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FEATURE

Are EHRs and Physicians Out of Sync ?

In the past decade , the U . S . health-care system has undergone a historic transformation from a paper-based system to electronic health records ( EHRs ), which – thanks to government mandates – have reached nearly 100 percent adoption among hospitals and physicians . 1
The rapid uptake of this technology has not been without incident , though , and many practitioners have what can best be characterized as a “ love-hate ” relationship with EHRs . The promises of easier data accessibility and better communication come at the cost of a greater documentation burden which , for many providers , means more time looking at the computer screen instead of the patient .
“ There is no question that EHRs have the ability to improve care , but there are still glitches with this relatively new technology ,” said Andrew D . Zelenetz , MD , PhD , medical director of quality informatics at Memorial Sloan Kettering Cancer Center in New York .
This month , ASH Clinical News spoke with experts in health information technology ( IT ) about the ongoing implementation of EHRs , how it has affected hematologists ’ practice and care delivery , and where the effort might be headed next .
HITECH Hijack ?
The Health Information Technology for Economic and Clinical Health ( HITECH ) Act was signed into law in 2009 , when fewer than one in 10 hospitals and 17 percent of physicians used EHRs . 2 The legislation , which received uncharacteristically strong bipartisan support in Congress , encouraged widespread adoption of health IT by providing financial incentives to clinicians and hospitals who demonstrate “ meaningful use ” of EHR systems . 3 The incentives worked : By 2016 , more than 95 percent of all eligible hospitals and more than 60 percent of office-based physicians had demonstrated meaningful use of certified health IT through participation in the Centers for Medicare & Medicaid Services ( CMS ) EHR Incentive Programs . 4 , 5
But adoption does not necessarily mean adoration . Providers commonly complain that the EHR interfaces are clunky and slow , Dr . Zelenetz noted .
“ HITECH incentivized users , but it didn ’ t incentivize vendors to make the best , most innovative strategies ,” he said . “ I ’ ve never understood why typing information
into an EHR [ can ’ t ] look and feel the same as typing in Microsoft Word . It feels like software developed in the 1990s because it is software developed in the 1990s .”
Slow interfaces mean more of doctors ’ limited time is spent on electronic documentation and the pervading sense that the medical profession has been hijacked by rules and regulations that have mostly served to make physicians unhappy – rather than improving the quality of patient-physician interactions .
“ The dysphoria in medicine revolves a great deal around the EHR , but not solely ,” said physician-author Abraham Verghese , MD , at a recent panel discussion on “ Medicine 3.0 .” He added that EHRs were “ imposed on us by federal fiat ,” mostly for better billing and quality reporting . 6
Doctor or Data Entry Clerk ?
So , are the headaches worth it ? “ I think EHRs offer better quality , better patient care , and better communication [ than paper records ],” said Bruce Brockstein , MD , medical director of the Kellogg Cancer Center and division head of hematology / oncology at NorthShore University Health- System in the Chicago area . “ But it takes us more time than when we had paper records , in part because we can do more things , and we can communicate more things to more people .”
For Dr . Brockstein , the question of whether physicians are happy with EHRs is beside the point . “ It ’ s been 15 years that we ’ ve been using EHRs in our hospital system , so most of the people here have never practiced without it ,” he said . “ After that amount of time , you either get settled or you abandon it , and we are quite settled at our institution , even though there is still much that can be improved .”
In 2011 , his group looked at the effect of EHR adoption on the culture of oncologists practicing in the four-hospital NorthShore University Health System . Survey results were largely positive : “[ EHR-conducted ] chemotherapy ordering is more complete and safer [ than in the paper-based system ]. Legibility errors are gone , communication is instantly available from any location , and both outpatient records of hospitalized patients and inpatient records of outpatients are available electronically .” 7
In a second report , the NorthShore group compared completeness of medical records between both systems , finding that ,
with EHR-based computerized physician order entry ( CPOE ), 93 percent of expected data points ( i . e ., patient information , treatment plan , laboratory results , etc .) were documented , compared with 67 percent in paper charts ( p < 0.001 ). 8 “ The nurses and physicians reported good satisfaction , statistically better than with the paper charts , in using the EHR system ,” Dr . Brockstein added .
The most-liked aspects of the EHR / CPOE system were the availability of previous laboratory results , identification of clinical trial participants , and completeness of chemotherapy orders . On the other hand , practitioners were least satisfied with how the system captured patients ’ past medical history and treatment calendars . However , these satisfaction ratings were still higher than the respective scores for the paper charts , he noted .
“ I think we are providing better care because , if you use the EHR correctly , things don ’ t slip through the cracks ,” Dr . Brockstein said , “ and communication with the rest of the health-care team is much easier .”
Patients also seem to be happier with the digitized system . “ Our patients can send a note in the middle of the night to say they are experiencing a certain symptom , and we can get back to them right away ,” he explained . “ They also receive their test results within 24 to 72 hours .”
Accelerating patients ’ access to their own test results , though , puts extra pressure on doctors to inform them of the results , before they receive potentially bad news electronically .
And , according to Dr . Zelenetz , any time saved by EHR-enabled communication with patients is eaten up by more administrative responsibilities . “ Unfortunately , the time we save with the EHRs is being taken up by demands for higher productivity , so I think part of the issue is that our practitioners don ’ t get to bask in the improvements ,” he said . “ It makes it hard to appreciate the advances we ’ ve made .”
In the process of gaining adherents , HITECH lost support with its meaningful use criteria . The broad definition of meaningful use is “ using certified EHR technology in a meaningful manner to :
• improve quality , safety , and efficiency ; and reduce health disparities
• engage patients and family
• improve care coordination , as well as population and public health
• maintain privacy and security of patient health information ” 9
Ultimately , CMS argued , meaningful use compliance would result in improved clinical outcomes , increased transparency and efficiency , empowered individuals , and more robust research data on health systems .
These criteria , according to virtually every U . S . hospital and provider , were overly burdensome . The former CMS Administrator himself , Andy Slavitt , MBA , was quoted in 2016 as saying , “ We have to get the hearts and minds of physicians back . I think we ’ ve lost them ,” in reference to the meaningful use rules . 10
In March , the new CMS Administrator , Seema Verma , MPH , announced a “ complete overhaul ” of the agency ’ s meaningful use program that will be aimed at reducing the time and cost burden of compliance for hospitals . Details of the renovation have not been released .
The Promises of Paperless
“ One thing that EHRs do unequivocally is give us immediate access to much more patient information , and with that data we can make much better choices about how to care for [ patients ],” said Dr . Zelenetz . “ No one complains about getting information from the system ; the complaints are about having to put the information into the system .”
Most research on EHRs reaches the same conclusion : They are a boon for clinical care . EHRs reduce medical errors and facilitate integrated care . Medication mistakes still occur , but mostly due to human error during manual entry .
“ Our CPOE system has dramatically reduced errors ,” Dr . Zelenetz confirmed . “ We don ’ t see lost orders or inaccuracies because someone couldn ’ t read the physician ’ s handwriting . The system has predefined [ chemotherapy ] regimens , so I just say what I want to give , and it ’ s all calculated based on the patient ’ s height and weight . It takes seconds to write [ the order ] and it gets transmitted to a verification nurse for review and then , boom , the pharmacy gets it .”
In their report on the rollout of the system , Dr . Zelenetz and researchers from the Memorial Sloan Kettering stressed that “ a
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FEATURE Features Are EHRs and Physicians Out of Sync? In the past decade, the U.S. health-care system has undergone a historic trans- formation from a paper-based system to electronic health records (EHRs), which – thanks to government mandates – have reached nearly 100 percent adoption among hospitals and physicians. 1 The rapid uptake of this technology has not been without incident, though, and many practitioners have what can best be characterized as a “love-hate” relationship with EHRs. The promises of easier data ac- cessibility and better communication come at the cost of a greater documentation burden which, for many providers, means more time looking at the computer screen instead of the patient. “There is no question that EHRs have the ability to improve care, but there are still glitches with this relatively new tech- nology,” said Andrew D. Zelenetz, MD, PhD, medical director of quality informat- ics at Memorial Sloan Kettering Cancer Center in New York. This month, ASH Clinical News spoke with experts in health information technol- ogy (IT) about the ongoing implementation of EHRs, how it has affected hematologists’ practice and care delivery, and where the effort might be headed next. HITECH Hijack? The Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law in 2009, when fewer than one in 10 hospitals and 17 percent of physicians used EHRs. 2 The legislation, which received uncharacteristi- cally strong bipartisan support in Congress, encouraged widespread adoption of health IT by providing financial incentives to clinicians and hospitals who demonstrate “meaningful use” of EHR systems. 3 The incentives worked: By 2016, more than 95 percent of all eligible hospitals and more than 60 percent of office-based physicians had demonstrated meaningful use of certi- fied health IT through participation in the Centers for Medicare & Medicaid Services (CMS) EHR Incentive Programs. 4,5 But adoption does not necessarily mean adoration. Providers commonly complain that the EHR interfaces are clunky and slow, Dr. Zelenetz noted. “HITECH incentivized users, but it didn’t incentivize vendors to make the best, most innovative strategies,” he said. “I’ve never understood why typing information ASHClinicalNews.org into an EHR [can’t] look and feel the same as typing in Microsoft Word. It feels like software developed in the 1990s because it is software developed in the 1990s.” Slow interfaces mean more of doctors’ limited time is spent on electronic docu- mentation and the pervading sense that the medical profession has been hijacked by rules and regulations that have mostly served to make physicians unhappy – rather than improving the quality of patient-physician interactions. “The dysphoria in medicine revolves a great deal around the EHR, but not solely,” said physician-author Abraham Verghese, MD, at a recent panel discussion on “Medicine 3.0.” He added that EHRs were “imposed on us by federal fiat,” mostly for better billing and quality reporting. 6 Doctor or Data Entry Clerk? 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