Share By Giovanna Fabiano
On the surface, having a universal communication tool that stores every patient’s medical records online seems like a no-brainer.
It certainly provides a practical (and more modern) alternative to hand-written forms in color-coded manila folders that get locked away, gathering dust in hospital records rooms.
Electronic Health Records are being implemented around the country at a fast pace, thanks to federal mandates, but in the healthcare field, not everyone agrees that they improve the doctor-patient experience —at least, not yet.
A study released last fall by the American Medical Association provided some sobering statistics: Electronic medical records chip away at doctors’ job satisfaction and compound their stress by piling onto their workload, eroding the quality of their care, and making their daily practice less efficient.
But renowned pulmonologist Dr. David Beuther, says it doesn’t have to be that way. If physicians are leading the conversation and customizing EHRs for their own needs, a better system for documenting patient records will emerge.
Beuther, chief medical information officer at National Jewish Medical & Research Center in Denver, talked to Real Business about the good and the bad of EHRs, how he made them work at his hospital, and how he got his most reluctant physicians on board.
Why do EHRs cause so much stress for doctors?
What most people that aren’t in healthcare don’t understand is this is much more complicated than Microsoft Word or an ATM machine. Everything about exchanging this data, or even documenting this data, is so nuanced. What is the validity of that diagnosis that you clicked on in the system? People have this black-and-white view of healthcare information, but there are so many shades of gray.
Another issue is that these EHR systems grew out of accounting systems, and they are further being designed by the way healthcare is being reimbursed these days.
The way physicians are even paid mandates a lot of not so useful, structured documentation. EHRs are based on a finance background, but healthcare is not that. When you and the patient are in a room together, these systems fall short.
We are still in an evolution with EHRs and, right now, they don’t do as much as they potentially could do to help us take care of patients. They aren’t designed and driven by physicians. I’m not a naysayer, but we have to be more involved and more vocal in designing these systems or they will never meet our needs. Currently, they’re difficult to use and difficult to adopt.
How much of the problem lies with the process and deadlines around implementing an EHR system?
The thinking is often, “EHRs help patients, they help us save money, they’re really cool,” so there’s this rush to put it in.
In all this madness, we over-implement them. Fifty percent of implementations fail, often because there isn’t physician involvement. Vendors are proud to show off all of their slick functionality, but when you’re actually a physician trying to use this system, many of these features are not as useful as the designer thought. It’s quite difficult, because in the absence of strong leadership, physicians feel pressured to use every feature of the system, regardless of whether it is actually reasonable or useful to do so. And patients don’t tell you their stories in a way that you can point and click as you go along.
For example, we haven’t implemented the structured note module (an EHR-based note-taking mechanism) and we’re still dictating. I think the way they’re designed right now, you lose a lot of value to your clinical documentation if you can’t have a narrative that says, “This is what I think is going on, this is the patient’s story.”
What has your hospital implemented and how has it worked?
At a very high level, the electronic physician order entry has worked well. When I’m ordering tests or meds, I do it in the computer, it checks against your allergies, it prompts me for things I might forget to do, etcetera. I get an alert sent to me that the results are back and I sign off that I saw it. When we were doing orders on paper, 20 percent never got ordered due to illegibility, or they got lost, or sometimes results didn’t get back to the person who ordered the test. We spent a lot of time focusing on integration of electronic medical records with radiology and lab: safety and care coordination.
We also decided we needed to reengineer our entire clinic to make it more physician-driven. We piloted a program where we put one junior person in charge of a division, where he had the core building materials of leadership but had not yet developed them. The organization became more productive and he grew to be a tremendous leader. We grew somebody from within. The pilot was so successful that we created new physician leaders in other clinical areas. Some are struggling and some are shining, but we realized we needed to spend a lot of time building physician leaders.
Was it a struggle getting physicians on board?
Yes, definitely. I had a senior physician who told me, ”I’m scared, sad, and going through all the stages of mourning of a career I used to have.”
We’re in the room with patients where they’re whole life is falling apart … it’s an intimate relationship, and you need to keep your focus on the patient and their story, yet there has been an enormous explosion in the checklist things we are required to do, most of them very legitimate and in many ways just as important. Sometimes the systematized aspects of modern medicine collide with the very human endeavor that this is. The EHR is being used as an agent to enforce systematization, but is not helping with the other half of this equation. There can be a real disconnect there. This breeds discontent with EHRs.
Think about how dramatically healthcare has changed in the last 20 years. The physician was the solo hero figure and everyone else was there to receive your wisdom. That was the model; you could do whatever you wanted. No one was looking over your shoulder.
We are lauded for what we do to help our patients, and encouraged to keep doing this, but simultaneously payment is being cut to unbelievably low levels, so we receive a financial productivity report telling us what a lousy job we are doing. Physicians hate these reports, because they feel de-valued. It basically says, “You’re not working hard enough.” Nobody has reconciled what patients need and expect with the financial reality, in a transparent way, with physician and patient input. This frustration often gets directed at the EHR, sometimes unfairly.
What does the future hold for EHRs?
My optimistic view is that we’re in the midst of this chaos and out of it will come a great system.
Nobody knows what the future holds … we’re in an era of change and I don’t think it’s just a period we’re going through. We need engaged physician leaders. We need an effort to infuse leadership and management skills into all aspects of physician training. Only then will we be positioned to lead the conversation and bring these EHRs to where they need to be.