Some of the changes EMRs bring will be for the better, some for the worse, depending on how the change is managed. Much of the 2011 HIMSS conference focused on those changes, and how physician practices and hospitals could prepare for them. Many discussions revolved around five basic themes: patient engagement; reporting; collaboration; efficiencies; and security and privacy.
Patients will be more involved in their care
With more information in their hands because of meaningful use, and more data available to physicians at the time of a visit, patients are going to be more involved in health care decisions, experts said at HIMSS. One way meaningful use rules address this is by granting patients access to medical records, including diagnostic results, problem lists and medication lists.
Many practices and hospitals already provide this access through patient portals, many of which combine data with patient education tools. Some of these organizations offered a glimpse of what other practices can expect when the physician-patient relationship is changed by technology.
On average, elderly, chronically ill patients see 14 physicians.
Michael Solomon, PhD, is practice lead of eCare Management at the Coral Springs, Fla.-based health information technology consulting firm Point-of-Care Partners. He and researchers from the Carolinas Healthcare System conducted a 12-week controlled randomized study of 220 patients using the portal offered to patients of Carolinas Physician Network, a large medical group operated by CHS. They analyzed the effectiveness of the portal to engage patients and affect patient outcomes.
“If we expect the patient to play a critical role in a patient-centered approach to care, then we need to measure the effect of care intervention on a patient’s level of engagement — that is, how activated they are in their own health care,” Solomon said. The group found that the more patients used the portal, the more engaged they were in their health care.
For Miramont Family Medicine, a family medicine practice in Fort Collins, Colo., adopting an EMR meant that patient visits were more meaningful because of the information available and collected at the time of visit. John Bender, MD, a family physician at Miramont, said “value-added time” — time patients actually spend with doctors as opposed to sitting in waiting rooms — improved from 64% to 67% after implementation.
“Now that doesn’t sound large,” he said, “But a 3 [percentage point] improvement across all 10,000 patients we were seeing at the time — that’s huge.”
Dr. Bender said this was especially significant, given that the average appointment time increased from 41 to 51 minutes after going electronic. Doctors are documenting several metrics they weren’t documenting before, and patients “are getting a lot more time per visit with the physician.”
Doctors will find it easier to see how they’re doing
Stephen Wagner, PhD, vice president of Carolinas Healthcare System, division of medical education and research, said patients can be engaged, but measures are needed to see how that engagement has affected their outcomes.
“We’re very good in health care at finding things that make lots of intuitive sense, and then we find out sometimes too late or way down the road that they really aren’t working the way we thought they would,” he said. “We need better intermediate markers.”
EMRs are expected to make these intermediate markers easier to measure what is and isn’t working. Before Miramont installed an EMR, Dr. Bender said, only 42% of diabetic patients had an A1c documented within the past year. Since implementation, the practice improved its metrics reporting to 91%.
“We all think we’re doing a good job but had no way of knowing that. We had to find out where we are,” he said. “We finally knew how many diabetic patients we had.”
“Doctors are Type A. You give them a report card and … then they start working really hard and they will fix [the problems]. And they will do it on their own without being told,” he said.
Physicians will collaborate more with other doctors
When physicians are making decisions about a patient’s care, “it’s not about the data, it’s about the knowledge that you create,” said Hal Wolf, senior vice president and chief operating officer of the Permanente Federation, which represents Kaiser Permanente’s eight Permanente Medical Groups.
Wolf said elderly, chronically ill patients see, on average, 14 physicians. Those doctors collectively write an average of 50 prescriptions a year during the course of 37 clinical visits.
The interoperability spelled out under meaningful use means that measures of progress physicians have access to also are available to other members of the patient’s care team. This interoperability, and the subsequent collaboration of care team members, will help ensure that integrated patient-centered models of care being created because of meaningful use are successful.
EMRs “create a fully integrated approach to an entire effort to take care of a patient,” he said. “When you have the information, as you all know, you have turned the magical corner, because every caregiver is looking at one up-to-date record in basic real time as needed. That is a tremendous step forward.”
Dept. of Health and Human Services Secretary Kathleen Sebelius said in her keynote address to HIMSS attendees that, on a national level, having this integration will make it easier for doctors to compare treatments quickly and cheaply to see what works. “Those same records connected together can help spread the knowledge at the speed of light throughout our health care system. In the Obama administration, we look at health IT not just as an opportunity to grow our economy but also as a powerful tool to help improve the health of our nation.”
Physicians will pinpoint practice inefficiencies
You must build a foundation before you implement and have a clear plan for execution, said Paul Kleeberg, MD, clinical director of REACH, the federally funded regional extension center serving Minnesota and North Dakota. The execution plan needs to address work flow and process problems that, if not addressed, will plague EMR adoption.Despite all the promises of improved efficiencies and quality of care, experts are quick to warn that practices need to identify inefficiencies before even looking at an EMR. They must know how an EMR system will help solve those inefficiencies. Otherwise, they could be made worse by going electronic.
“Turning on the [EMR] will be like shining the flashlight in the corner. You get to see all the cockroaches,” Dr. Kleeberg said.
“That which was bad before gets worse,” said Tina Buop, chief information officer of Muir Medical Group in Walnut Creek, Calif. When a practice goes electronic, there will be a “beacon light” shining on poor work practices.
She used the example of physicians taking patient files home at the end of the day. “It’s now a beacon light, because everyone will now know they didn’t finish charting that day.”
Buop said the importance of training and work flow tracking during implementation cannot be overstated, because work flow changes when a new technology is introduced.
After implementation, physicians might discover new data that come to doctors electronically. But a lot of the work of charting that data can be delegated to medical assistants or nurses. Otherwise, physicians may find that the workday has gotten longer, she said.
Physicians will need a firmer grip on data security
One area that is a relatively minor provision in the stage 1 meaningful use requirements, but needs to be a major focus of any adoption plan, is patient privacy and security, Buop said.
The stage 1 requirements include only one line on security and privacy, she said. “And it’s a shame, because privacy and security, honestly, can be one of the biggest nemeses of the success of stage 2 and stage 3” meaningful use criteria.
Under stage 1, a gap risk assessment needs to be conducted that will identify security and privacy vulnerabilities. Stages 2 and 3 have not yet been finalized but will focus on an increased use of data, which could create more vulnerabilities.
The confidentiality, integrity and availability of data is part of the Health Information Portability and Accountability Act, which is separate from meaningful use, Buop said.
“If you are a solo practitioner with your own EMR and are trying to qualify for meaningful use, you are responsible for the information for privacy and security,” she added. That means you need processes in writing that ensure confidentiality, integrity and availability of data.
Pittsford, N.Y., pediatrician Alice Loveys, MD, is the chief medical information officer for the Monroe County Medical Society Health Information Technology Service Bureau, which assists physicians in technology issues. She strongly suggests that practices have a HIPAA security manual in place at the start of implementation. The manual is something a practice develops and writes itself that details how it ensures the security of patient information.
She said developing the manual is no small feat, and something that the RECs cannot do for a practice, because each one is unique to that practice. But the REC can help direct doctors to other resources that can help.
Health IT challenges
Each year, HIMSS conducts a survey of health IT professionals to identify the priorities and challenges they face. Respondents continued to list meeting meaningful use criteria as a high priority.
|Top IT priorities over the next two years|
|Achieving meaningful use||42%||49%|
|Focus on clinical systems||27%||23%|
|Optimizing current systems||8%||11%|
|Focus on ambulatory systems||7%||2%|
|Demonstrating ability to exchange information||n/a||1%|
|Providing patient-centric solutions||2%||1%|
|Integration of IT and medical devices||1%||0%|
|Barriers to achieving meaningful use|
|Lack of data metrics||n/a||26%|
|Achieving end user acceptance||24%||22%|
|Lack of adequate staffing resources||37%||18%|
|Lack of funding||n/a||8%|
|Inability to complete requirements on time||n/a||6%|
|Lack of adequate technology||17%||5%|
|Don’t understand requirements||n/a||5%|
Source: 22nd Annual HIMSS Leadership Survey, released Feb. 21