Are pediatricians prepared to go paperless?

An interim final rule on Standards and Certification Criteria calls for a three-phase EMR adoption process beginning in 2011.

Imagine having access to your patients’ complete medical records anywhere, anytime, as long as there is a computer nearby. This is a reality for Michael Ryan, DO, associate chief medical officer and chairman of pediatrics at Geisinger Health System; medical director of Janet Weis Children’s Hospital in Danville, Pa.; and associate in pediatric infectious diseases.

“It’s inpatient, it’s outpatient, on every patient; it’s not partial, it’s not something we’re transitioning to, it’s a done deal,” Ryan, told Infectious Diseases in Children.

With an online feature called My Geisinger, Ryan’s patients can view medical records remotely, lab and x-ray results as soon as they become available with the click of a mouse, access copies of immunization records for the school nurse from their home computer and request appointments by email, eliminating the time they spend on the telephone trying to reach busy office personnel.

The Geisinger Health System is a network of health care providers serving 43 counties and 2.6 million people throughout Pennsylvania and serves as an example of what health information technology proponents envision when they say electronic medical records (EMRs) have the potential to revolutionize health care delivery.

If a patient comes in with a sprained ankle or an upper respiratory infection and they are missing an immunization, an automated alert will appear in their record, notifying Ryan. “I can vaccinate in that visit,” he said, adding that Geisinger is one of the highest ranking groups in the country in terms of immunization compliance. “A lot of that has to do with automatic reminders.”

In Ryan’s experience, electronic medical records have also been beneficial for coordinating care.

“If you’re a referring doctor, you hear about the patient the next day. When I send someone to another doctor, I always wonder what happened, but in our system I find out right away because they can click ‘send to primary care doctor’ and I get a report immediately.”

But Geisinger is an exception, not the standard. Only about 1.5% of 2,952 American Hospital Association facilities that participated in a survey of electronic medical record use had a comprehensive system in place, data published in the April 2009 New England Journal of Medicine indicated.

Broader estimates from the American Academy of Pediatrics (AAP) put basic EMR usage at about 20% among pediatricians.

“The percentage of physicians using EMRs the way the government would like us to and the way we should be using them is probably less than 10%,” Joseph H. Schneider, MD, chief medical information officer at Baylor HealthCare System and an assistant professor of pediatrics at the University of Texas Southwestern, both in Dallas, said in an interview. Schneider also is the current chair of the AAP Council on Clinical Information Technology and practices at Parkland Hospital, also in Dallas.

These numbers are a little less than shy of the goal for universal EMR adoption that Washington policy makers have set for 2015. In 2009, Congress allocated $19 billion in stimulus funds as part of the American Recovery and Reinvestment Act to incentivize the conversion from paper to electronic files. Funding programs are structured to encourage early EMR adoption by boosting Medicare reimbursements to physicians who use EMRs meaningfully, and to discourage procrastination by limiting reimbursements to those who have not converted by 2015. The American Academy of Professional Coders provides a detailed outline of the Medicare payments and penalties on its Web site. But as policy changes by the minute, many physicians are grappling with practical concerns related to implementing EMRs while continuing to care for patients.

The case for converting

In 2001, the Institutes of Medicine identified six aims for improving health care in the 21^st Century and bridging the chasm that exists between current patient standards of care and ideal care. These goals are called the STEEEP framework — an acronym for Safe, Timely, Efficient, Effective, Equitable, Patient-centered care. “It’s extremely difficult to achieve those things without patient data in an electronic, portable and mutable form,” Kevin B. Johnson, MD, professor of pediatrics and professor and vice chair of biomedical informatics at Vanderbilt University in Nashville, told Infectious Diseases in Children.

In addition to general benefits such as creating a more cleanly archived patient health record, eliminating problems with eligibility that can arise from handwritten records and freeing up space in the office occupied by bulky filing cabinets, Johnson identified three areas of pediatrics where EMRs are particularly useful.

One area is electronic prescribing. With the use of computerized physician order-entry systems (CPOE), EMRs can improve patient safety by alerting physicians and pharmacists about potential medication dosing errors, possible reactions between a patient’s varying medications, and a patient’s history of medication allergies. Additionally, automated weight-based prescribing features can simplify the process for residents and surgeons who may be less familiar with determining specific dosages, especially for pediatric patients.

In a 2003 report, the Center for Information Technology Leadership (CITL) analyzed data from 25 studies, spoke with CPOE vendors and conducted an expert review panel to determine the financial, clinical and organizational value of these systems in the ambulatory care setting. They estimated that use of advanced CPOE systems could eliminate more than 2 million adverse drug events and 190,000 hospitalizations each year, for an estimated cost-savings of $44 billion per year in related expenditures.

Although advanced interactive CPOE systems that work interactively with patient data from EMRs are about five times more expensive than basic, passive systems that consist of a physician using medication templates and printing paper prescriptions for patients, CITL projected that advanced CPOE resulted in 12-times greater financial returns. “Intermediate and advanced systems pay for themselves within two years of operations,” CITL members wrote.

Another advantage of EMR use is immunization maintenance. Beyond generating reminders when a patient is missing an immunization, EMRs can gather data from fragmented information sources. This is beneficial for tracking compliance with increasingly complex immunization requirements that require children to get a certain number of vaccines at specific intervals within a specific time frame.

EMRs also have the potential to sustain continuity of care for patients with special health care needs.

“When these children travel, right now their medical records are basically unavailable because they are on paper,” Schneider said. “If there is an emergency, they wind up with all sorts of repeat tests and they may or may not be with a caregiver who knows their medical history, so there is the potential for a lot of confusion.”

Anticipating challenges

Schneider called poorly implemented EMRs “money down the drain,” and acknowledged the difficulty associated with transitioning to an electronic system, equating it to “converting from the horse-and-buggy age to the automobile age.”

High initial costs, lost income due to lower patient loads and varying levels of computer proficiency among health care personnel are among some of the difficulties Infectious Diseases in Children Editorial Board member Stan L. Block, MD, recalled from when his practice made the transition to EMRs in 2006.

He estimated that he spent between $70,000 to $75,000 per doctor within the first year to get an EMR system in his practice — a private ambulatory care facility in Bardstown, Kentucky. This included expenses for necessary computers and technical assistance to troubleshoot problems that arose.

In addition to the expense, Block said that clinicians can count on losing patients in the “hectic and scattered” environment during the transition period.

“For the first few months that we had an EMR, we saw about half of the patients we normally saw. So not only are you paying out a $50,000 to $70,000 loan per doctor that year, but you’ve also decreased your income precipitously.”

Trouble getting appointments and frustration with lag times while the office staff adjusts to the new system are two factors that keep patients away. Another can be physician demeanor.

“It was terribly frustrating at first,” Block said, noting frequent crashes at the start, and frustration getting IT support.

Although EMRs offer some exciting possibilities for improving health care, it is important to remember that the technology is only as good as the people that use it. Making sure that clinicians truly understand what happens when they push a button is essential, according to Schneider.

“There is an enormous amount of training needed to take people from a system that’s 100% paper-based to systems that rely on technology,” Johnson said. “Almost always when you’re going from a practice that has no health information technology to one that wants to become fully functional there are very significant process issues.”

Block puts the standard time frame before practices begin to see patients at normal levels at about one month; add an additional month before office personnel are comfortable using the program, and, he said, expect six months to pass before EMR usage can be considered smooth. Remember to schedule the transition when workflow is normally slow and when everybody in the office will be there. “I recently talked to a group who tried to implement it during October this year, which was during the H1N1 epidemic and it was a terrible disaster,” Ryan said, suggesting that pediatricians transition during the summer months.

Offering typing courses for those who have never had them or as a refresher for employees who have not used the skill in a while are simple steps that can help health care workers adjust to the change.

“If you’re not a proficient typist, [using an EMR] is very, very slow,” Block said, noting that typing skills are critical for effective time management.

Paying attention to the physical placement of computer systems in examination rooms is another simple technique that may help reduce one of the biggest EMR drawbacks — decreased patient face time.

“One of the complaints we get all the time is ‘the doctor doesn’t look at me, he looks at the computer’ ” Ryan said. “That’s a tremendous distraction if you’re a patient.”

He suggests positioning computers in such a way that eye contact is still possible. “It really helps to look at the patient,” Ryan said. “Sometimes I just type as fast as I can go when they’re telling me the initial story and then I stop, look them in the eye and go back over the details to make sure I’ve gotten it correct.”

Block suggested laptop use, but noted that laptops require multiple wireless routers and access to IT personnel.

Managing workflow

Diversity in the way health care providers work presents other challenges for EMR design and adoption.

“Medicine is very much a cottage industry,” Johnson said. “Individual single practices may have adopted a particular work flow, style and cadence to their visit that is not consonant with the development of electronic health records.”

Where Ryan praises EMRs for the ease with which he can provide referrals for patients who have special health needs, Block laments the past in these situations.

“If there are more than three to five diagnosis in the history or there is a complex exam — let’s say the child has congenital heart disease, has pneumonia, a rash and acute otitis media — EMR cannot capture all of that without spending at least an additional 10 minutes.”

Block said that even though it is possible to build personalized templates for these patients, there are so many variations that it is not very helpful.

These disparities highlight the need for better collaboration between the clinicians who use EMRs and the vendors that design them.

“Every hospital, every practice needs some really good clinical people … who have a thorough understanding of how clinical care takes place who can translate that to programmers,” Schneider said.

Potential for new errors

Technology is not immune to human error and EMRs have just as much potential to facilitate mistakes as they do efficiency.

In 2005 researchers from the University of Pennsylvania School of Medicine and the Center for Health Equity Research and Promotion, both in Philadelphia, identified 22 new risks for medication errors with CPOE and EMR systems in a study published in the Journal of the American Medical Association. They grouped these risks into two categories. The first were errors facilitated by data fragmentation and lack of interoperability between computer and information systems. These included:

• Clinician reliance on CPOE dosing information when they are unfamiliar with a medication. This information was often based on pharmaceutical warehouse and purchasing decisions rather than existing clinical guidelines.
• Problems modifying medication use or ordering new medications because discontinuing an existing medication was a separate process, or because multiple screens were needed to view a patient’s medication. These included accidentally doubling doses, duplicating medications or adding conflicting medications.
• Inappropriate antibiotic prescribing because of faulty communication between house staff and infectious disease specialists or pharmacists related to lack of system interoperability.
• House staff disregarding allergy alerts because of rapid scrolling, need to order multiple medications and the “post hoc timing of allergy information,” which may encourage reliance on pharmacists. When pharmacists are called to clarify questionable orders both they and house staff reported that this generates tension.

The second type of error was those facilitated by “human-machine interface flaws,” in which the way the technology was programmed does not correspond to usual work behaviors. These included:

• Difficulties selecting the right patient because of small font sizes, lack of a patient name on all medication screens, and organization systems that list patients alphabetically instead of by house team or room number.
• Wrong medication selection due to multiple screens (as many as 20 for a single patient).
• Loss of data, time and focus when CPOE systems crash. In the hospital setting, if a patient is moved from a room when the system is down, medication may be sent to the wrong room.
• CPOE inflexibility may result in inability to enter nonstandard medication specifications.

Many of these problems are easily corrected, but often go unreported, according to the researchers, in part because of “beliefs that problems are due to insufficient training or noncompliance” and “erratic error-reporting mechanisms.”

Several possible solutions exist. Schneider advocates for a “no fault” database where end users can report the problems they experience with EMRs, much like those that exist in the airline industry.

Secondly, EMR design has room for improvement. Vendors must keep failure in mind, according to Schneider. “Get the clinicians in during the design phase,” he said. “They will give them all sorts of seemingly strange ways to operate these systems, but it makes sense to the doctor or the nurse. Let them try to break it, so that buffers can be built that prevent those problems from occurring once the program is released.”

In addition to introducing quality control measures, more user friendly formats are needed. Although some vendors may be working on alternative ways of entering information into EMR systems in the laboratory setting, Schneider said he has yet to see improvements beyond prettier displays. Infrastructure improvements will also be necessary.

“A practice may be able to implement a very simple EMR system that costs almost nothing. But there’s still a need for networking outside of the practice, which in some states isn’t achievable everywhere,” Johnson said. “While it’s still possible to have an EMR that is available in every room and every practice, if you don’t have good broadband connectivity, costs go up because nothing can be shared across multiple practices.”

The creation of uniform standards is something that could enable EMRs to communicate with one another across technological platforms, geological divides and medical subspecialties.

Creating standards

In December 2009, the Office of the National Coordinator for Health Information Technology (ONC) issued regulations designed to provide standards for EMRs.

An interim final rule on Standards and Certification Criteria for EMRs outlines a three-phase adoption process for newly defined meaningful use criteria, beginning in 2011 and continuing to 2015 and beyond.

Emphasis during the first two years will focus on making the basic transition from paper to a coded format, tracking key clinical conditions for care coordination purposes, implementing clinical support tools and reporting quality measures. Goals for the second phase include moving toward CPOE adoption and electronically transmitting diagnostic test results. The final phase will prioritize quality improvements, extend patient access to health management tools, focus decision support on national high-priority conditions and improve access to comprehensive patient health.

The report also includes the first proposed standards for exchanging information among and between providers and patients and includes guidelines for improving the functionality, utility and security of health information technology, as well as requirements for EMR certification and technical specifications, and can be found online. This fulfills requirements in the HITECH Act, signed by President Obama in early 2009 to provide grant funding opportunities for practices who wish to adopt EMRs.

A second rule proposed by the Centers for Medicare & Medicaid Services, also issued in December 2009, will help determine those professionals and hospitals that qualify to receive Recovery Act incentive payments that could begin as soon as October 2010. The rule defines minimum standards and also proposes that states could request CMS approval to implement additional meaningful use measures as appropriate, but could not request approval of fewer or less rigorous measures.

The new rules were effective as of January 2010 and are open for public comment for a 60-day period. “We strongly encourage stakeholders to provide comments on these standards and specifications,” David Blumenthal, MD,the National Coordinator for Health Information Technology, said in a press release.

Both the CMS proposed rule and fact sheets are available online here, as well as ONC’s interim final rule here.

“I’m very excited about the comments coming out of Washington right now,” Johnson said, but he added that it is highly unlikely that a complete national health information network will exist by 2015. “I think it’s probably realistic to hope for a much greater than 50% adoption during the next five years.”

“I still see a lot of people sitting on the sidelines and waiting,” Ryan said. “I think that’s a huge error. This is the only way it’s going to be in a very short amount of time.” – by Nicole Blazek

Are policy makers’ expectations for EMR adoption by 2015 too high?

For more information:

• The Center for Information Technology Leadership. www.citl.org/research/ACPOE_Executive_Preview.pdf. Accessed Jan. 13, 2010.
• For more information about the Office of the National Coordinator for Health Information Technology, visit http://healthit.hhs.gov/.
• Jensen RE. Pediatrics. 2009;124:e648-e654.
• Jha AK. N Engl J Med. 2009;360:1628-1638.
• Kim GR. Pediatrics. 2008;122:e1287-e1296.
• Koppel R. JAMA. 2010;293:1197-1203.
• O’Malley A. J Gen Intern Med. 2009;doi:10.1007/s11606-009-1195-2.