GOING PAPERLESS

The end of days is near for paper charts in U.S. medical practices. With the federal mandate to switch to electronic health records (EHR) by 2015, the transition has become inevitable for the 28 percent of American physicians still handwriting patient evaluations.

The change has several compelling benefits: more efficient care, easier billing, and the ability to access a patient’s medical history from any location. Ideally, the move to EHR should lower costs and improve patient outcomes, but electronic health records face several major concerns.

Cost to Convert

The most obvious among the challenges are the upfront costs and the task of converting paper records. Researchers estimate that conversion takes six months to a year depending on the size of the practice. Most practitioners start with chronic disease patients because they come in most frequently, explains Dave Ludwick, PEng, MBA, PMP, PhD, COO of the Sherwood Park Primary Care Network in Alberta, Canada. Otherwise, physicians must simply decide how many years to go back and begin data entry.

Costs intimidate practitioners as well. With a $15,000-$70,000 investment on the line, choosing an EHR system can feel like a gamble, making many physicians hesitant to commit.

“Most often the benefits of adopting electronic medical records don’t accrue to the physicians themselves,” Ludwick says. Doctors must pay for the software license, the hardware, and the conversion process, but the patients and the insurance companies reap most of the benefits.

To counteract some expenses, physicians may apply for up to $44,000 through Medicare or $63,750 through Medicaid in reimbursements. Payment hangs on the contingency of meeting “meaningful use” standards, such as taking the proper security measures to protect electronic records and running drug interaction checks. Currently, only about 40 percent of medical practices meet the minimum requirements of a basic EHR, according to the U.S. Centers for Disease Control and Prevention.

Other concerns have less-definitive solutions. What if the software company goes out of business? Can the confidentiality of patients be entrusted to a digital medium? What if the system crashes with 30 patients in the waiting room?

Unfortunately, none of these questions have perfect answers. Computers do occasionally crash, and practices must take care to avoid cyber security breaches. Back-up systems are an additional but often necessary expense. If a company goes out of business or merges with a larger organization, physicians may run into obstacles.

A Failure to Communicate

The primary issue with electronic health records begins offline, says Dr. Ann O’Malley, Senior Fellow at the Center for Studying Health System Change (HSC) in Washington, D.C. “Most commercial records are not as useful for clinical management of the patient and are more designed to maximize coding for billing purposes,” she says, adding that she believes this is due to the pay-for-service-system in the U.S. “It really creates this incentive to document in a way that allows you to bill rather than focusing on making the EHR clinically useful.”

Ludwick says programmers design the systems based on how they think medical offices should operate, and it is difficult to create a product that will work for each individual provider and specialty. Some larger organizations, like Kaiser, have built a custom EHR or EMR to suit their needs, but most practices can’t afford this option.

Whether custom-built or “off -the-shelf,” the different systems rarely communicate well. “Because EHR vendors are competing with one another, it is very difficult to get the records in one office to talk to the records in another office,” O’Malley explains.

A single, standardized EHR program seems tempting under these circumstances, but would likely involve serious unintended consequences. Ludwick, an expert in electronic medical records and telehealth systems, used Scotland’s migration to EHR as a cautionary tale.

Several years ago, the Scottish government chose a single system for the entire country to eliminate compatibility problems. “The vendor became very complacent within only a year or so and wasn’t motivated to make any software improvements,” Ludwick says. His own research indicates that a range of competitors is necessary. He claims a nation should have no less than three but no more than six preapproved EHR programs in order to provide physicians with options while maximizing interconnectivity.

A Cloudy Future?

The EHR options in the U.S. may seem endless, but, according to Ludwick, most systems off er the same basic functionality, varying widely in customer service instead.

A standout vendor has not emerged. “People are in all different phases of adoption and there is no one perfect EHR out there that meets both clinical and billing needs,” adds O’Malley. The burden of choice thus falls on the provider.

Despite the initial challenges of going electronic, longterm results include many positives. O’Malley has interviewed doctors and staff who have been using off -the-shelf EHRs for at least two years, and discovered common benefits. “The biggest plus we hear is that data is easily accessible at the point of care for an individual patient.” Physicians can read records online if working from home or find critical information at a moment’s notice. Even a simple instant messaging function has proven very useful, allowing physicians and staff to communicate from different sides of the office.

Some expect the future of EHR data sharing will include a secure Cloud system that allows providers to access a patient’s past records from any approved practice or hospital, O’Malley notes. For example, a person could arrive unconscious at an emergency room and his or her medical history would be instantly available to the physician. Ludwick concurs that such a system is in the future, and anticipates advances in telehealth as well, such as the ability for patients and doctors to remotely communicate.

For endocrinologists undergoing the EHR transition, O’Malley recommends lobbying vendors for electronic records that better support clinical care and improved compatibility among systems. Receiving electronic referrals and sharing patient data will be critical to endocrine care in the digital age. EHRs have enormous potential, but to resolve current issues, doctors need to take a greater role in the design.

—Mapes is a freelance writer in Washington, D.C., and a regular contributor to Endocrine News.

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