Saturday, June 11, 2011

EMRs and Primary Care: The good, the bad, and the challenges

One of the centerpieces of health reform as promulgated by almost everyone, and very much the Affordable Care Act (ACA) is the use of electronic medical records (EMR, also called, in a more inclusive formulation, electronic health records, or EHR). The Health Information Technology for Economic and Clinical Health Act (HITECH) specifically addresses specifications for EMRs. Demonstration of effective use of EMRs, including “e-prescribing” (in which prescriptions are routed electronically directly from the physician’s office to the patient’s pharmacy of choice), maintenance of patient registries (who in your practice has diabetes?) and compliance with a set of quality measures (What percent of the people in your practice with diabetes have had their sugar measured? What percent are in control?) account for a great deal of the added payment for chronic disease management, as well as payment for patient-centered medical homes (PCMH).

EMRs are a good thing for many reasons. At the simplest level, the fact that the records are on-line, rather than in paper charts, means that they don’t get “lost” and any doctor can see the notes of any other doctor. A number of years ago, prior to going to a real EMR, a large public hospital with many clinics where temporarily lost charts often meant that patient notes generated in one clinic visit were unavailable to another clinic, scanned literally millions of pages into a very basic EMR. While having none of the advantages described below, even this primitive method was a real step forward for them in being able to access the records. At their best, EMRs allow effective communication between doctors in a practice. For large multispecialty practices, this can also be between different specialists, and can even be integrated with the hospital’s medical record so that information from hospitalizations is immediately available in the same “chart”. The more that information is put in “digitally retrievable” format rather than free text, the more easily and thoroughly that a patient’s health trajectory can be understood. This is not only for numeric values, such as lab results and blood pressures that can be displayed on a flowsheet or graph, but even for history and physical items: Was that heart murmur present at the last visit? What is the history of the different medications that the patient has been on? Patient registries, as noted in the first paragraph, become an effective way of evaluating and improving the care given in the entire practice, not just for one patient, and are almost impossible without an EMR.

EMRs are not problem-free, however. The most common issue for physicians is that charting takes longer; filling in all this data takes time. This is worst when a new EMR is implemented, as old data has to be input (and this can even be when changing EMRs, not just going from paper, since of course they rarely “talk to” each other), but continues to be, on average, more time consuming than paper charting. In part, this may be because the notes are “more thorough”, or, looking at it the other way, that paper chart notes were inadequate. But it is also because the very structured nature of the EMR requires that a significant number of things be  entered/clicked (even to indicate “not applicable” or its digital equivalent) that would have appropriately not been mentioned in a paper note. Much of this added documentation goes beyond the information necessary to provide medical care for the patient, but is required to comply with government regulations and ensure that the document is “legally” sound. (It is a time long since the medical record existed solely as a reminder to the physician of what s/he had done for the patient in the past!) In addition, some of those regulations require the physician, as opposed to another health professional such as a nurse, to personally document certain items in the record, often to a degree that seems unreasonable to physicians.

There is an ironic turn to this. Most discussion in public policy circles is directed to increased inter-professional function and team work, as characterized by the patient-centered medical home. In part, this is because the current and projected shortage of primary care physicians means that there is no way that they, working alone, will be able to meet the health needs of the American people; if they are already working on a “hamster wheel” (see Family Medicine in the Era of Health Reform - 3, May 23, 2011), the changes described by Phillips (see Primary Care, Medical School Debt, and US Health Needs: Analysis from the Graham Center, May 30, 2011 ) and discussed in detail by Margolius and Bodenheimer[1], will increase the burden beyond any hope of sustainability. In addition, an effectively functioning team of health professionals (including nurses, pharmacists, social workers, and others[2]) makes for higher quality care. This is very clearly articulated in Dr. Atul Gawande’s recent address to the Harvard Medical School commencement, “Cowboys and Pit Crews” published on his New Yorker  blog. The irony is the increased requirements mentioned above, sometimes explicitly stated in law, but often in federal regulations and most commonly by Medicare “carriers” and interpreted by institutional compliance officers, have increased what the physician, him or herself, needs to document in the medical record (and, by implication, have actually done him or herself). These requirements both decrease effective team function, and increase the burden of electronic charting.

Thus, the ability of the EMR to record, and hopefully make retrievable, large amounts of data, raises the expectation that that data will be inputted, and also allows monitoring to ensure -- in the cases where lawyers or compliance officers have concern – which individual is doing it. In any new technology that increases the ease of accomplishing something, or the availability of a person or data, there is the corresponding tendency to expect it; this often has the ironic effect of increasing, rather than decreasing, workload. The internet and email allow us to work from home; cell phones, pagers, and email all increase our availability even when not at work or at home. This allows us more flexibility, but it has also led to the expectation of immediate access and, for many professionals including physicians, the virtual elimination of the concept of “work” versus “off” hours. The electronic medical record allows me to chart from home – or anywhere I can get an internet connection – and so I do.

The introduction of a new EMR, already a complex, difficult and daunting process, is also often used to change workflow, the processes by which the work of the practice is accomplished. This is virtually always a mistake, for providers and staff must now learn not only how to navigate and document in a new and strange systems, but to do things in a completely different way. The changes may be desirable, or they may not be, but certainly will require time and effort to identify whether they are, work it out, and “get it right”. Thus, it is greatly preferable to change that workflow prior to institution of the EMR (or if necessary after it is successfully adopted); the alternative is that learning new processes, especially when they are poorly conceived, gets lumped in with and blamed upon the EMR, increasing resistance to its adoption and potential benefits.

An interesting, and perhaps important, sidelight of the introduction of the EMR in our family medicine clinic was that the implementation team, composed of experts from the computer company and “superusers” of nurses from our group practice, saw how much more complicated the practice – and thus the documentation – is in primary care than in other specialties. In most sub-specialty practice, a few diagnoses -- and thus a few types of workflow and documentation strategies -- account for almost all visits, while in primary care the breadth of encounters (acute/chronic, prevention, adult/child/pregnancy, medical/psychosocial) in a single session, combined with the complexity of dealing with multiple chronic conditions based in a variety of organ systems rather than one, is actually breathtaking (see, for example, Primary Care: What takes so much time? And how are we paying for it?, May 21, 2010, "Uncomplicated" Primary Care?, Oct 8, 2009). Contrary to what they had been led to believe, they discovered that primary care was harder and more complex and more difficult to document – and of course required seeing more patients in shorter amounts of time for less reimbursement (which also leads to an ability to afford fewer support staff). This team, at least, gained a new respect for what primary care practice involves.

As we inevitably and inexorably move to reliance upon EMRs, we must be on guard to resist all the temptations to load every possible expectation upon them, and upon the providers who use them. They have enormous potential to not only increase quality but to increase teamwork and communication, and to even be labor-saving, but only if used wisely and judiciously.

[1] Margolius D, Bodenheimer T, “Transforming primary care: from past practice to the practice of the future”, Health Aff (Millwood). 2010 May;29(5):779-84.

[2] Even, for example, lawyers. A number of practices, particularly in academic medical centers (including our family medicine clinic at KUMC) have legal partnerships where lawyers (often from Legal Aid) and law students help patients with legal problems they could not otherwise get help with, right in the clinic. It is amazing how often a person’s health improves when they no longer are as worried about their immigration status, getting evicted, receiving benefits, or the implications of divorce, among other issues.


johnjose said...

Josh captures much of the possibilities of the EHR and its contributions. However, the most important issue that NO ONE seems to be addressing clearly is interoperability - that my records are available no matter where I am - that is the benefit that is most important. I recently had to see a doctor in another state for an acute situation - there was, of course, no access to the extensive EHR that I had at home and so the value was mimimal and I had to repeat all the data just like in the paper days. Now I have two EHR database that can't communicate with each other. But the same EHR - EPIC - won't work on the other side of my home town if I happen to go to another health system than my home system - and the problem is with the health system, not the EHR. The solution??? Have a cloud based miminum data set for all people in the US that by law has to be populated from whatever EHR one is using. That would be worth it.

Josh Freeman said...

From Holly Kaufman, MD:
WELL put! 50 percent of my note is required by the hospital system but not pertinent to the patient sitting in front of me. New game - patients watch me type while they sit silently "read what I am writing and tell me if I got what you told me right" this doesn't work in Spanish though and depends on education level, then the notes pile up to be typed at home.

KrishaLiva said...

Very interesting topic! "EMRs and Primary Care: The good, the bad, and the challenges" Glad that you've shared it with us. I enjoyed reading this one. Looking forward for your next post.

electronic medical records

Matthew Anderson said...


Your posting relates primarily to the burdens that the EMR places on clinicians; this is an important topic. I have several additional concerns about EMR’s.

1) The introduction of the EMR was done without a robust evidence base. This is odd for an intervention that has the potential for so vastly altering medical care. We would not, let’s say, introduce a new anti-hypertensive drug without requiring some clinical trials. This is a particular concern with current EMR’s which remain quite primitive and do not talk to one another. Would it not have been better to test and perfect this technology before introducing it extensively? I suspect a lot of companies have gotten rich from this early introduciton (particularly because of its inclusion in federal law) and that we are going to be suffering from the consequences for many years in terms of balkanized information.

2) There are major privacy issues associated with EMR's that have been widely discussed in Britain and ignored here. Do you want to discuss the most intimate details of your personal life with your family doctor when you know that the number of people who have access to that information is probably in the thousands (in a large medical center) and potentially much, much bigger (think insurance companies)?

3) The EMR essentially codifies what we understand to be the work of the doctor. But who decided what that work was? I remember several years ago hearing the head of Blue Cross Massachusetts interviewed on the BMJ saying: "We know what quality care is and we are not going to pay for substandard care." I marveled at his knowledge of what quality care was (I struggle with the question every day) and am horrified by the idea that the EMR gives him a powerful tool to monitor and control what I do with my patients. Let me be clear, I do not mind having my work monitored and evaluated. But I do want that body to be people whose priorities are the patients and communities I care for and not the economic interests of accumulating more capital. I think there has been a sea change in the locus on control over clinical practice from the professionals (who perhaps weren't doing such a good job) to corporate interests. This has gone largely unchallenged by the profession which has been continually brow-beaten for not following corporate models.

4) Finally, think of the implications for the EMR and "social justice." What questions are we asking that might promote social justice? What questions are we asking that might hinder social justice? These topics are not on anyone's agenda as the EMR rolls out. Do we ask about race? Do we ask about abortion? Are abortion protocols easy to access and included in all EMR’s? Is marijuana use a "problem"? Do we require PSA testing? What about questions regarding food insecurity? Or past histories of incarceration? What about immigration status? (Yes, what do we do about immigration status, a major determinant of health?) Do we mention criminal activities, parole status, police abuse? All of these problems were issues with the paper record and they continue to be issues on a larger scale with the EMR.

Best, Matt

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