Technology in Medicine

EHRs Spur Fundamental Changes in Medicine, but Questions Persist About Overall Effectiveness

April 17, 2013 03:30 pm James Arvantes

Chris Tashjian, M.D., has been a family physician for the past 25 years and has spent most of his career practicing in a paper-driven medical environment. In that paper-based world, Tashjian says he was forced to practice reactive medicine, responding to the needs and concerns of his patients rather than proactively managing and delivering care.

[Doctors using electronic devices]

Then, in 2010, Tashjian's small two-physician practice in Ellsworth, Wis., adopted an electronic health record (EHR) system, which eventually made it much easier for the practice to capture and analyze patient data and use that data as a means to reach out and manage patient care on a proactive basis.

"In the paper world, we reacted -- we waited for the patient to get sick and then reacted to it," said Tashjian in an interview with AAFP News Now. "In the electronic world, we can practice proactive medicine. We can actually try and reach out to patients before they get sick and before they have bad sequelae that come with diabetes, high blood pressure and heart disease.

"It changes the way we look at the patient," he added.

story highlights

  • The adoption of electronic health records (EHRs) has ushered in a new era in medicine.
  • Family physicians say there are both benefits and drawbacks to EHRs.
  • Analysts insist, however, that EHRs are a necessary component of the emerging health care system.

Tashjian's experience is an example of how technology is transforming the practice of medicine. In 2009, the federal government enacted the American Recovery and Reinvestment Act (ARRA), which made major investments in health information technology and created financial incentives for physicians and other health care providers in the Medicare and Medicaid programs who achieve meaningful use of EHRs.

As a result of the ARRA, the percentage of physicians in the country with EHRs jumped from about 15 percent in 2009 to more than 50 percent today, thus ushering in a new electronic era in medicine. The rate of EHR adoption among family physicians reached 68 percent in 2011, double the percentage in 2005, according to a recent study in the Annals of Family Medicine. Researchers for the study, "The Rise of Electronic Health Record Adoption Among Family Physicians(annfammed.org)," predicted that the EHR adoption rate for family physicians likely would surpass 80 percent by the end of 2013.

By having EHRs, physicians, at least in theory, have the ability to capture and use patient data to inform medical decisions, thereby improving efficiencies and outcomes.

Tashjian said after adopting an EHR system, his practice, the Ellsworth Medical Clinic, was able to hire a care coordinator to help manage the care of patients with chronic diseases. The care coordinator analyzes clinical data from the EHR on a monthly basis and reaches out to patients who may need a follow-up visit.

"Rather than waiting for the chronically ill to get worse, we can actively and pre-emptively strike and say, 'Mrs. Jones, we see you haven't had your A1c done in the last six months, and the last time we checked, it was kind of high,'" said Tashjian, laying out a common scenario. "We will say, 'Let's (test) it again and redress it.'"

The practice follows a similar approach with other conditions, such as heart disease and hypertension.

"Before the EHR, we were lucky if we could do this twice a year," said Tashjian. "It was very expensive. We had to go into our practice management system and get a list of the charts of those diagnoses and then pull the charts. Then someone had to look through the charts, gather the data and assemble it."

With the EHR, the practice also is able to chart its progress in managing chronic conditions and diseases. For example, the hypertension control rate among patients in the practice has climbed from about 70 percent to more than 90 percent during the past few years. At the same time, the practice has recorded similar improvements with diabetes and other diseases, said Tashjian. "This means better care for patients. It means prevention of things like heart attacks and strokes and blindness and amputations resulting from diabetes."

EHR Adoption Can Include Struggles

This is not to say that the adoption of EHRs is a panacea that will solve medicine's most pressing issues and concerns. In many cases, physicians have struggled to adopt and implement EHR systems, and, in some practices, physicians complain that EHRs are impeding and even undermining the provision of patient care. In other situations, physicians cite payment delays resulting from problems with the billing software.

"Most EHR systems today have been designed to create a billable note rather than efficiently collecting and analyzing clinical administrative data to support shared clinical decision-making," said Jason Mitchell, M.D., director of the AAFP's Center for Health IT. "To get these systems to support the proactive patient care that Dr. Tashjian and his team are delivering takes vision, customization and an ongoing commitment to continuous quality improvement."

But as Mitchell pointed out, "That doesn't come in the box with the EHR."

"EHRs are absolutely necessary," said family physician Shaun Grannis, M.D., M.S., a biomedical informatics research scientist with the Regenstrief Institute, a supporting organization of Indiana University. "However, we risk mischaracterizing their role in the health data-sharing ecosystem."

According to Grannis, "research and practical experience tell us that patients receive care in many clinical settings." This means that a patient's data are not just within a single EHR. "Consequently, to maximize the value of health information technology investments, disparate and highly variable clinical data must be standardized and integrated," said Grannis. "While EHRs supply an important functionality, they don't provide all the pieces necessary for a learning health care system. They do not focus on standardizing and integrating data from disparate sources, and their ability to transmit or exchange data is limited."

Some Inherent Inefficiencies Exist

In some respects, EHRs are inherently inefficient because they require a certain amount of manual data entry, said Grannis, who also is an associate professor of family medicine at the Indiana School of Medicine and the director of the Indiana Center of Excellence in Public Health Informatics.

"I observe other physicians, including my wife, who also is a family physician, spending an increasing amount of time entering data into the EHR," said Grannis.

In some practices, EHRs risk transforming physicians into part-time "data entry clerks," he added.

"Their benefits notwithstanding, until information technology supports near human-like responsiveness and interactivity, EHR users will continue to face workflow inefficiencies," said Grannis.

Although the enactment of meaningful use incentives has led to a dramatic increase in the number of EHR systems, Grannis is convinced that some physicians are implementing EHRs primarily to obtain meaningful use incentives, and not necessarily to improve patient care.

"Many rightly claim that meaningful use incentivizes (entities) to deploy EHRs, but given the pressing need to integrate and standardize, are we sufficiently incenting efficient data movement across organizations and systems?" Grannis asked.

Moreover, the implementation of EHRs requires a certain amount of pain and disruption even among practices that succeed in implementing such a system. It is not uncommon for a practice to lose at least one staff member when making a transition from paper records to an EHR system because of their discomfort with the technology, said John Bender, M.D., CEO and medical director of Miramont Family Medicine in Fort Collins, Colo., and a past president of the Colorado AFP.

"For the first six months, I hated my EHR," said Bender. "But I would never go back to (paper) now."

EHRs Are Critical Health Care System Component

Bender and others are convinced that EHRs represent a critical part of the emerging health care system. Miramont Family Medicine, which is made up of five practices, adopted an EHR system five years ago, greatly enhancing the capabilities of the practice.

"Eight years ago, if someone asked how many diabetic patients I had at Miramont, I would say, 'I don't know,'" Bender said. "And if someone came back and said, 'How many patients have A1c levels less than 10 percent?' I would say, 'I have no idea.'"

With the EHR system, Miramont now has ready access to this type of information, putting the practice in a much stronger position to participate in accountable care organizations and other types of practice arrangements that hold physicians accountable for patient care and outcomes.

"This allows us to externally report metrics to payers so we can justify the care-coordination fees and the pay-for-performance bonuses," said Bender. "It also allows us to participate in gain-sharing contracts that we would not be able to participate in in years past because we did not have the data."

Tashjian, meanwhile, credits his EHR for making medicine much more enjoyable and fun. And he is convinced EHRs will continue to evolve and improve in a way that paper never could.

"It is more fun because we prevent people getting ill rather than trying to fix them after they get ill," he said. "We now put so much more emphasis on keeping patients healthy rather than fixing illnesses. And that is much more rewarding."


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