacturer. If the patient qualifies, the doctor might have to provide additional information. Then the drugs are either mailed to the patient or their primary care physician.
	
	While a specialist could do this as well, Mundozie says it’s usually primary physicians due to a close and long-term relationship with the patients, since these meds need to be prescribed for a long time and papers need to filled periodically.
	
	“We have a nurse coordinator that helps our patients get the process started and makes sure they understand the process and helps them get their medications on a regular basis,” Mundozie says.
	
	Many states offer drug assistance programs. These vary and tend to be geared toward the elderly, the disabled, those in financial need, or patients with specific conditions, like HIV/AIDS or end-stage renal disease.
	
	In addition, there are assistance programs run by nonprofit groups, such as Partnership for Prescription Assistance, that help low-income, uninsured patients get free or low-cost brand-name medications.
	
	Thomas Sullivan, MD, a cardiologist with 44 years of clinical practice experience and former associate medical director of Blue Cross Blue Shield of Massachusetts, says when a physician prescribes a new drug, the problem is that the patient and prescriber typically do not know the copay until the pharmacist checks the patient’s coverage. If the copay is unaffordable in the eyes of the patient, then it requires a usually inconvenient call or return visit to the prescriber to discuss alternatives. This might take considerable time and delay treatment.
	
	That’s why DrFirst and Humana created “myBenefitCheck” (widely known in the industry as Real-time Benefit Check), which enables patients and providers to collaborate on medication selection based on a patient’s current insurance benefit and potential out-of-pocket costs. 
	
	“Physicians are now able to quickly look up what the copay is while the patient is with them in the office and know the exact copay before it is sent to the pharmacy,” Sullivan says.
	
	


	
	There are also a multitude of apps that doctors and patients can use to help find lower prices for prescription drugs. For instance, Mundozie has had great success with the app GoodRX, which offers price comparison among pharmacies near a specific location so a patient gets the most benefit in savings on their prescriptions.
	
	“Prescription drug prices can vary widely from pharmacy to pharmacy, even if you have insurance,” he says. “This app shows you the comparative prices at the local pharmacies so patients can choose to go to the pharmacy that saves them the most.”

Data from the Centers for Medicare and Medicaid Services reveals that on average, Americans spend approximately $1,200 a year on prescription medications, numbers that have gone up due to rising prices. Here's how doctors can help.

Assisting patients with rising costs of prescription drugs

Over the last decade, few issues in politics have been more polarizing than healthcare. It’s driven a deep wedge between Democrats and Republicans, particularly following the passage of the Affordable Care Act (ACA) and the subsequent efforts to repeal it, and has 

Yet despite all the animosity, there is one subset of healthcare that has had the opposite effect, pulling ample support from both parties to drive multiple initiatives forward: telehealth. Whether it takes the form of remote patient monitoring (RPM), online video discussions between patients and providers (telehealth), asynchronous information exchange or some other option, it’s a concept politicians of all persuasions, from fiscal conservatives to social liberals, are lining up to promote for one simple reason: it makes 

Despite all the wrangling over the specific path to get there, most politicians are in favor of transitioning healthcare from fee-for-service (FFS) to value-based care. Paying for outcomes rather than for activities is very American; we like to see results. It’s also critical to bringing the 

 under control, especially if the ultimate goal is to keep people healthy so they consume fewer healthcare resources and dollars.

The challenge, however, is that nearly everyone spends more time outside of the healthcare system than within it. That makes it far more difficult for primary care physicians and other providers to monitor the health of their patients on a regular basis, which means they often don’t learn of developing health issues until they get so bad their patients can’t stand it anymore.

Telehealth solves that challenge by enabling easy, convenient contact between patients and providers. Remote patient monitoring in particular can give providers daily or even real-time data on the conditions of their highest-risk patients so they can address developing issues before they require an emergency department visit or inpatient stay. And these days, telehealth is easier than ever to put in place, because the enabling technology is nearly universal.

 now own smartphones, and more than half (52 percent) own tablets. So in many cases, the infrastructure is already there. Providers simply need to take advantage of it to drive better health outcomes.

That’s also what makes it easy for politicians to get behind telehealth. They don’t need to spend billions to create a new system. They merely need to throw their support behind it to encourage its use and growth. Here are some of the ways they are doing that:

) intends to allow health savings account (HSA)-eligible high-deductible health plans to cover chronic disease prevention and treatment on  a pre-deductible basis. Bill sponsors include John Thune (R-SD) and Tom Carper (D-DE) in the Senate and Earl Blumenauer (D-OR) and Tom Reed (R-NY) in the House. Since telehealth is an important component of the preventive aspect of chronic disease management, this bipartisan legislation will make it easier and more affordable for health plans to cover these services. America’s Health Insurance Plans also 

 Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act

), which took effect July 1, 2019, enables an individual’s home to be used as a site for treatment and recovery from opioid abuse via telehealth. Among the major beneficiaries are older Americans and people of all ages in rural areas, as both of these populations may find it difficult to travel to an outpatient clinic for regular treatment. It is particularly important to older Americans who live in rural areas, as the death rate from opioid addiction there is 

10 times higher than the national all-populations average

Medicare patients with End-Stage Renal Disease (ESRD)

 can now use their homes as an approved site for a telehealth consult. 

Changes in the Centers for Medicare and Medicaid Services’ (CMS) 

 mean that as of January 1, 2019, patients with ESRD who are receiving dialysis in their homes can now use telehealth services to consult with their physicians rather than going into the office. To be reimbursed, physicians must simply encode the encounter under HCSPS/CPT code 90963.

 Reducing Unnecessary Senior Hospitalization (RUSH) Act of 2018, 

This bill seeks to minimize disruption in the lives of senior citizens by giving skilled nursing facilities (SNFs) additional financial incentives to use telehealth to connect patients to the emergency department during an emergency rather than automatically transferring them to the hospital. Originally, the bill received bipartisan sponsorship from three Republicans and two Democrats. It now has 10 cosponsors-four Republicans and six Democrats.

Medicare Advantage plans make telehealth a standard benefit

. As of January 1, 2020, CMS will allow telehealth services (including remote patient monitoring) to be offered as a standard, covered benefit rather “optional” coverage for which members must pay extra. CMS also allows anyone with basic Medicare coverage, rather than just beneficiaries in rural areas, to have a virtual check-in with their physicians by phone or video chat.

 looking at telehealth changes in Medicaid programs

 are realizing the value of recognizing the home as a site of care. They are seeing that giving Medicaid beneficiaries the option of connecting to their physicians via technology rather than in-office visits can help beneficiaries address acute issues earlier and take advantage of more preventive care. Use of telehealth can eliminate the need for Medicaid populations to take unpaid time off of work or coordinate care for healthy children when another child is ill.

These are just a few current examples of the gathering momentum and support for telehealth services on both sides of the aisle, from the grassroots up to the Federal level. The changes being implemented now will have a profoundly positive effect on the way care is delivered in the future.

Primary care physicians will find it particularly beneficial, especially as more of their revenue shifts from FFS to value-based care, where they take on more risk and are more directly responsible for the health outcomes of their patients. The sooner they take advantage of this trend, the better-prepared they will be as telehealth becomes the norm in healthcare.

Eric Rock is CEO of Vivify Health, an innovator and leader in connected healthcare delivery solutions, offering holistic remote care management while serving the nation’s largest and most progressive health systems, healthcare organizations and employers. He can be reached at 

Telehealth solves many challenges by enabling easy, convenient contact between patients and physicians

October 25, 2019 edition

2019 EHR Scorecard: Physicians rate their EHR systems

Fixing EHRs

E/M coding changes

Assisting patients with rising costs of prescription drugs

Bipartisan support keeps telehealth adoption moving forward