Dr. Eden Miller’s tiny clinic in Sisters closes at 5 p.m., but her workday is far from over.
The family practice physician, who works for High Lakes Health Care, says some days she won’t be done for another four hours after the “closed” sign goes up. That’s because she has to write down notes from each of her patient visits that day. Later, a medical assistant will enter all that information into the clinic’s electronic health records (EHR) system, a vast database that contains patients’ medical information, including their demographics, diagnoses, medications and family history.
Lots of doctors just type in that information while they’re sitting with their patients, and many have experienced this firsthand.
But Miller doesn’t want to do that. She wants to make eye contact with her patients. She wants to maintain relationships. And she doesn’t want to miss the more subtle things patients don’t say, but that reveal themselves in facial expressions or movements.
“I sacrifice my life to be able to spend more time with patients,” she said.
The rise of EHRs is transforming the practice of medicine. Whether that evolution has been good or bad depends on who you talk to. An estimated 8 in 10 physicians now use them.
The federal government hails EHRs as a tool for collecting massive amounts of valuable data and, once the kinks are worked out, for ensuring patients’ records follow them seamlessly as they move from one provider to another.
In theory, it sounds like just the thing that could make the health care system more efficient (no more faxes from office to office), safe (no unsafe medication combinations) and population-centric.
But many doctors say so far, it hasn’t worked out that way. They say the systems available are hard to use, take up a significant amount of their free time, make medicine less personal and are expensive to implement and maintain, often requiring new staff members just to enter data.
And despite the promises of benefits to patients, some doctors say EHRs, by and large, aren’t having much of an impact yet — especially in Central Oregon, where very few EHRs currently have the ability to share data, a work in progress both locally and nationally.
Local doctors, like Miller and Dr. Steve Mann, High Lakes Health Care’s medical director, say they each know several doctors who’ve gone into retirement early because EHRs had made their practices more difficult.
“Basically, they worked as hard as they could for a year or two to adapt and basically they said, ‘That’s it. I’m done. I wasn’t planning to retire, but I no longer have a passion for medicine,’” Mann said. “It kind of killed their career.”
— Dr. Eden Miller
Miller isn’t afraid to voice her frustration over EHRs. She estimates for every 10 minutes she spends with a patient, she spends another 20 documenting that visit. For that to happen, she said, doctors must either shorten their time with patients — become “door handle docs” who never let go of the door handle — or sacrifice their own free time to enter data into their EHRs.
Miller has chosen the latter.
“I now spend more time with either dictation, clerical work or data entry than I do with the patient,” she said in a meeting in her office that doubled as her lunch hour. “It now outnumbers it.”
In an era in which glasses allow wearers to scan the Internet, printers produce human cells and video game characters can seemingly pop out from the screen, lots of doctors say they’re miffed by the clunkiness of today’s EHR systems.
A significant number of medical professionals complain about how arduous it can be to perform simple functions in their EHR systems, and the casualty of such unwieldy technology winds up being their free time. On average, family practice physicians report having lost 48 minutes per day or four hours per five-day work week of free time to their EHRs, according to a November 2014 study in the Journal of the American Medical Association Internal Medicine.
For some doctors, like Miller, it’s even more than that.
Dr. Bill Reed, an emergency physician at St. Charles Bend, takes on a salty tone when he explains the unpleasant thing he calls “mouse miles,” the amount of area his cursor must travel across his computer screen just to enter simple data about a patient. A click at the bottom of the screen to order a medication, another screen pops up, you have to go to a different screen to print, confirm the print, and so on.
“It is really hard on the brain,” he said. “Whereas, with your phone, sending a text is really easy. It’s all right here in this one little tiny space. It’s just designed better. That piece of it hasn’t really trickled down to the end user yet, and maybe it will in 10 years once they’ve fine-tuned it.”
The proliferation of less than stellar EHR platforms is often traced back to the federal government’s nearly $30 billion push for widespread — and swift — EHR adoption. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, enacted under the American Recovery and Reinvestment Act, or the stimulus, created an enticing platter of financial incentives for clinics, practices and hospitals that adopted EHR platforms. That money began to flow in 2011, and by February 2014, more than half of eligible providers had received $21.6 billion in incentive payments, according to the U.S. Centers for Medicare & Medicaid Services, which administers the payments.
The payments are part of the government’s so-called Meaningful Use program, which is divided into stages providers must prove they’re at in order to receive payments or, in the future, avoid penalties. To reach Stage 1 of the program, providers must prove they’re using EHRs to perform a number of tasks, including ordering medications, maintaining active patient diagnoses, medication and allergy lists, entering summaries for each office visit and providing patients electronic copies of their health information. Entering Stage 2 requires having the ability to share EHR records with other providers, regardless of the platform they’re using.
CMS data released in late 2014 showed that less than 17 percent of U.S. hospitals had reached Stage 2, and less than 38 percent of eligible hospitals had met either Stage 1 or 2. Beginning Jan. 1, Medicare-eligible providers who aren’t at Stage 1 or 2 could be seeing less reimbursement from CMS for providing services to patients.
St. Charles Bend is among the small proportion of hospitals that met Stage 2 requirements in 2014. Its other three hospitals are at Stage 1. Bend Memorial Clinic has met both Stage 1 and 2 requirements. Mosaic Medical, another large Central Oregon provider, has met Stage 1 requirements.
The American Medical Association, along with a handful of other health care organizations, has repeatedly urged CMS to give providers more time to meet the requirements, reasoning that not doing so would lead to growing dissatisfaction with EHRs and disenchantment with Meaningful Use.
Meanwhile, there’s another important deadline on the horizon for providers: the implementation of a new massive set of billing codes that cover everything from diseases, symptoms and causes of injuries. It’s called ICD-10 (short for International Classification of Diseases), and it’s scheduled to replace its predecessor, ICD-9, on Oct. 1, several years later than originally intended. Congress has pushed back the ICD-10 implementation several times, and some believe it could do so this year, too.
EHRs and billing systems are intimately connected because the diagnoses and treatments entered into EHRs are used to generate bills for that care. Lots of providers are worried about the transition to ICD-10, which is significantly more detailed than ICD-9, in part because they could miss out on payments if they can’t account for them in their billing systems.
The ICD-10 transition is mandatory. Failing to adopt EHRs, by comparison, carries financial penalties for providers. The AMA has urged the government to repeal ICD-10, which it argues will be extremely expensive for providers. Unlike its position on EHRs, the AMA says allowing providers more time to implement ICD-10 won’t solve the problem.
“The AMA has long considered ICD-10 to be a massive unfunded mandate that comes at a time when physicians are trying to meet several other federal technology requirements and risk penalties if they fail to do so,” AMA President-elect Steven J. Stack wrote in a statement.
Money has indeed proven to be effective bait for getting providers to adopt EHR platforms. Sixty-two percent of doctors who adopted EHRs between 2010 and 2013 named money as their top reason for doing so, compared with 23 percent who adopted them in 2009 or earlier, according to a December 2014 study by the Office of the National Coordinator for Health Information Technology, a division of the U.S. Department of Health and Human Services.
But some argue it’s been a little too effective and has encouraged manufacturers to push out products that weren’t ready for prime time.
“The government says, ‘Carrot now, stick later, and here’s all this money,’ and the software companies are like, ‘We’re in. We have a product and we’ll sell it to you,’” Reed said.
Dr. James Verheyden, an orthopedic surgeon with The Center Orthopedic & Neurosurgical Care & Research in Bend, said despite all of the money the government is offering to give doctors and threatening to take away depending on their EHR use, there simply doesn’t yet exist an EHR system that’s economical, efficient and that integrates with other EHR systems.
“In some ways, they’ve got the cart before the horse,” he said.
For some of Central Oregon’s biggest providers — St. Charles Health System and Bend Memorial Clinic — such shortcomings have proven especially time-consuming and costly because they’ve chosen to abandon existing EHR systems for entirely new ones. St. Charles’ Bend and Redmond hospitals have switched EHR platforms twice and even completed an internal investigation to determine why their third system, Paragon, was causing so much frustration for providers.
“A lot of our physicians, and a lot of them here on the Bend campus, felt that it was just very inefficient and it caused them extra time,” said Dr. Mary Dallas, St. Charles’ chief medical information officer.
Despite the complaints, though, St. Charles plans to stick with Paragon rather than avoid the massive task of transitioning to yet another system, which Dallas said is a multiyear, labor-intensive process that involves intensive training for caregivers.
“It’s actually almost harder to switch EMR vendors than it is to start from paper to electronic transition,” she said.
BMC, which first implemented an EHR system called Allscripts Healthcare Solutions in 2006, is in the throes of transitioning to another platform offered by Epic, a leading EHR vendor. The provider is currently ensuring all of its caregivers and staff members agree on a design — a process that began in the summer of 2014 — and plans to go live with the new system in August, said Dr. David Holloway, BMC’s chief medical officer.
Holloway said he disagrees that EHR systems were rushed out before they were perfected, especially when it comes to a system like Epic, which has been around for years. He said creating systems to handle data for an industry where every provider does things differently and every patient is unique is inherently going to be tricky.
“You start doing a formula for how complex this is, it’s just unbelievable,” he said. “So how do you create a technology, an electronic record, that helps manage all of that? I just think it’s tougher than everybody thought.”
Several physicians interviewed cited the multistate, California-based health system Kaiser Permanente as an example of a provider that’s got EHRs down to a science. Its records are thorough and can be easily shared with other doctors in and out of their network.
The downside, though, is that the records tend to look like pages upon pages of check boxes rather than a narrative explanation of the patient encounter.
Mann, a family physician and medical director for High Lakes Health Care, said some electronic patient charts are more like “data warehouses.” He said it’s not uncommon for him to read through six pages of a patient’s record and not fully understand what happened.
“It’s just page after page of data points, but nothing that creates a summary saying, ‘This is how this process has evolved over the past year and here’s what the patient’s experience is and here are the different ideas I have about how to treat it,’” he said. “You can’t data point those things.”
High Lakes doesn’t yet have the ability to send patient records across providers using its EHR system, so Mann still faxes his notes in narrative format to other doctors who see his patients. Once the provider is able to tap into a community portal being developed that will allow providers to enter one another’s patient records, that narrative will likely go by the wayside, and other providers will see only the patients’ vital signs, diagnoses and physicians’ assessments.
Miller, of High Lakes in Sisters, said templated charts — the ones with only check boxes — tend to leave out the more subtle, yet important things. For example, if the doctor checked the patient’s heart, she may have checked in the patient’s record that the rhythm was regular. But perhaps the patient flinched when the doctor put the stethoscope on her chest and the doctor asked the patient why – none of that would be in the chart, she said.
“You don’t get any flavor,” Miller said. “It’s like Burger King or fast food.”
Dan McCarthy, an administrator for Adaugeo Healthcare Solutions, a company that provides local clinics with EHR and overall practice management, including billing and administration, said health care is evolving between two extremes. At one extreme — the one society is slowly moving away from — is the fee-for-service world, in which a doctor might churn through 50 patients per day in order to be reimbursed for services. The move toward EHRs, however, permits a broader focus on preventative health and evaluating providers based on quality measures.
“Now the extreme would be pure data and you’re more of a data analyst than a provider,” McCarthy said.
The truth will be somewhere in between, he said.
Lack of compatibility
In a perfect world, patients would be able to visit their primary care provider, hospital and a specialist, and each one would be able to instantly call up that patient’s complete medical history, including all the providers she saw over the past several years.
No longer would the patient need to strain to remember the last time she went in for her annual checkup, nor would she have to guess at how many milligrams of a certain medication she was taking, nor would she need to recall which grandparent died of lung cancer. All of that information would follow her there.
And with those databases packed full of demographic information comes the opportunity to harness vast amounts of data about the health of populations to figure out where improvements can be made.
That’s the dream of EHRs. At the moment, though, it’s far from reality.
“That’s just a joke,” said Dr. Tim Hanlon, a Pendleton cardiologist who used to work at BMC. “That does not exist.”
If one were to chart out all the different EHR platforms operating in Central Oregon, they’d get a massive quilt sprinkled with a wide variety of players. Dallas, of St. Charles, guesses there are at least 15 different EHRs operating locally.
“Different vendors, different databases, different systems, and none of them talk directly to each other,” she said. “They’re all separate, little, silo (electronic medical records).”
And so far, the vast majority of those EHRs cannot share information when a patient moves from one provider to another. Often, it’s done the old-fashioned way: fax or email, local providers say.
But work is underway to bring the technology to Central Oregon that will connect those independent EHRs. The relatively new group spearheading the task is called the Central Oregon Health Information Exchange. Executive Director Pat Bracknell, the group’s only paid staff member, just came on board in September. She’s got 15 years of consulting experience in implementing and integrating EHRs. Until now, the work has been mostly developing privacy and security rules, which are currently under legal review.
February is when the real fun began: Implementing the information exchange technology and starting to load data into it, Bracknell said. The group, which consists of eight local providers, including St. Charles, BMC, Mosaic Medical and the Central Oregon Independent Practice Association, already has chosen a software vendor and has an idea of how it wants the technical architecture to work.
When all is said and done, the information exchange will be able to help providers access their patients’ records from other providers the patients have gone to. Whether that can truly happen depends a lot on whether participating providers have EHR systems that can accept data from other interfaces, Bracknell said.
The real tricky part when it comes to interoperability is making sure the data identifies each patient across the various records that are roped into the system. Some EHRs will use different identifiers to denote different patients, and it’s sometimes tricky to develop an algorithm that will ensure each patient’s records are merged together, Bracknell said.
But to some extent, the success of a project like the information exchange is out of the hands of the people leading it. It depends on other, perhaps smaller, providers throughout the community agreeing to be a part of it. And it means they need to have their own EHRs up and running.
“Without the full picture, there is going to be holes in that view,” Bracknell said. “When we manage a population, we really want to manage that entire population and all of their records, so it will be important to us that we try to engage as many providers as we can. I’m not going to say we’re going to fail completely if we don’t have every single provider, but I’m also not going to say that, ‘Eh, we don’t need them.’ I mean, that’s just not true. We do. We need them.”
The U.S. Department of Health and Human Services, also eager to see interoperability succeed on a national scale, in December 2014 issued its draft Federal Health IT Strategic Plan 2015-2020, which was open for comments until early February. Soon, HHS will use the feedback to release a broad federal strategy, called the Nationwide Interoperability Roadmap, that will define how the federal government and private sector will approach sharing health information through EHRs.
In Central Oregon, the information exchange is currently funded by a grant from the local coordinated care organization, the group that oversees care for the Oregon Health Plan population, the state’s version of Medicaid. The funding model for the future hasn’t yet been determined; one potential avenue would be providers paying fees to use the service, or it could run on donations, Bracknell said.
McCarthy, of Adaugeo Healthcare Solutions, is a board member of the information exchange. He said being a part of the information exchange requires providers — many of whom are for-profit entities — to focus on something beyond their own bottom lines.
“You have to take it as a good for the community,” he said. “That’s what makes it so difficult for all of us to get together.”
Fraud made easier
Hanlon, the Pendleton cardiologist, recalls a time when he visited a physician and was shocked to subsequently learn from another physician that the first doctor had recorded in his patient records that the exam he had performed on Hanlon had turned up normal.
“I said to this other doctor, ‘How did you know my exam was normal, because the first doctor never touched me,’” Hanlon said, “and he said, ‘Well, it’s all here in your EHR.’ I said, ‘That never happened. None of that ever happened.’”
Hanlon’s experience illustrates yet another shortcoming of today’s EHRs: They make it easier than ever to commit fraud. In the past, doing so would have required a trail of lies and fraudulent note-taking. Today, Hanlon said, it’s just a matter of checking boxes in the EHR.
“Now, you click one button, it autopopulates an EHR, and you may not have done any of that,” he said. “This goes on all the time.”
A January 2014 report by the HHS Office of Inspector General warned that certain EHR documentation features, if poorly designed or used inappropriately, can make it easier to commit health care fraud, which is estimated to cost between $75 billion and $250 billion annually.
The OIG report placed specific emphasis on an EHR capability called copy-pasting, or cloning, which allows providers to replicate information from one note and paste it into another location. Doctors, nurses or other providers often do this speed up the process, but fail to ensure the information is updated for accuracy, which can result in inappropriate billing to patients or insurance companies, the report found.
EHRs also make it easier to commit a form of fraud called overdocumentation, or inserting false or irrelevant documentation in order to bill for services that weren’t performed. Some technologies let the user build templates that autopopulate fields, generating extensive documentation with a single click.
Despite all this, the OIG found very few EHR vendors had stepped up their policing of EHR documentation. Further, not all of the vendors surveyed reported even having the capability to determine whether copy-pasting or overdocumentation had occurred among their clients.
And such habits are becoming increasingly common, especially among medical school students, residents, and attending physicians. In fact, an examination of the notes of residents and attending physicians found 82 percent of residents and 74 percent of attending physicians had copied at least 20 percent of the notes from previous ones, according to a February 2013 study in the journal Critical Care Medicine.
“The process of training is being lost,” Mann said. “Everybody is just kind of cutting and pasting off of each other’s work and not documenting what they’re actually seeing.”
High Lakes is among more than 80 providers that contract with Adaugeo Healthcare Solutions to manage their practices, including administration, billing, insurance contracts and a shared EHR system.
McCarthy, Adaugeo’s administrator, said his company has a control in place designed to prevent chart cloning. Certified coders review all of the providers’ encounters before claims are submitted to CMS, which has condemned chart cloning. So, for example, if the coders see that a physician submits a claim for a chart note that looks exactly the same as his previous four notes, they would go back to that physician and question whether he actually performed the service, McCarthy said.
“That’s a control that has to be in place,” he said. “Otherwise, the temptation to just copy and send is too great. People will abuse it.”
Fraud isn’t the only concern that grows along with EHRs. As the prospect of linking many EHRs together starts to look more feasible, some have raised questions about whether providers can assure the information can be kept secure. Despite a federal privacy law designed to protect patient health information, numerous security breaches have taken place in recent years, including stealing patient information for financial gain or using the information to submit insurance claims or obtain medical treatment.
Since enforcement of the Health Insurance Portability and Accountability Act began in 2003, HHS has received more than 100,000 complaints of privacy infringements regarding patient medical records. Not all of those involved EHRs, but HHS says a lack of administrative safeguards around electronic patient information is among the top compliance problems it sees.
Bracknell, who heads the Central Oregon Health Information Exchange, said the system her organization will use to link EHRs is the same one used by the U.S. Department of Defense.
“We feel like it’s very secure,” she said. “It’s not something that we really plan to grant access to everybody and their brother to.”
The considerable benefits of having reams of data on countless patients comes at a considerable price: Someone needs to enter it all into a computer. That often ends up being the doctor, who must check boxes indicating whether a patient smokes and whether there is a firearm in the patient’s home — even if the visit is for, say, trouble sleeping.
“I went to medical school to enter in smoking data? Is that the best use of my time?” said Miller, of High Lakes.
Aside from being a burden on providers, it’s also having an impact on the patient experience. Often, patients are separated from their doctors by a computer screen, and, in some cases, that’s been detrimental to the patient-provider relationship.
Each provider has his or her own way of managing the new EHR responsibilities. Some enter the data into the computer while the patient is in front of them. Some have a medical assistant, nurse or other provider enter the information before the physician enters the room. Some have what are called medical scribes, trained information managers who sit in during patient visits and document the encounters, including entering EHR data, in real time. Others write down notes after the visit and enter them into the computer after the patient has left. There are other tactics, too, such as recording notes about patients into tape recorders during a visit and entering them into the system later.
Some providers, like Miller, have decided that a screen separating them from their patients just won’t do. To her, looking at patients while they’re talking is important. She makes eye contact during visits, remembers their discussions, writes down notes after the visits and, at the end of the day, reads the notes into a voice recording. Someone else, sometimes a medical assistant, then enters that information into the EHR system.
Miller estimates for every 10 minutes of time she spends with a patient results in 20 minutes of clerical work at the end of the day.
“Patients love it. Why? I can listen to them,” she said. “I can hear them. Electronic health records are awesome for data. There is nothing that compares. The challenge is, who puts the data in? It takes time to put it in.”
When The Center went live with its EHR system, Allscripts, in August 2008, Verheyden, the orthopedic surgeon, estimates he spent between 300 and 400 hours setting up customized notes and templates to make his practice more efficient. But even with all that front-end work, he found himself spending an average of six minutes per patient visit documenting the visit, regardless of how short the visit itself was.
“If I were to spend 10 minutes with a patient, it would take me six minutes to document that. It’s a tremendous amount of effort.”
Four years ago, Verheyden became one of the first physicians in Central Oregon to make scribes a regular part of his practice. He estimates he’s gone through seven or eight scribes at this point, but he’s now been using the same person for the past 10 months, a fast typist who used to work in an emergency room and aspires to one day go to medical school.
Using a scribe allows Verheyden to walk into the room with a patient, make eye contact, and have a conversation without worrying about writing anything down. The scribe sits at a computer behind him and enters all of the notes, diagnoses and other necessary information into the EHR.
Verheyden says his observations about the patients out loud so the scribe can enter them into the computer. At first, he said he was nervous that might offend patients, but he’s come to realize they appreciate it.
“Even though my visits usually don’t take too long, patients feel like they’ve had a good visit and are very appreciative,” Verheyden said.
There’s another important, easily overlooked benefit of looking at a patient during a visit echoed by several physicians interviewed for this article: They’re able to pick up on the subtle things patients don’t always say, but show in their mannerisms, gestures or appearance.
“If they stand up or sit down, how they move, how they walk,” Verheyden said. “What they do with their hands as I examine them for scars or deformities.”
Hanlon, the Pendleton cardiologist, recently saw a patient complaining of chest pain. During their discussion, he noticed a change in her facial expression.
“I said, ‘What are you feeling right now? What’s going on?’ She started bawling,” he said. “Had I been looking at a computer screen, I would have missed that. I wouldn’t have realized how scared this woman was. That changed my whole approach of what I’m going to do with her. I have to prove to her that she doesn’t need to be scared.”
Today, Verheyden said he’s down to two minutes of documentation per patient visit, and he sounds like walking advertisement for scribes
“It’s the single best thing I’ve done for my personal practice and from a free-time standpoint since I’ve started practicing,” he said.
But hiring someone to enter that information costs money. Verheyden takes on scribes as a personal expense, one he says he’s willing to pay to improve his quality of life.
Dr. Michael Murphy, the CEO of ScribeAmerica, a leading provider of medical scribes in the U.S., said, scribes are paid between $10 and $20 per hour.
Miller said she’d love to have a scribe, but wouldn’t be able to afford one.
The rise of EHRs has dramatically strengthened demand for scribes. Between 2004 and 2009, ScribeAmerica went from no clients to 32 hospitals on its roster, Murphy said. In 2009 — the year that saw the passage of the federal stimulus and, with it, HITECH — ScribeAmerica’s demand took off. Today, the company has close to 600 hospital clients, Murphy said.
Murphy said he understands the value of collecting the data EHRs contain, but the systems are not intuitive to the practice of medicine, and have turned physicians into “data entry specialists.”
“I don’t want to say they’re doing more harm than good, but they’re causing a lot of difficulties,” he said. “What scribes are really there for is to really put the physician back in front of the patient and allow them to just focus on what’s really important: medical decision-making.”
Central Oregon Emergency Physicians, which employs many of the emergency physicians that staff St. Charles hospitals, contracts with a company that provides medical scribes to its physicians, said Reed, the emergency room physician who works at St. Charles Bend but is employed by COEP. Much of the scribe industry’s clients are from the emergency setting. At ScribeAmerica, 97 percent of revenue last year came from emergency medicine, Murphy said.
Reed’s experience with scribes was much different than Verheyden’s. While he found them to be motivated and pleasant to work with, he couldn’t get over the discomfort of having someone else — someone who didn’t go to medical school — controlling his charts.
“They don’t know what the pitfalls are of saying things one way versus another and making sure you document this, and it’s OK to skip that part,” Reed said. “There are accuracy issues, flavor issues to the story.”
Reed used scribes for about six months, and during that time, he would spend time after every shift going over the scribe’s work to make sure it was accurate.
Verheyden said he still goes back after every visit and reviews his scribe’s notes to make sure nothing was misinterpreted, but that still takes a lot less time than not having the scribe at all. He said scribes take patients, and generally a couple months of training on the specific system you use and jargon of your specialty.
“A lot of it is really finding a good scribe,” he said, “because it’s just like every profession. There are some that are very good, and some that are OK.” •