Doctors Disagree on Efficiency of Electronic Medical Records

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COLUMBIA - Electronic medical records, or EMRs, have given some physicians joy and others nightmares. 

The federal government mandated all health care providers in the U.S. switch to EMRs by January 1, 2014. EMRs replaced the previous medical records systems done by hand on paper.

The days of the 4-inch thick patient chart are over.

"We knew it was coming, we knew we had to do it." said Tom Selva, chief medical officer at University Hospital.

But University Hospital was always ahead of the game. It switched to an EMR provider 15 years ago when it started using Cerner, based in Kansas City. Selva said this has given the hospital a distinct advantage.

"It lets us get really new cutting edge technology at a much lower cost," He said.

For example, the hospital's medical records have different interfaces to meet the needs of specific specialists.

"We design the system so that if you sign in as an orthopedist, you see what an orthopedist sees," Selva said. "I could sign into the same record as a pediatrician and see a totally different view - same data presented to me in a way that makes my life more efficient and helps me see you in a way I think."

For doctors like oncologist/hematoligist David Schlossman, however, with change comes uncertainty, and he said EMRs have caused quite the controversy in the medical world.

Schlossman splits his time between his office and Boone Hospital Center. His office uses an oncology specific EMR called IKnowMed. Boone Hospital Center uses a number of different EMR systems provided by McKesson.

"The insufficiencies are so many it's hard to know where to begin," Schlossman said.

Schlossman recently received a master's degree in medical informatics, which is the science of EMRs and using information processing technology to improve patient care.

He said EMRs slow physicians down.

Doing key clinical tasks takes an average of three times - or even five times - as long on an electronic medical record as it used to take us on paper, Schlossman said.

But Selva said, "You may say that the EMR doesn't function fast enough, it doesn't retrieve data fast enough, and that's true. But if you go back to the world of paper, there were many times you saw a patient, and there was no record at all."

Schlossman said, "I could be slowed down by 25 percent, maybe, on behalf of better quality, but when you start slowing people down by a factor of three, it just makes it really hard to get through the work day."

Dr. Rochelle Parker, an assistant professor of clinical medicine with the internal medicine department at University Hospital, said EMRs save physicians time.

"During the course of the day, it probably saves you hours of running around and writing paper orders," Parker said. "You can do a lot more efficient, meaningful monitoring of the patients by just getting into the EMR."

Schlossman said, "Faculty physicians are largely shielded from the usability problems of their electronic health record because the people who have to wrestle with it, put in all the information and make it work, are their interns and residents. Those of us at Boone who are in private practice have to do it ourselves."

Schlossman also said the EMRs distract a physician's attention from the patient.

"It never fails to astound me that it's illegal for me to text while driving, but it is required for me to text while seeing a patient," Schlossman said. 

Schlossman said the EMR gets in the way of interaction between doctor and patient.

"Having that electronic record in there slowing me down is sort of almost an embarrassment to a caring physician," Schlossman said. 

Selva said the age of a physician might play a factor, as well, when it comes to working with EMRs. 

"Physicians who are coming into practice now right out of residency - they don't know a world without a computer, and for them this is just the way you do things," Selva said.

Parker, who has been practicing medicine for more than 30 years, said her main frustration with EMRs is the learning curve, but she said at University Hospital, there's always someone to help.

"I know that on the holidays, in the middle of the night, if I need them to help me, they're there, I call them," Parker said.

University Hospital has its own EMR training center where physicians and nurses go to learn to use the programs. Selva said many of the staff in the training center have master's degrees in education, particularly in education of adults.

"This is very unique. So one of the biggest issues that you'll see with EMRs, and part of the reason they get such bad name, is that like any other tool, you have to learn how to use it and physicians don't have a lot of time," Selva said.

Schlossman said there is also a training center at Boone Hospital Center, but the set up is different.

"The teachers are me and my colleagues on the information technology committee. We don't have any grants to fund master's level teachers that are full-time employed to do that."

Selva said another issue with EMRs is the time it takes to document patient information.

"What drives doctors crazy about EMRs is the burden of documentation," he said. "Nobody wakes up in the morning going 'I can't wait to document my patient care today.'"

Schlossman said EMRs hide the pertinent information doctors need to know about patients. 

"The electronic medical notes often depend on templates, and plug in huge amounts of extraneous information, so that our documentation is turning into five pages of material where four pages of it is automatically computer entered by a template," Schlossman said. "The physician reasoning that you need to see is two or three sentences in there and it's hidden."

Selva said there is a growing need for trained scribes in hospitals to help physicians document patient information. They would make it so physicians would not have to deal with the EMR, and they could just focus on taking care of patients.

"I think electronic medical records have brought that to the fore and made that more of a focal point," Selva said. "It's always been an issue. Whether I was doing it with a pen or a Dictaphone or a checklist, nobody likes to document."

EMRs make it easy for physicians to use such technologies as Dragon, a voice recognition program that captures the words spoken into a microphone and types them automatically into the computer.

"When Dragon works great, it's awesome. When Dragon hiccups, it'll drive you crazy," Selva said.

Parker said another issue with EMRs is they do not talk to each other, meaning hospitals with different EMR providers cannot transfer patient information easily, even with the patient's consent.

As an example, she cites a patient who had major lung surgery in Iowa then became short of breath on the return trip to Columbia and was admitted to University Hospital, which used a different system.

"They're still having to fax the records from their computer system, and then they'll scan them and put them into our EMR. So it would be much more efficient if we could somehow just transmit them through the computer, but it wasn't available."

Selva and Schlossman disagree on whether such problems have been appropriately addressed at the federal level.

"About a year ago, the federal government was upset that they [EMRs] were not talking to each other as much as they should," Selva said. "If the private EMR vendor didn't figure it out, the feds were just going to mandate it."

In early 2013, several major EMR vendors formed the CommonWell Health Alliance, aimed at finding a way to share data between themselves.

Schlossman said, "We're now 15 months down the pipe and as far as I can see, it hasn't produced any progress."

All of the major EMR vendors are a part of the alliance, except for Epic, which generated the second highest annual revenue per EMR provider in 2013, according to this medical economics report.

Selva said, "The actual sharing of data is the easy part. It's the agreements that have to exist between organizations that data can be shared, and your willingness as a patient to allow that data to be shared, that makes it very murky. But from a technology standpoint, it's really not that hard."

Schlossman said he thinks EMR vendors don't want to share their information. 

"My own personal view is that, if the information was available and easily exchangeable between medical records, then physicians in health care organizations could more easily change software vendors, and, to some extent, the EMR vendors don't really want that to happen and may be dragging their feet," Schlossman said. "But I don't have any direct evidence of that." 

EMRs are very expensive, and if a vendor loses a client that could mean millions of dollars lost. 

Selva said, "We are millions and millions and millions and millions of dollars into our investment. Remember, we are a very large healthcare system. The average clinic is going to spend tens of thousands of dollars to install an electronic medical record, if not more."

Schlossman said, "Once you install an electronic health record it costs you 20 percent of the original purchase price every year for maintenance and upgrades."

A key sticking point is a concept called meaningful use, which requires physcians to meet a certain number of requirements during a patient visit to qualify for incentives designed to offset the costs of EMRs.

Selva said, "The bigger incentive that the public doesn't hear about, is that they will start withholding what they pay you, so there's a penalty."

Those penalties are assigned to individual physicians, Selva said, not groups or organizations. So if a physician moves to another hospital, the employer will know about the penalties assigned to his/her name.

"People talk about the millions of dollars being spent on meaningful use. What they're not seeing is the billions of dollars in penalties that will be recouped by the government for people who choose not to meet meaningful use," Selva said.

For those who do meet meaningful use, Selva said, the reimbursements don't always add up. 

"The money that a practice can get from meaningful use will not cover the cost of implementing an EMR. It doesn't even come close."

Selva said there are additional costs that come with purchasing an EMR as well.

"It's not just the software," he said. "It's the computers. It's the server. It's the backup power source. It's the duplication of drives, because you can't really look at a patient and say 'sorry we lost your files because the server went down and we didn't back it up.'"

Schlossman said the the federal government rushed to implement the meaningful use program, and now it needs to be revisited.

"What we have now, what this rapid forced adoption has brought about, is immature systems which are unable to fulfill the promise of electronic health records or to support the huge regulatory system which has been based upon that promise. That's why we need to make them better."

Selva said, "I don't know if I could think of a better way to do it. That's the way government, particularly through Medicare, has done things for a very long time."

Schlossman said that in the first quarter of 2014, four of the roughly 5,000 hospitals in the country had successfully attested to meaningful use standards stage 2.

If federal regulators see what is happening, he said, there might be progress made regarding EMRs.

"They're solvable, and like I said, I don't want to throw the baby out with the bath water."

Parker, Schlossman and Selva agree EMRs are inherently a good thing.

Parker said, "I think initially people were grumbling, what are we doing, why do we have to change all these systems, because people were so used to certain styles and charting, writing orders and that sort of thing. But now, I wonder how we ever lived without it."

Schlossman said, "I don't think anybody believes that we can reach the triple aim of improving the quality of care, improving population health and reducing the unsustainably rapid rise in the cost of health care without good information technology."

Selva said, "We know that people were dying in hospitals from errors, and there were errors made by human beings who are fallible creatures in a complex environment. Well EMRs allow you to take that complex environment and standardize it."

Schlossman said, "To have a chance to augment my brain and make myself a better physician, that's my dream, that's what I want these systems to do. We're not there yet, but we'll get there."