I lay there, staring at the ceiling. I'd spent the last two hours in bed tossing and turning. My wife had had enough! She had gone to sleep with our kids in another room.
I was the clinical manager of a large physical therapy department and I had just signed off on a large, multi-year contract with a market-leading electronic health record (EHR) vendor. We had just signed a contract that cost our clinic many thousands of dollars up front, and many thousands more in ongoing fees, licenses and maintenance costs.
Had I done the right thing? Could I assure my therapists that patient care would not be impaired? Could I tell my CEO that I hadn't wasted her company's money? I reviewed the nagging doubts that kept me awake.
Do EHRs Add Value?
The idea that electronic patient notes will speed up therapy documentation by improving on handwritten notes just seems reasonable. But, new stories of expensive electronic medical record cost overruns kept popping up in the media. To be fair, most of these stories were on the hospital side of the healthcare industry.
"Adoption of expensive electronic medical record systems may hurt a hospital's bottom line, despite promises that the new systems will increase efficiencies and lower costs. Yet another hospital is reporting that the high cost of implementing a new EHR is having a negative effect, with Henry Ford Health System in Detroit, Michigan reporting its investment. being a major factor in a 15 percent decrease in net income - from $62.9 million in 2011 to $53.1 million in 2012."1
Would my decision just cost my clinic money without adding some valuable benefit?
Many, if not most, providers say that EHRs decrease their productivity. This is not just anecdote - 85% of small practice physicians and specialists reported in 2013 that they were less productive than in 2009 with paper charts. The author of the new study from IDC Community Insights reports the following:
"Despite achieving Meaningful Use, most office-based providers find themselves at lower productivity levels than before the implementation of their EHR," said IDC Research Director Judy Hanover. "Most providers using EHR are less productive than they were using paper in 2009, and the inability to restore productivity with EHR has clearly affected the business outlook for many providers."2
Additional findings of the study confirm that patient care was not the top goal for initial EHR adoption. The top three goals of 212 ambulatory and hospital-based providers were to improve Medicare and regulatory compliance (56%); improve quality of patient care (43%); and qualify for Meaningful Use incentives (40%).
I was not comforted by the last point, because I knew that physical therapists don't qualify for federal reimbursement for Meaningful Use of EHRs under the 2009 Health Information Technology and Clinical Health (HITECH) Act.
Docs 'Stressed and Unhappy'
I thought of my physician colleagues who also complained about their particular EHRs. They told me that it took a long time to learn and that each patient's data took a long time to enter. In general, my physician buddies didn't like how EHRs impacted their daily work. I remembered reading an Oct. 2013 study from the RAND Corporation that described the determinants of physician job satisfaction:
"Physicians want to be able to provide high-quality care, and that is a primary driver of job satisfaction for doctors, and that anything that hinders that ability is a source of stress."4
Study author Mark Friedberg qualified the findings in the context of EHRs. "Physicians believe in the benefits of electronic health records, and most do not want to go back to paper charts," said Friedberg in a statement. "But at the same time, they report that electronic systems are deeply problematic in several ways. Physicians are frustrated by systems that force them to do clerical work or distract them from paying close attention to their patients."4
Most therapists I know also derive their job satisfaction from high-quality interactions with their patients. I hoped my decision to buy this new EHR wouldn't impair their job satisfaction.
Copy and Paste or 'Sloppy and Paste'?
I had also heard that there are concerns with the current generation of EHRs that allow essentially unrestricted copy-and-paste functionality between different dates of service. The clinician is trained to "document everything," which is almost too easy with computers. I had a concern that patient information entered by the therapists would not be accurate.
According to an article in the Journal of the American Health Information Management Association, "Up to 90 percent of physicians use the copy/paste function in their EHRs, and between 20 to 78 percent of physician notes are copied text (from one session to the next)."5
Copy-and-paste has become such a compliance and payment problem that U.S. Dept. of Health and Human Services Secretary Kathleen Sebelius, together with Attorney General Eric Holder, wrote a letter last year to industry medical groups underscoring the seriousness of doctors "gaming the system, possibly to obtain payments to which they are not entitled."
Several physicians also complained about "note bloat" at an Oct. 9 meeting of the College of Healthcare Information Management Executives (CHIME). They said the content of the electronic note in the EHR lacked value because it was not "concise, complete and informational."
One example cited by the CIO of the University of Pittsburgh Medical Center was a new EHR used between 2009 and 2012, which produces over 7 million notes each month in their new EHR. A survey of nearly 2,000 Pittsburgh clinicians found less than half thought the notes were valuable for patient care.6
The Year of the 'Great EHR Switch'?
More physicians and physical therapists are using EHRs every year. Currently, the Centers for Disease Control and Prevention (CDC) estimates that 72% of practices in 2012 use an EHR, up from 54% in 2011.7 However, many providers are dissatisfied with their current EHRs and 17% of physicians are planning to switch to a new EHR within the next year, according to the industry survey Black Book Rankings.8
Interestingly, specialty providers expressed the highest dissatisfaction with the current crop of EHR vendors due to the lack of customizable features. The federal Meaningful Use mandates from the HITECH Act have created a "one-size-fits-all" EHR model that contains too many features that too many providers don't want.
According to surveys comprised from 16,000 EHR users and 550 EHR vendors by Black Book Market Research, "Nine of ten EHR industry insiders agree that the majority of EHR vendors currently implemented will fail to sustain operations by 2017. Eight of ten EHR industry insiders predicted that well-funded, inventive small vendors that carve a niche in specialist sectors should have better foundations for viability than those who failed to resolve the fundamental flaws caused by being all things to all physicians."8
What Will Happen To Vendors?
I wondered whether specialty vendors that serve the rehabilitation industry will survive the expected EHR downturn. Will they survive by narrowly focusing on the needs of therapists and patients? Can relatively small EHR vendors control and mitigate the abuses expected to arise from unrestricted copy-and-paste?
Will a therapy-specific note reduce "note bloat"? Can small vendors improve on the productivity loss demonstrated by large EHRs? Will patients and therapists be happier? My mind reeled with all the negatives. I tried to comfort myself by re-framing my knowledge in a more positive light.
I suspect the market shake-out will leave less-fit EHR vendors in the dust. Many smaller EHR vendors have the same weaknesses that small clinics and businesses have faced recently - inadequate capitalization and small user base.
The strength of the EHR industry is likely based on the same thing other industries are based on: sound balance sheets and a good cash flow. Even great technology can't trump the ruthlessness of market forces.
As I lay there, I told myself that our health care system is staffed by talented, hardworking people who use technology not dreamed of by previous generations. Every day we work to improve the current system. The limitations of the current EHR technology are not our biggest problems. Someday, with a little luck and a little ingenuity, technology will be a part of the solution. And, with that, I fell asleep.
References are available at www.advanceweb.com/pt under the Toolbox tab.
Tim Richardson is a physical therapist licensed in Florida. He is director of quality at the Suncoast Regional Health Information Organization (RHIO) and manages PQRS implementation for physical therapy and physician practices.