Electronic health records (EHRs) have been touted as key in improving medical care in the United States, but that is not the perception of many clinicians. A recent survey conducted by Medscape shows that roughly a third of physicians believe that EHRs have negatively affected patient services and clinical operations.
Between April 2014 and June 2014, roughly 19,000 physicians responded to the survey on EHR use. Eighty-three percent said they had implemented an EHR system, with the most popular being Epic (23%), Cerner (9%), and Allscripts (8%). Oncologist responses, 404 of the total, were in line with the overall survey population.
While 35% said EHRs improved patient services, 34% said they made them worse. In terms of clinical operations, 39% said EHRs improved them, and 29% said they had a negative impact. The majority of oncologists, 67%, said EHRs took away from face-to-face time with patients, and 26% said the new technology diminished their ability to effectively manage patient treatment plans.
Jeremy Warner, MD, MS, chair of the American Society of Clinical Oncology's Health Information Technology Working Group, said that Medscape's findings mimic other survey results. A 2013 report by the RAND Corporation is one example.[1] According to Dr Warner, perception may play a role in the answers to questions on clinical operations. "EHRs clearly enable you to work from home," said Dr Warner. "If you don't finish your notes in the clinic, you can go home, have dinner, log in, and then work until midnight, if that is what you want to do. Some people might say that improves operations because it frees up more clinic time to see more patients, and others might say it worsens operations because now they are working more hours."
The Medscape survey also showed that oncologists were more likely to say that EHRs had a positive impact on data collection (40%) vs a negative impact (6%). A greater number thought EHR systems improved documentation vs made it worse (63% vs 25%).
Others in the oncology field were also not surprised by the new survey results. "The idea that EHRs are a panacea to solve all medical errors and problems has turned out to be way overstated," said George Kovach, MD, a medical oncologist at Genesis Cancer Care Institute in Davenport, Indiana, and past president of the Association of Community Cancer Centers. "EHRs basically replace one set of problems with another set of problems."
Workflow is one troubling area. Do EHRs provide structured and free text fields in a manner that makes sense with the way physicians interact with patients? According to Kristin Darby, MBA, chief information officer at Cancer Treatment Centers of America, the industry has looked at EHRs from the perspective of technology implementation rather than clinical implementation, and this has been a mistake. "If you don't involve clinicians throughout the entire process of the design, then frequently, the outcome is more of a system that does not flow the way that a clinician administers care," said Ms Darby.
EHRs may be an information repository, but can clinicians easily find the facts they are most interested in? "Clinicians want to document everything that is relevant to their patient and to their care, but nothing more," said Ms Darby. "One of the things that we have to be careful of is that we are adding complexities that don't add clinical value."
Dr Warner agreed. At Vanderbilt-Ingram Cancer Center in Nashville, Tennessee, where he practices, they use a homegrown EHR called StarPanel. "StarPanel might improve my own documentation, but then the documentation that I get from others might be worse. Some of the vendors put in all sorts of extraneous information," Dr Warner said. "For example, sifting through pages of medication lists on every single progress note, with details about the route delivered, how many refills are remaining, and which pharmacy the medication was filled at, this is probably the kind of information that an oncologist doesn't need to take care of their patient, at least not when it autopopulates into multiple documents."
Dr Kovach also uses a homegrown system, Medical Concierge (Open Software Solutions). He says that many EHRs on the market do not customize information in a format that fits the way a physician collects data or one that fits the particular physician who is receiving it. What is important to an oncologist is going to be different from what is important to a cardiologist or primary care physician.
According to Amy Baltz, director of implementation and account management at McKesson Specialty Health and regional director of iKnowMed at US Oncology, the key to successful EHR implementation is to integrate it into the patient experience. "The most positive experience and value are going to come from using the technology in the patient experience," said Ms Baltz. Physicians should be sharing their computer screen or iPad with their patient. Doctors, she said, should not be entering information into a computer while their back is to a patient. Ms Baltz says that the second generation of iKnowMed can be used on smartphones and iPads, but clinicians should only perform tasks on these devices that don't require a lot of resolution. The task should fit the electronic device. For example, signing labs is something that can be easily done on an iPhone, whereas recording detailed notes is not.
Ms Baltz also recommends that oncology practices look for an EHR that specifically meets their needs. "The biggest complaint that I hear from physicians coming from another EHR system is that it didn't have the content and type of support they needed, oncology-specific," said Ms Baltz.
The rush for implementation has caused many of the inefficiencies. The financial rewards for "meaningful use" of EHR technology provided by the Medicare and Medicaid EHR Incentive Program spurred many clinics into action. "Meaningful use has put a lot of focus on oncology practices implementing EHRs to meet the deadlines but not necessarily optimizing them," said Ms Darby. "As a result of that, you end up with a lot of frustration that the system doesn't work the way physicians want."
Interoperability, the ability for different EHRs to talk to each other, is another big hurdle. "The only thing that is going to allow an Allscripts to talk to an Epic, that can then talk to a Cerner etc., and have data formatted in a way that will import into all those systems is a standard. We don't have that industry standard today. There are standards out there, but nobody is required to comply with them," said Ms Darby. "Until a standard is agreed upon by all EHR vendors, and it becomes part of a future meaningful use regulation or a requirement in the industry, I think the challenges are going to continue to exist."
Most in the oncology arena believe that while EHRs are falling short, they might eventually live up to the hype. Dr Warner pointed out that EHRs were actually not created to improve clinical operations but for billing and legal reasons. "The early wins for EHRs were to create a billing and legal repository of facts, so that procedures were justified and facts were readily available in the case of things such as a malpractice investigation," said Dr Warner. "Eventually human factors will take increasing importance in EHR design and redesign, and maybe efficiency will actually increase. The goals of the users and the creators have been somewhat misaligned, but I think it is getting better."
Dr Kovach is owner and founder of Open Software Solutions.
Medscape Oncology © 2014 WebMD, LLC
Cite this: Kate M. O'Rourke. EHRs Not Living Up to the Hype - Medscape - Oct 20, 2014.
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