ASH Clinical News ACN_4.7_FULL_ISSUE_DIGITAL | Page 8

In the past decade , the U . S . health-care into an EHR [ can ’ t ] look and feel the same system has undergone a historic transformation from a paper-based system to software developed in the 1990s because it
as typing in Microsoft Word . It feels like
electronic health records ( EHRs ), which is software developed in the 1990s .” – thanks to government mandates – have Slow interfaces mean more of doctors ’ reached nearly 100 percent adoption limited time is spent on electronic documentation and the pervading sense that among hospitals and physicians . 1
The rapid uptake of this technology has the medical profession has been hijacked not been without incident , though , and by rules and regulations that have mostly many practitioners have what can best be served to make physicians unhappy – characterized as a “ love-hate ” relationship rather than improving the quality of with EHRs . The promises of easier data accessibility and better communication come “ The dysphoria in medicine revolves a
patient-physician interactions .
at the cost of a greater documentation great deal around the EHR , but not solely ,” burden which , for many providers , means said physician-author Abraham Verghese , more time looking at the computer screen MD , at a recent panel discussion on instead of the patient .
“ Medicine 3.0 .” He added that EHRs were
“ There is no question that EHRs have “ imposed on us by federal fiat ,” mostly for the ability to improve care , but there are better billing and quality reporting . 6 still glitches with this relatively new technology ,” said Andrew D . Zelenetz , MD , PhD , medical director of quality informatics at Memorial Sloan Kettering Cancer EHRs offer better quality , better patient Center in New York . care , and better communication [ than paper records ],” said Bruce Brockstein , MD ,
This month , ASH Clinical News spoke with experts in health information technology ( IT ) about the ongoing implementation Center and division head of hematology /
medical director of the Kellogg Cancer
of EHRs , how it has affected hematologists ’ oncology at NorthShore University Healthpractice and care delivery , and where the System in the Chicago area . “ But it takes effort might be headed next . us more time than when we had paper
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
ASHClinicalNews . org 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
FEATURE
• 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 .
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
ASH Clinical News 35

Letters to the Editor

The Problems With Paperless

Features
Are EHRs and Physicians Out of Sync ?
HITECH Hijack ? The Health Information Technology for
Doctor or Data Entry Clerk ? So , are the headaches worth it ? “ I think
April 2018 feature
The Promises of Paperless “ One thing that EHRs do unequivocally is
In our April issue , we looked at the U . S . health-care system ’ s transformation from a paper-based system to electronic health records ( EHRs ), and clinicians ’ love-hate relationship with the latter (“ Are EHRs and Physicians Out of Sync ?”). Experts in health information technology spoke about how the ongoing implementation of EHRs has affected hematologists ’ practice and care delivery . Below , a reader expands on a few implementation challenges mentioned in the article , sharing the perspective of a clinician who uses the EHR system .

HELP HEMATOLOGY PATIENTS FIND YOU !

To the editor : I read with interest the feature article on EHR issues in the April issue . While the article touches on some important points concerning the issues confronting EHR use , there were several missing pieces that I think should be pointed out .
First , the experts that were interviewed for the story – and those who served on panels discussing this issue in general – probably do not spend much time “ in the trenches ” with an EHR system . Heads of departments rarely have heavy clinic schedules and might not understand the burdens of time and clinical responsibility experienced by most of their more junior peers and practicing physicians . Furthermore , the patients seen by these experts are a highly select group of individuals , often seen in consultation and then not again . It is not surprising , therefore , that the senior physicians don ’ t feel the pain that those of us in active practice do . This is not to say their opinions don ’ t matter , but their perspective is somewhat limited .
Second , there are limited data to support the claim that EHRs make for better patient care , fewer errors , and more efficient practice . There are few randomized trials comparing patient outcomes before and after the implementation of EHRs . While a couple of unique small studies were mentioned in the article , the larger question of risk reduction and better outcomes was not addressed . Most of the “ improved outcomes ” of EHR institution relate to gathering “ big data ,” instituting clinical pathways and guidelines , and – above all – patient billing . It is
no coincidence that Epic software is based on a hospital billing system and remains a very efficient way to collect money .
Third , all this data collection and pathway compliance comes at a cost – time . Practicing physicians often state that they could occupy an entire patient visit by just clicking on boxes to demonstrate compliance in the EHR . Hence , the frustration and high dissatisfaction amongst primary-care and active tertiary-care providers .
As a practicing hematologist , I applaud the Centers for Medicare & Medicaid Services ’ EHR-related initiatives . This kind of scrutiny was never undertaken during the prior administration , and there was no attempt to regulate the proliferation of for-profit organizations that have done so well with the money the government has spent on the Health Information Technology for Economic and Clinical Health ( HITECH ) Act . I am glad to see the American Society of Hematology and other organizations starting to pay attention to this issue , which stands to be a critical component of our practices in the future .
Robert F . Taylor , MD Aurora BayCare Medical Center
Milwaukee , WI
Have a comment about an article ? Let us know what you think ; we welcome your feedback . Email the editor at ACNEditor @ hematology . org .
ASH members can help patients find their hematology practice by signing up to be included in ASH ’ s Find a Hematologist directory .
Visit www . hematology . org / Patients / FAH . aspx to add your information !
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