We Deserve Much Better: A Small Practice and First-Generation Perspective on Electronic Health Recor

Peter Zacharia, MD

My single-physician, private Ophthalmology practice is now entering its second decade using electronic health records (EHRs). We went live 10 years ago after about a three-year search process researching software functionality, computer hardware requirements and costs, as well as interviewing vendors who would do the implementation, in order to find the EHR and practice management system that would best meet the needs of my practice. We identified a vendor who provided the programmer with whom I worked over a period of about 18 months to design templates for clinical data entry into the EHR that were customized for ophthalmology, and also provided hosting of our system remotely, as well as software and hardware support. We had an extremely bad experience with the initial vendor, who was insufficiently responsive to our needs, and we subsequently transferred our practice database to an in-house server with the help of a small but outstanding local IT consultant. This consultant configured and has maintained our server so we have smoother access to our EHR without the small delays that followed every click of the mouse and the numerous episodes of down time we experienced with the initial vendor and remote hosting model.

Since going live with the EHR I have had to make small changes to my templates as I determined what would improve workflow, and also as documentation and billing code requirements changed with the implementation of ICD-10, CPT code modifications, and the onerous MACRA mandated Quality Payment Program (QPP), which should probably have been termed the Burdensome Payment Program.

10 years into implementing the EHR, I can state that the experience has been overall positive and provides several advantages over paper records, but also several significant shortcomings. We can and should do much better. The obvious advantages include greater legibility and remote accessibility. We no longer require chart rooms or personnel to file and pull charts, and we no longer need to add pages to manila file folders and stamp blank progress notes with patient names and exam dates. Pages no longer fall out of patient records when the punched holes tear through edges of paper pages. Automatic time stamps more accurately log the course of the clinical interaction. Time savings are gained as a result of smart phrases that allow for shorthand generation of large amounts of commonly-used text. The EHR also carries forward previous observations, as long as they are modified and updated to reflect the current exam.

The EHR also has shortcomings. The carryover feature mentioned above can save a large amount of time when clinical descriptions are complex, but unfortunately can result in inaccurate propagation of old information when the examiner is not conscientious enough to review the entry. I have on occasion been guilty of this myself and have frequently received exam notes from previous physicians which carry forward the same exam observations, impressions and plans over numerous distinct visits when the exam descriptions, impressions and treatment plans have no longer been applicable. While smart phrases and carry-forward features save time, in some cases the actual keying in of other information can take more time when compared to data entry in a paper chart. This is especially true when data must be entered on multiple successive template screens; check boxes and drop-down menus must be navigated, endless CMS-mandated QPP items must be checked (the existence of these facilitated by the requirement to have an EHR), and frequent pop-up warnings (some useful but many unnecessary) must be managed as though playing whack-a-mole. Speech recognition software can help if one is willing to invest the time to train and customize it, but it also is plagued by errors.

Data transfer between physicians is often less efficient and less effective with the EHR. I have seen exam records sent by previous physicians for which each single visit is documented by an EHR note printed to paper occupying six-to-seven pages of endless boldfaced underlined headers, many followed by unnecessary and repetitive lists of information. Before the EHR, documentation for a single exam may have been summarized on one or two sides of a page. I no longer have the benefit of a well-written consultation letter with a well-phrased summary of a physician’s impression, but rather now depend on an impression filled with a list of stock generic descriptions of ICD-10 diagnoses. Similar inefficiency characterizes the e-prescribing software I use on a daily basis, for which it is obvious that the software developers have had no exposure to clinical settings and have no appreciation for a clinician’s time by requiring twice the mouse clicks than should be necessary to send or renew a simple prescription.

Perhaps the greatest shortcoming of the EHR is the lack of standardization among EHR software packages resulting from a monumental lapse in judgement by the regulatory powers which mandated the hurried adoption of the EHR. Had we waited perhaps another decade before requiring or pressuring practices into adopting electronic records, perhaps useful standards may have been defined to facilitate the transfer of data between disparate EHR software, obviating the need for care givers to wade through hundreds of pages of records from previous care givers.

The cost of implementing and maintaining our EHR unfortunately has not been offset by the meager physician reimbursement increases (and decreases) of the last two decades. For my small practice, startup costs for our EHR and practice management system approached $100,000. My practice’s annual and periodic expenses include EHR software maintenance and support fees, anti virus software updates for multiple devices, operating system and coincident hardware updates when old operating systems fall into planned obsolescence, data back up cost, and high-speed broad band Internet connectivity. Our expenditures for recording and maintaining clinical data are many multiples of previous expenditures on copy paper, manila file folders and shelving to hold charts. The (sometimes) skilled labor required to maintain computerized records is also many times more costly than the labor required to pull, stack and file paper charts. In the case of our EHR software, a venture capital group purchased rights to the software, saw an investment opportunity and conveniently felt free to charge exorbitant software upgrade costs to helpless physicians with the ease of shooting fish in a barrel. There seems to be no regulation of the profit savvy investors can make providing items of necessity to physician practices.

I have heard of practices that have suffered flooded file rooms, and I am sure medical office fires have obliterated many patients’ medical history information over the last several decades. However, there is no greater fear to a practice or a hospital system than having a computer system hacked, and this has afflicted even some of the largest hospital systems staffed by ample IT professionals recently. Security of patient information is beyond a doubt the source of the greatest anxiety with respect to medical records and remains one of the greatest problems which require a solution.

The concept of the EHR is one that is worthwhile and has the potential to improve healthcare. However, in practice and in current form, the EHR has evolved as an amalgamation of rushed and imperfect mandates, a tool that wastes as much time as it saves, and increases practice expenses while facilitating the burdens which bureaucracy places upon medical practices. Thus far, EHR implementation is chock full of missed opportunities to improve healthcare. We can and should do so much better.

Peter Zacharia, MD is an ophthalmologist in private practice in Worcester who has been on the editorial board of Worcester Medicine for several years.