Wishing For a Better EHR

Joseph Goedert, News Editor
Health Data Management Magazine, September 1, 2008

Guillerm

o Diaz, M.D., really likes his electronic health records system—for the most part. The chief medical officer of QueensCare Family Clinics, comprising six community care centers in Los Angeles, appreciates having more patient data at his fingertips. But he’d like to do more with that data than he presently can. “I’d like to query free text for aggregate reporting and tracking,” Diaz notes.

John Scibal, O.D., wants better integration between the disparate EHR and practice management systems used at Carteret Optometry in Morehead City, N.C. His records vendor says it’s easy to do but cooperation is required of the practice management vendor, and that vendor says it isn’t technically able to integrate the system that Scibal bought in 1992. “I’m kind of stuck in the middle,” he sighs.

These two caregivers are not alone. All EHR users want better reporting and workflow capabilities, says Lyle Berkowitz, M.D, medical director of clinical information systems at Northwestern Memorial Physicians Group in Chicago, and clinical associate professor of medicine at the Feinberg School of Medicine at Northwestern University.

“A growing chorus of established EHR users are saying that we want to start getting the value of the data in our systems,” Berkowitz contends. “In other words, give us easy and robust reporting capabilities. Some EHR systems are already doing this, others have the capability if you pay extra, and others simply were not well designed for data analysis from the start.”

For every EHR user there is a wish list of missing functions and capabilities that are not available. Ideally, these wishes should be negotiated during the vendor selection process, says Kevin Carr, M.D., associate chief medical officer at BearingPoint Inc., a McLean, Va.-based consulting firm.

But when evaluating software, it is difficult to envision future needs, such as capturing codified information to report on quality of care, Carr adds. Many providers, he notes, also believe out-of-the-box EHRs will codify the data and generate the reports that a practice will need.

Some functions, such as electronic records interoperability with personal health records software, aren’t being demanded now, but could become a priority need if consumer use of PHRs accelerates. “Doctors working with younger populations are more keen on working with PHRs,” says Steven Waldren, M.D., director of the Center for Health Information Technology at the American Academy of Family Physicians in Leawood, Kan. (see story, page 32).

Vendors enhance their EHR systems for a variety of reasons, particularly to satisfy existing clients, stay competitive in the market or to meet new regulatory requirements. Newer forces also are at play, such as the Certification Commission for Healthcare Information Technology. The commission certifies EHRs as meeting specific criteria for functionality, interoperability and security.

The commission has been in operation for only a few years, but is making a big difference in the functionality—and value—of EHRs, Carr says. “CCHIT compelled functions that vendors would not have done on their own,” he contends. “Vendors are moving to e-prescribing faster than they would have.” Pay-for-performance reporting, he adds, also has accelerated (see story, page 30).

Still in paper mode

Clinicians may be moving toward EHRs, but many of their vendors are still stuck—figuratively at least — in a paper world, says Berkowitz of Northwestern Memorial Physicians Group.

Most vendors, he asserts, “developed their systems using a paper-based paradigm, meaning they try to replicate how a paper-based medical record looks and acts.”

But that doesn’t optimize workflow in an electronic environment, or utilize the power of computing, he adds. “Everything looks like Microsoft Word and Excel. Nothing takes advantage of the type of processing power and information visualization theories that have enabled video games to represent complex three-dimensional worlds but be easy enough for a 6-year-old to use.”

Not only do many EHRs poorly support appropriate workflows, they also don’t support what Berkowitz calls “thought flow,” which is how physicians really work.

“For example, reviewing recent lab results in a paper medical record involves looking at the results clipped to the chart and comparing to recent notes and past labs in the chart,” he explains. “A lot of analysis and scanning is going on during this process, but it is all done almost instantaneously in a virtual process in the physician’s brain. However, in the typical EHR system, that ability to find and review other pieces of data involves a lot of clicking and scrolling—making it both harder and less efficient as compared to paper. Wouldn’t it be great if an EHR system figured out how to let a user view current lab results, see the other data needed, and presented options for notifying the patient—all at the same time?”

Finding Information

All that data in an EHR should be easier to find, concurs CMO Diaz of QueensCare Family Clinics in Los Angeles, even if much of it is entered as free text.

Thirty physicians or nurse practitioners work at the clinics. They must enter discrete data elements for laboratory orders, prescriptions and diagnoses into the Intergy EHR, from Sage Software Healthcare of Tampa, Fla. They can enter data elements or free text for all other documentation.

Limiting the mandated amount of discretely entered data was a decision designed to aid in acceptance of the EHR by reducing the impact on clinician practice patterns, while still getting real value from the system, Diaz says.

But he’d like to be able to search free text for a family history of cancer or other conditions. That could help him narrow down possible diagnoses for a patient or target preventive treatment. His EHR vendor is working on improvements to templates to support more detailed coding of conditions. That way physicians may enter more data elements and less free text. That will help, Diaz says.

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