Engaging Patients with EHR

Imagine this scenario. You’ve waited almost an hour to see your family doctor. You spend a few minutes telling her your symptoms. As you talk, her eyes are almost constantly on her tablet as she types things in. You’re not sure what she’s doing, but it sure seems like she’s not paying attention to you.

Now, most of us know that of course the physician in this fictional scenario is listening. She’s typing in symptoms and navigating the system, both of which will help her provide better care for her patient. But to her patient, the one person who matters most, the doctor isn’t listening at all.

This is a simple example of how EHR can create distance and disengagement with patients. And, it’s why physicians and other health practitioners need to be more aware of how their use of EHR might affect patient relationships.

It’s a tough balancing act. Physicians need to look at their screen or tablet. And, they need to listen to the patient. So it’s tempting, especially with the time pressures of the day, to do both. However, keeping your eyes down cuts you off from patients. And they notice that you’re a bit disengaged.

You can overcome this by engaging patients with the EHR experience. Instead of silently typing things in, hold the tablet up so your patient can see the screen. Tell them what you’re doing, and explain how the EHR system will help you provide better care.

As the patient is talking, take some time to actively listen to what they’re saying. Give them your full attention, and let them know you’re listening with verbal cues such as “Ok,” or, “I understand.”

A wonderful article published on Medscape about this very issue quoted a statement issued by the AMA. Apparently, enough patients have complained about the interference of EHR in the examination room that they’ve deemed it necessary to start providing physicians with tips and strategies they can use to interact with both patients and technology effectively.

One thing that the AMA recommends is that physicians start putting questions related to EHR on their patient satisfactions surveys. Getting feedback from your patients on how you handled the EHR system is one of the best ways to discover what you need to improve.

Another strategy you can use is to put the laptop, computer, or tablet in a strategic location. Make sure it’s located in a place that allows you to see the screen and the patient at the same time. Better yet, put the computer on a wall mount or swivel arm so you can easily share information, graphs, or x-rays with the patient.

EHR is going to be a part of your relationship with your patients from now on. It’s incredibly important that all physicians learn how to integrate technology into their relationships with patients. Not only will your own practice grow, but your patients will leave feeling as if they were really heard. And, all of us need more of that feeling in our lives!


New Study Shows EHR Can Help Reduce Hospital Readmissions

According to a new study conducted by BMJ Quality and Safety, EHR can help reduce the instances of hospital readmissions by stratifying risk, thus giving doctors the additional insights they need to adjust their treatment.

The study examined over 1,700 inpatients with heart failure readmissions and other heart-related conditions at Parkland Health and Hospital System. Specifically, they looked at patients with heart failure, as well as two control conditions, acute myocardial infarction (AMI) and pneumonia (PNA.)

According to the study’s methodology, “the EHR system stratified all patients admitted with heart failure on a daily basis by their 30-day readmission risk using a published electronic predictive model. Patients that showed the highest risk received an intensive set of evidence-based interventions designed to reduce readmission using existing resources.”

What they discovered was the the EHR data helped them reduce the instances of hospital readmissions by a significant margin. From the study, “The unadjusted readmission rate declined from 26.2% in the pre-intervention period to 21.2% in the post-intervention period.”

Another study, this one through the El Camino Hospital in California, found that readmissions were reduced by 25% when EHR used predictive analysis to guide patient care.

Stop and think about what this could mean for your own practice or facility, and for the health care industry, and patient health and safety, as a whole. According to some studies, nearly 2 million Medicare patients annually are readmitted within 30 days of their initial procedure due to complications or other conditions.

Using EHR’s predictive analysis could eliminate 25%, at least (in these early stages) of these patients. This would cut down on mortality, and the high risk of secondary infection these patients are exposed to when they re-enter the hospital.

I’m excited by these findings because it shows the huge potential EHR has for improving patient care. And I’m sure that as the technology continues to evolve, we’ll see readmission rates drop even further.

NextGen Adopting a New Developer Code of Conduct

NextGen just announced it will be adopting a new developer code of conduct, a code that was developed by by EHR Association (EHRA,) a collaboration of over 40 EHR companies.

According to News Medical , the Code of Conduct is meant to, “to improve care, increase efficiencies, enhance patient safety and provide better outcomes.” These are all good things in my book, and I’m really excited that NextGen is taking this step. I really believe this will help improve the industry overall because these companies are making a promise to everyone, doctors and patients alike, that they will will abide by these principles.

The Code of Conduct focuses on these areas:

  • General business practices
  • Patient safety
  • Interoperability and data portability
  • Clinical and billing documentation
  • Privacy and security
  • Patient engagement

So, what’s in this new code? Here are the principles, which I’ve taken from the full Code of Conduct by the EHRA, which you can see here.

EHRA Code of Conduct

1. Our business practices will emphasize accurate communication about the functionality and
benefits of our products and services.
Patient Safety
Recognizing that patient safety is a shared responsibility among all stakeholders in an increasingly health IT-enabled, learning healthcare system:

1. We are committed to product design, development, and deployment in support of patient safety.

2. We will utilize such approaches as quality management systems (QMS) and user-centered design methodologies, and use recognized standards and guidelines.

3. We will participate with one or more Patient Safety Organizations (PSOs) (and/or other
recognized bodies) in reporting, review, and analyses of health IT-related patient safety events.

4. The exact nature, extent, and timing of our participation will depend on the outcome of current industry and policy discussions; such factors as legislative, regulatory changes, or agency guidance; the availability of the appropriate recognized organizations; development of standardized definitions for safety events; and other implementation factors. This work will require close collaboration with our customers.

5. We will share best practices with our customers for safe deployment, implementation,
maintenance, and use of our products.

6. We will notify our customers should we identify or become aware of a software issue that could materially affect patient safety, and offer solutions.

7. We recognize the value of our customers’ participation in discussions about patient safety. We will not contractually limit our customers from discussing patient safety issues in appropriate venues. In applying this policy, we will maintain fair and reasonable intellectual property protections.

Interoperability and Data Portability

Recognizing that data should follow the patient:
1. We will enable our customers to exchange clinical information with other parties, including those using other EHR systems, through standards-based technology, to the greatest extent possible.

2. We will use available, recognized, and nationally uniform standards to the greatest extent
possible in developing interfaces.

3. As customers implement interfaces and work to achieve interoperability, we will share best practices with them about the safe deployment, implementation, and use of the supporting tools and technologies.

4. We will work with our customers to facilitate the export of patient data if a customer chooses to move from one EHR to another. We will enable, at a minimum, the export of one or more standards-based clinical summary formats such as CCD/CCDA (or the then-current equivalent) for all patients.

See the Full Code

Again, this is only a portion of the EHRA’s new Code of Conduct. You can see the full contract here.

I applaud every EHR developer who has adopted this new code of conduct, and urge those who haven’t to hop on board. I also applaud the EHRA for developing these best practices; I think they will really help guide developer decisions and hopefully make the industry safer and more accountable.

Reimbursement Concerns Over EHR Workarounds

Several weeks ago, I wrote a post about physicians using workarounds in their EHR system.
The American Medical Association (AMA) released a statement about this very issue last week, and the implications are serious. Media Health Leaders wrote an in-depth post about the statement, and its potential effects.

According to the AMA, some Medicare carriers have issued rules stating that if patient charts look too similar, they will deny payment for them. This is the case even when physicians are using the EHR software appropriately.

In essence, this means that some physicians will have to reengineer their clinical notes in order to receive payment.

All of you who work in a clinical setting understand how serious this is. And, we all know that inputting a clinical experience into some EHR systems can be an incredibly frustrating, time-consuming chore. Because of this, some physicians use workarounds like templates and cut-and-paste for static information. Of course they do: these shortcuts save time and energy. And it’s understandable, especially when physicians are forced to work within a system that doesn’t meet their needs.

The problem is that these shortcuts can potentially harm patients when they’re used with non-static information like notes. Physicians who cut-and-paste notes without attribution or attention to what’s written there can seriously undermine patient care, and even put them at risk.

So, this is a valid concern and risk. However, threatening physicians with non-payment if charts look too similar is not an intelligent way to address this risk. Many charts DO look the same, with the same wording, tone, or style, simply because one physician may describe a condition so precisely and eloquently that other physicians adopt the description for their own use. Even with attribution, this causes charts to look “the same.”

But according to the rules set forth by some Medicare carriers, this practice (even though it’s harmless) can result in non-payment moving forward.

Many CIOs are pushing for a 12-month extension of Meaningful Use Stage 2; this would give everyone more time to address this issue, along with other pressing concerns, and hopefully iron out the details before physicians are penalized for practices that are necessary for effective patient care.

What do you all think about this issue?

Study finds Doctors Using Workarounds with EHR Systems

When physicians encounter a problem or inefficiency with their EHR system, they often use a workaround to get through the issue and on with their work.

This is a fairly common occurrence in most practices; after all, doctors, nurses, and support staff stay constantly busy, for the most part. They don’t have the time that’s often required to deal with a technical issue properly. More often, however, a workaround occurs because the EHR system hasn’t been designed to accommodate the unique needs of a clinic or practice. For example, physicians might not be able to find data, or a particular process might be so complex that it’s just faster and easier to use a paper form.

Workarounds are something that all of involved in the healthcare industry are familiar with. However, a study released in mid-March found that the problem of workarounds might be putting patient safety at risk.

The study, titled, “Paper- and Computer-based Workarounds to Electronic Health Record Use at Three Benchmark Institutions,” found that workarounds are fairly common in most healthcare institutions. Researchers wanted to see how doctors and support staff were using, and circumventing, their EHR systems. They collected data at 11 primary care outpatient clinics across three healthcare institutions. They interviewed 120 staff members, and observed 118 patients.

So what did they find? Well, they discovered that although each of the three institutions were all using different EHR systems, all the staff they observed used workarounds in the same type of categories. The three most common reasons for a workaround was memory, awareness, and efficiency. However, they also found that some physicians had to use a workaround because there was “no direct path,” or, put simply, there was just no way for them to perform a particular task through the EHR. It wasn’t an option in the system.

What all this means is that many EHR systems are still not meeting the needs of healthcare institutions and practices. When doctors and support staff have to use a workaround, either by leaving themselves a paper reminder or overriding a particular alert function, they could be putting patient safety at risk.

In the end, all this goes to show that EHR still has a ways to go before this technology is meeting 100% of the needs of physicians and larger healthcare institutions. Sadly, workarounds are still necessary in many cases in order for workflow efficiency ..but these workarounds might come at a cost to patient safety over time.

If you’re a physician or support staff, have you every used a workaround in your EHR system? If so, what did you have to do?



Copying Notes Into EHR Can Increase Patient Harm

Recently, the American Medical Informatics Association came out with a report that outlined how physicians and clinics can reduce EHR errors. Of course, there are always going to be errors in just about anything; we’re human beings, and they happen.

However, the amount of errors some doctors are reporting are a bit disturbing. A writer on the Fierce EMR blog spoke with one physician who said that every EHR has errors in it. Some of these are “copy and paste” errors that are messed up when they’re transferred from one EHR to the next. While copy and paste can be a useful, time-saving tool, it can also cause problems and put patient safety at risk.

How to Reduce EHR Errors

Fierce EMR spoke with a physician with the Medical College’s Department of Medicine, who listed some good ideas for reducing errors in EHR.

1. Don’t use the copy and paste function for patient notes without attribution.

2. Don’t repetitively copy and paste lab results and radiology reports.

3. Note important results with proper context, and document any resulting actions.

There are two other useful steps, which you can find in the original Fierce EMR post.

The AMIA Report-Aviation and EHR Lessons

The AMIA Report made a unique and useful correlation between the medical industry and the aviation industry. Here’s what they concluded:

The aircraft industry developed industry groups where topics are discussed and conventions sanctioned by a large number of airframe manufacturers and aviation software and hardware vendors. These cooperative efforts have occurred despite the intensely competitive nature of the aviation sector as competitors see value in working together in this arena.

And, a bit later on in the report….

No single measure alone accounts for this success, but the mixture of measurement, reporting, and regulatory incentives has resulted in an admirable level of safety and continuous improvement from which other industries—including healthcare IT—can learn. In the USA, the Federal Aviation Administration regulates aircraft airworthiness, issues aircraft safety alerts, operates the Aviation Safety Reporting System, and in many other ways regulates aviation. Some have suggested that a structure analogous to the Aviation Safety Reporting System should exist in healthcare.

I think this is sound advice that should be acted upon. The aviation industry has to make decisions that play a key role in passenger safety; they have established processes in place to check and recheck equipment safety and emergency backstops.

While our industry doesn’t really need assistance with patient care or new triage techniques, we do need to put safety decision-making checks in place to make sure EHRs are accurate, and patients are kept safe. And, we could learn a lot from the mistakes the aviation industry has already had to go through.

I’ve written often about the cost-savings physicians, clinics, and hospitals can see with EHR.

According to an article in iHealthBeat, citing research from RAND Corporation, cost-savings have been falling below users’ expectations in part because of the sluggish adoption pace, and the lack of interoperability. Another factor that’s slowing the savings is the reluctance of physicians and support staff to learn and adopt this new technology; many of them simply don’t have time to learn the ins and outs of an EHR system.

Although tech support wasn’t cited as a specific concern in the iHealthBeat article, another study, this one published in PhysBizTech states that tech support is incredibly crucial during and long after an EHR implementation. Research shows it takes a minimum of nine months of constant EHR exposure, and at least 8-9 technical assistance visits, to demonstrate significant improvements.

Now, this particular study was focused on patient care improvements, not cost-savings, but you can easily see the parallel. Clinics who don’t have a lot of extra money to spend on technical assistants are going to see their cost-savings opportunities fall quickly when physicians need help using the system, and that help isn’t there. The EHR system will also fail to saving a clinic money if it crashes, and it takes days for help to arrive because there’s no in-house support staff.

These two studies, when looked at together, offer a number of lessons for smaller clinics. First, EHR can help you save money and improve patient care. But you can’t implement a system if your physicians and support staff aren’t willing to invest the time and energy needed to learn this new technology. If they’re aren’t, then you might be wasting your money.

Another key lesson is support; tech support is crucial before GoLive, and in the year that follows the system’s implementation. Clinics should over-budget for support to make sure they have the help they need while they’re learning the system, and when it goes down.