EHRs: Heartache & Helpmate for Cardiologists

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 - CART
The VA Clinical Assessment Reporting and Tracking (CART) program was developed specifically for cardiologists in the VA system,
Source: Tamara Box, PhD, Health IT Lead, Denver VA Medical Center

According to a recent American College of Cardiology (ACC) survey, nine out of 10 cardiologists run EHRs in their practice. For eight out of 10, those EHRs are two or more years old. However, even with so many practices using EHRs, only 35 percent of respondents were relatively satisfied with their EHR. CardioSurve, which invites a panel of more than 350 ACC members to respond monthly to topics of interest, conducted the survey.

Similarly, responses to a survey by RAND and the American Medical Association on physician satisfaction found that of physicians using EHRs, 35 percent responded that EHRs improved job satisfaction. Sixty-one percent of respondents stated that the EHRs improved quality of care.

Most cardiologists can take notes, order prescriptions and track medications via EHR. Systems continue to develop and cardiologists increasingly have lab and imaging results available to them. New features are continually being developed.

However, many physicians have mixed feelings about EHRs. Sure, they can electronically prescribe and take notes, but many complain that electronic records are still little more than paper files: flat, undynamic, unsearchable text. Worse, interoperability and connectivity among specialists, subspecialists, primary care physicians and hospital records remain unavailable unless they’re part of the same healthcare network.

Mixed bag

“We were really quite surprised by the influence of electronic health records on physician professional satisfaction in terms of intensity,” says Mark W. Friedberg, MD, MPP, a natural scientist at RAND and an associate physician at Brigham and Women’s Hospital, both in Boston. Friedberg was one of the minds behind the survey published by RAND in 2013.

Based on survey responses, in some ways physicians found EHRs very useful. “Some typical things we would hear would be, ‘Now I can see all the notes from my practice; not just what I wrote, but what my colleagues wrote from home. When I take a call from a patient I don’t know, I can just look up their records and deliver much better care. I feel more comfortable [and] that improves my professional satisfaction,’” Friedberg says.

However, while physicians responded that the use of EHRs improved their performance in some areas, they also provoked more irritation than adulation. “It’s not like physicians either said, ‘I love my EHR' or ‘I hate my EHR.’ The same physician would be telling us ‘Yeah, it improves my life in this way, but it worsens my life in these other ways.”

This was echoed by the results from CardioSurve. “We’re seeing high levels of installation of electronic medical records and we’re seeing limited positive signals here in terms of, specifically, e-prescribing, electronic medication lists, the availability of lab results,” says John S. Rumsfeld, MD, PhD, the national director of cardiology for the U.S. Veterans Health Administration in Denver. Rumsfeld is part of the leadership behind the ACC’s CardioSurve. The survey found that these positives did not balance what cardiologists disliked about their EHRs.

“What strikes me in reading the results of the survey is how far there is to go for EHRs to fulfill their promise,” Rumsfeld says. “I would say that cardiovascular clinicians strongly support and understand the need for electronic health records, but I would say they largely hate the reality of electronic health records so far.”

The distance between promise and reality fuels part of the negative feeling toward EHRs, Rumsfeld notes. However, there are other factors that affected physicians’ satisfaction with EHRs as well.

When the customer isn’t happy

Unhappy patients had a big impact on physician satisfaction. In both surveys, physicians remarked strongly that EHRs cut into face-time with patients. Physicians spent more time behind the computer during visits, making it harder for them to speak directly to patients and create adequate patient-physician rapport. In a nut shell, “Patients don’t like it either. And physicians know patients don’t like it. No one likes displeasing their patients,” says Rumsfeld.

Douglas Goldberg, MD, a member of the ProHEALTH Care Associates LLP group in Roslyn, N.Y., says, “It detracts from our doctor-patient interaction. We don’t talk to patients anymore. And, half the time that I’m with them, I’m clicking and typing.”

He notes, “It’s adding time.”

Goldberg has been an independent and multipractice cardiologist and is part of the CardioSurve panel. He adds that distracted, rushed patient interactions have a secondary effect: omissions and errors. “Miss on medications and a couple of other things and that hurts patient care, and that’s not good.” Access to other’s notes provides continuity of care, Goldberg agrees, but he emphasizes that patients need to be seen and heard rather than just recorded.

Still, 38 percent of cardiologists who responded to CardioSurve indicated that EHRs enhanced patient communication, providing a platform to open discussions, share recommendations and give out patient-focused materials. Meanwhile, 86 percent found timely access to patient files helped enormously. 

But, the ability to communicate through EHRs is still growing, and with that growth comes hiccups.

Hello? Operator?

The most reported hiccup appears to be that EHRs fall short in their ability to communicate with one another. “Interoperability remains a real issue across settings, particularly between hospitals and practices,” says Rumsfeld. 

When two physicians share the same system they can exchange notes, but that benefit may not extend outside their network. This lack of interoperability with other software dissatisfied 51 percent of CardioSurve respondents.

“Part of the selling point that physicians really bought into was that they were going to be able to see all of the records from all of the providers of the patient they were taking care of,” says Friedberg. “This was especially important for subspecialists who may want to see primary care physician records and hospital records and vice versa. And that just doesn’t exist much at all, particularly during the time period of our study.” 

Friedberg notes that when they performed their study in 2013, “Most people were still communicating with other providers by fax. Those faxes would get scanned into an EHR, but those faxes aren’t searchable because the data aren’t structured.”

Some systems do connect clinics, practices and hospitals, and the number of these is growing. Forty percent of cardiologists from CardioSurve access hospital data through their EHR. However, most of them either purchased the same system their local hospitals run or participate in much larger healthcare networks.

Because systems don’t share information or have compatible data fields, it not only makes getting data from providers outside a system difficult, it makes starting or switching systems challenging as well.

Time & money

Goldberg is acutely aware of is how hard starting a new EHR system can be. In clinical practice alone, he started with one EHR system, switched to another and then back to a newer version of the previous system. The two hospitals he works with each run a different system, neither of which is compatible with what he uses in his practice. “So every time I’ve had to change systems it requires a huge amount of manual imputing and time to get patient data into the systems.”

And, that doesn’t cover the cost.

Physicians invest time and money into installing systems, only to find that both recur continually. Friedberg says that some practices assumed that the upfront installation would be the main cost. “This turned out not to be the case in many cases. Maintenance costs have been substantial both in terms of having to continue to have to invest in hardware and software upgrades and having to hire a new kind of person in the practice that’s never existed before,” that is, an IT specialist.

And when physicians aren’t satisfied with their first EHR, they move on to another one. “Up to a quarter of practices and hospitals that install electronic health records subsequently deinstall them out of dissatisfaction with use and try to move on to a second system, which is unbelievably disruptive to practices and hospitals,” says Rumsfeld. And it’s costly.

In several surveyed practices, IT specialists and scribes joined teams in place of transcriptionists. While they help, these new faces don’t tame other issues physicians have with electronic systems.

Usability vs. functionality    

Systems aren’t always intuitive to the way physicians work, even though most EHRs have physicians on their boards. Since clinicians aren’t necessarily tech people and tech people aren’t necessarily clinicians, physicians find both usability and functionality of systems disconnected.

Rumsfeld notes that nonintuitive data entry, multiple screens and clicks, layouts that don’t provide quick information access and lack of interoperability all contribute to usability issues that made physicians unhappy with EHRs. Friedberg adds that what EHRs request and when are not well matched to clinical workflows.

In addition, Rumsfeld and Friedberg note clinicians were frustrated with a lack of functions they had expected to have out of the box. What’s available, says Rumsfeld, has evolved over time and while features such as lab results, imaging results and communication between practices now may be offered,  clinicians had viewed them as a given. At present, 76 percent of cardiologists have EHRs that import lab results. Half of EHRs import imaging results.

“The true functionality of an EHR should be where it can support clinical communication between clinicians and settings of care and support clinical decision-making by making information available for guideline-based decisions” and appropriate testing standards, Rumsfeld says. He emphasizes that EHRs should allow physicians to take stock of how they’re doing in terms of quality care and detect patient safety issues, “and all of these things are poorly available in most electronic records at this time.”

As useful as trends data would be, Rumsfeld and Friedberg agree that the way data exist in systems stands in the way of being able to find trends and alert potential adverse events. If they aren’t scanned into the system, they’re narrative text notes—and therefore flat and unsearchable.

Work in progress

Change is coming, though. EHR companies and independent groups alike are developing functions and algorithms to allow text to be searched, for instance.

Rumsfeld points to templates and standard data fields as helping. “The American College of Cardiology and other professional societies are working with government agencies to push the availability of standardized data capture and templates, which still could be customized to the individual patient but would at least capture the core set of data needed to be able to measure quality of care and communicate that out to participating registries, to send to payers, or to use for quality improvement for certification and so forth.”

Friedberg notes that some practices use registry features to monitor patients who need follow-up. “This was a lot easier than it had been before EHRs and so this was also improvement, and resulted in an improvement in satisfaction.”

Certainly, another major positive is that the infamous physician handwriting legibility problems are a thing of the past.

The consensus is there’s a long way to go, but no one is going back to paper. Not now.


A Fully Integrated EMR

Getting physicians, patients, hospitals and clinics working together is the ultimate goal of any EMR system. Kaiser Permanente has been building a system that allows physicians and patients to review data from anywhere. Mark Groshek, MD, medical director from Kaiser Permanente’s Digital Services Group in Littleton, Colo., writes below about their system, KP HealthConnect.

Physician attitudes

“Some absolutely love it, some are less enthusiastic, but I think everyone agrees we would never want to go back to paper charts. It is key to our being able to provide the best possible care to our patients.”

Patient care

“Because we are an integrated healthcare system, we are able to capture and see almost all of a patient's health information in the EHR, so physicians have the right information at their fingertips, and that helps us provide the best care. The EHR also enables clinical decision support tools at the point of care, so I can see what the best treatments are immediately when the patient is sitting right in front of me. There's also a safety benefit. For example, the EHR will alert me if there is a possible drug interaction that I should be aware of.”

Buy-in

“Since we have clinicians involved in how the EHR works, we have been able to make changes to reduce [workflow] frustrations over time.”

Training

“I can't stress enough how important training is to helping physicians understand and use the EHR. Knowing how to use the system makes it easier for them to integrate the EHR into their workflows. When providers do integrate the EHR into their workflows, it becomes a complement to a doctor's visit, not the focus in the room.”