Between Doctors & Patients…Technology in the Treatment Room

Editor’s Note: This article was originally published in the Spring 2016 issue of Alabama Medicine magazine

Love them or hate them, electronic records are here to stay.

Electronic health records, or EHRs, are an evolution of the electronic medical records, or EMRs, that some medical practices use internally. EMRs are a digital version of the paper charts containing the medical and treatment history of the patients in one medical practice. EMRs have advantages over paper records in that they allow physicians to track patient data over time, identify which patients are due for preventive screenings and check ups, and monitor overall quality of care within the practice.

EMRs, however, are not built to travel easily outside the medical practice should the physician need to send the patient to another physician. This is where EHRs are intended to pick up and be more effective. EHRs are built to share patient information between medical practices, laboratories, hospitals and other health facilities. Should your patient be seen in the emergency room, EHRs are supposed to allow you to view those charts and results, including all the physician’s notes, labs and any films.

That’s how the system is supposed to operate. While the EHR systems work well for some, mostly larger practices and specialty physicians, they cause more problems than they solve for others, particularly smaller practices and family care physicians.

The surgeons with Alabama Orthopaedic Specialists, PA, in Montgomery, began looking for a solution to their charting issues in 2006, long before federal regulations started to trickle down concerning electronic records. Finding the best solution for the practice didn’t happen
overnight. It was a process, according to practice manager Ron O’Neal.“It took a little while for us to discover exactly what this would mean to the practice…the good and the bad…and it needed to be something everyone was on board with,” O’Neal explained. “It took time for us to come up with a checklist of everything we wanted and needed our EHR to do. It was important we found a system that would work for our practice instead of our practice working for that system, so we took our time.”

“It took a little while for us to discover exactly what this would mean to the practice…the good and the bad…and it needed to be something everyone was on board with,” O’Neal explained. “It took time for us to come up with a checklist of everything we wanted and needed our EHR to do. It was important we found a system that would work for our practice instead of our practice working for that system, so we took our time.”

Michael Davis, M.D., a surgeon with Alabama Orthopaedic Specialists, helped lead the search to find the perfect EHR for the group and agreed with O’Neal that while the search for the best system may have seemed long, it was for a good reason.“Historically we had paper charts. So, when a patient would be seen by one of our physicians yesterday and referred to me today didn’t really have any idea why they were seeing me and would expect me to know why they were here. It would take time for me to collect the paper chart, if everything was there, and sometimes re-interview the patient. That took a lot of time. If you don’t have to filter through all those notes to get to the bottom of the problem when someone else already has, you save a lot of time. You’re not duplicating tests and x-rays, and patients aren’t exposed to more tests or irradiated more than once just because you can’t get your hands on those results,” Dr. Davis said.

“Historically we had paper charts. So, when a patient would be seen by one of our physicians yesterday and referred to me today didn’t really have any idea why they were seeing me and would expect me to know why they were here. It would take time for me to collect the paper chart, if everything was there, and sometimes re-interview the patient. That took a lot of time. If you don’t have to filter through all those notes to get to the bottom of the problem when someone else already has, you save a lot of time. You’re not duplicating tests and x-rays, and patients aren’t exposed to more tests or irradiated more than once just because you can’t get your hands on those results,” Dr. Davis said.For Dr. Davis, having the EHR in hand can make explaining a complicated procedure a bit smoother when the tool can be used to illustrate the nuances of a surgical procedure by showing the patient his or her x-rays, MRIs, and other test results. But, the EHR is just that…a tool, which Dr. Davis is quite mindful of making sure doesn’t become an intrusive object in the treatment room.

For Dr. Davis, having the EHR in hand can make explaining a complicated procedure a bit smoother when the tool can be used to illustrate the nuances of a surgical procedure by showing the patient his or her x-rays, MRIs, and other test results. But, the EHR is just that…a tool, which Dr. Davis is quite mindful of making sure doesn’t become an intrusive object in the treatment room.

Yet, Dr. Davis and O’Neal agreed EHRs work better for specialties than with family practices when considering the diagnostic possibilities family physicians face with their patients. What’s streamlined in a specialty is often wide ranging in family practice.

Maarten Wybenga, M.D., a family physician in Prattville, hasn’t made the switch from paper charts to EHRs and doesn’t have any plans to in the immediate future. For Dr. Wybenga, e-prescribing and electronic billing are sufficient to keep the federal mandates at bay.

“I’m always going to be ‘pro-the-patient.’ I never jump on the bandwagon when something new comes out. I want to read the research, see how it works first before I start using it with my patients. It’s the same with technology in the medical office,” Dr. Wybenga said. “I’ve wanted to stand back and watch it a little rather than jump right in. When things started getting interesting with electronic records, we talked about it. Should we do this, or should we wait and see what’s going to happen? Should we give it a year or two? As we watched the technology arena grow and grow, the software companies exploded. There were just too many offering too much. We keep watching, but I’m just not satisfied, and I haven’t made that decision. To this day, we’re still on handwritten medical records.”

According to Amy Wybenga, Dr. Wybenga’s practice manager and immediate past president of the Alliance to the Medical Association of the State of Alabama, the number of reasons against using EHRs in the practice simply outweighed the positive outcomes.“No one could give us a good, sound reason of what benefit it would be to us or our patients if we changed over. For our practice, the negative reasons definitely outweigh the positive reasons,” Wybenga said. “We would have to cut down on the number of patients we could serve for at least a year because it could take up to that long for us to switch everything over, and it would slow us down too much. Being a family practice in a rural area, there’s just no way we can cut back on the number of patients we see. Those patients have to be seen. Why would we go to a system that would slow us down even more, something that we can’t share with anybody, would still have to print off information to fax or email to other doctors because it won’t communicate with other systems…where’s the benefit?”

“No one could give us a good, sound reason of what benefit it would be to us or our patients if we changed over. For our practice, the negative reasons definitely outweigh the positive reasons,” Wybenga said. “We would have to cut down on the number of patients we could serve for at least a year because it could take up to that long for us to switch everything over, and it would slow us down too much. Being a family practice in a rural area, there’s just no way we can cut back on the number of patients we see. Those patients have to be seen. Why would we go to a system that would slow us down even more, something that we can’t share with anybody, would still have to print off information to fax or email to other doctors because it won’t communicate with other systems…where’s the benefit?”

For one gastroenterologist who just started a new practice in January using paper charts, Bradley Rice, M.D., of Huntsville, who is also a member of the Association’s Board of Censors, is working to make the transition to EHRs a seamless one for his staff and patients. “I actually try to use the computer a small amount of time while in the room with a patient. I talk with the patient and take notes on a sheet I have designed,” Dr. Rice noted. “I prefer to speak with the patient instead of talking to them while looking at a computer, so I wait until the end of the appointment to then work on the computer, then escort them up to the check-out area. My goal is to make sure the patient feels comfortable and understands that I am there to meet with them instead of focusing on the computer in the room.”

“I actually try to use the computer a small amount of time while in the room with a patient. I talk with the patient and take notes on a sheet I have designed,” Dr. Rice noted. “I prefer to speak with the patient instead of talking to them while looking at a computer, so I wait until the end of the appointment to then work on the computer, then escort them up to the check-out area. My goal is to make sure the patient feels comfortable and understands that I am there to meet with them instead of focusing on the computer in the room.”

Dr. Rice and his staff have seen both sides of the EHR coin and agree with Dr. Davis and O’Neal that the initial setup of a system can be difficult and costly. It takes time to scan and input data into a new system, but once the system is online, it can help with documentation and accountability.

Interoperability was one of the initial selling points for EHRs from the Office of the National Coordinator for Health Information Technology. Fully functioning EHRs are designed to “talk” to other systems. However, many physicians are finding this may not be the case, and after years of voicing complaints through their medical societies and associations, their concerns seem to be getting through.

Department of Health and Human Services Secretary Sylvia Burwell recently announced the nation’s top five health care systems and companies, which provide EHRs covering more than 90 percent of hospital patients, have agreed to principles designed to improve patient access to health data and eliminate the practice of data blocking. These groups have also agreed to adopt federally recognized, national interoperability standards by 2018.

To unlock the data and make it useful to physicians, the companies have agreed to:

• Implement application programming interface (API) technology so smartphone and tablet apps can be created, facilitating patient use and transfer of health care data.
• Work so physicians can share health data with patients and other physicians whenever permitted by law, while not blocking such sharing either intentionally or unintentionally.
• Use the federally recognized Fast Healthcare Interoperability Resources data standard.

In late 2015, the Medical Association led a coalition of nearly 40 Alabama specialty and county medical societies in asking to the Alabama Congressional Delegation to support the Patient Access and Medicare Protection Act, which granted the Centers for Medicare & Medicaid Services the authority to expedite applications for hardship exemptions from Meaningful Use Stage 2 requirements for the 2015 calendar year. President Obama signed the bill. Because CMS didn’t publish the MU Stage 2 final rule until Oct. 16, physicians weren’t informed of the requirement until fewer than the 90 required days remained in the calendar year, leaving most in a penalty-assured lurch. CMS extended the deadline for physicians to apply for MU hardship exemptions to EHR incentive program. The new deadline is now July 1, 2016. The extension is being granted “so providers have sufficient time to submit their applications to avoid adjustments to their Medicare payments in 2017.” The new application forms and instructions to file a hardship exemption are on the CMS website.

Because CMS didn’t publish the MU Stage 2 final rule until Oct. 16, physicians weren’t informed of the requirement until fewer than the 90 required days remained in the calendar year, leaving most in a penalty-assured lurch. CMS extended the deadline for physicians to apply for MU hardship exemptions to EHR incentive program. The new deadline is now July 1, 2016. The extension is being granted “so providers have sufficient time to submit their applications to avoid adjustments to their Medicare payments in 2017.” The new application forms and instructions to file a hardship exemption are on the CMS website.

For physicians contemplating switching from paper charts to EHRs, Dr. Rice and his office staff offer these tips:

1. Always remember, “Treat the patient, not the computer”
2. Think about the big picture in terms of technology and how the flow and setup will affect the office. For example, how many screens, what type of computers, scanners, etc., should I choose? Who will be using these computers? Laptops vs. desktop computers in treatment rooms? A personal analysis needs to be conducted of what type of layout/format fits your practice.
3. Choose a good program that has excellent technology support. Make sure to choose the correct computers and equipment necessary for the EHR program that is chosen for your practice.

Article by Lori M. Quiller, APR, director of communications and social media