Electronic Health Records Pros, Cons Debated by Otolaryngologists

BOSTON—Michael Seidman, MD, director of the division of otologic/neurotologic surgery at Henry Ford Health System in Detroit, shared a few opinions about electronic health records (EHRs) that were posted on the American Academy of Otolaryngology-Head and Neck Surgery’s “ENT Connect,” an online member network, with audience members of a panel session presented during the April 2015 Annual Meeting of the Triological Society, part of the Combined Otolaryngology Spring Meetings.

While EHRs might allow for more thorough data acquisition, there is a “risk for mass loss of records,” wrote one poster. A properly designed EHR can be “extremely useful,” but the problem lies with “meaningless use,” wrote another, referring to federal meaningful use incentive requirements. Meaningful use stage 2 requirements are “beyond ridiculous,” said another.

The posters are not alone in their impressions of EHRs. The panel discussion, which Dr. Seidman moderated, touched on the pros and cons of EHRs, their impact on patient safety, the federal regulations surrounding them, and professionalism in using them.

Pros and Cons

Susan Cordes, MD, an otolaryngologist with Ukiah Valley Medical Center in California, said two of the biggest cons of an EHR system are time and money. “It’s a huge investment,” she said. “And then, once you get it up and running, it’s still not perfect. The computer goes down, and it ruins your entire office for the afternoon and drives your patients and staff crazy.”

Additionally, she said, interoperability is “way too low.” EHRs are not made for the efficiency of physicians but for compliance and billing purposes, she said. Plus, face time with patients is hindered.

On top of all this, quality of communication can actually be hampered by the amount of data. “This is probably one of my biggest pet peeves with the computer system: All this auto-population, and meaningful use and compliance, makes this huge patient chart that suddenly becomes meaningless because you can’t find what you’re looking for,” Dr. Cordes said.

The pros of EHRs, she said, are that they are space-efficient, and paper could be saved “if we can decrease the reliance over time.” Also, while paper charts are gone forever when lost, computer records can be backed up. Computers, she added, are evolving and have “a lot of room for improvement,” whereas paper charts have “hit their peak.”

She said it’s important to be part of the improvement process and communicate with legislators about physicians’ issues with the current EHR situation. “The pressure should come on interoperability and making the systems better for patients and for providers,” she said.

Patient Safety

Brian Nussenbaum, MD, patient safety officer in the department of otolaryngology-head and neck surgery at Washington University School of Medicine in St. Louis, Mo., said EHRs can improve patient safety—with easier access to information, by improving communication and with computerized physician ordered entry (CPOE).

But there’s a flip side.

“The EMR, unfortunately, introduces new kinds of risks into our healthcare environment, which is already very complex.” Wrong clicks and entries, over-reliance on automation, and design problems can all go awry, he said.

An overdose of an adolescent patient on Bactrim, relayed in the book The Digital Doctor, by Robert Wachter, MD (McGraw-Hill Education, 2015), came about when a resident entered the number of milligrams of the drug into a field required in the EHR. The resident thought the field required him to enter the total amount, but it was actually asking for milligrams per kilogram. The downstream systems did not prevent the error from affecting the patient, who almost died from this error, Dr. Nussenbaum said.

He also mentioned a 2014 survey of the American Society for Healthcare Risk Management and the American Health Lawyers Association in which more than half of respondents reported at least one serious EHR-related safety event over the previous five years, and 10% reported more than 20 such events (J Healthc Risk Manag. 2014;34:14-26).

Meaningful Use

Richard Scher, MD, a head and neck surgeon at Duke University in Durham, N.C., reviewed what meaningful use requirements mean for physicians.

The 2009 HITECH ACT legislated the availability of $30 billion for the improvement and use of EHR systems, and some of this money was directed toward physicians putting the electronic record to “meaningful use.”

“Meaningful use meant that you were using the EHR to improve quality, safety, and efficiency for patients and our populations while maintaining appropriate care and privacy and security,” he said.

He distinguished an electronic medical record, a system physicians use on a computer in their office, from an electronic health record, which allows information to be shared—the latter is what is required to meet meaningful use requirements.

Meaningful use requirements for physicians and hospitals are different, though interconnected.

Stage 1 of meaningful use, which began in 2011, was focused mainly on promoting the consistency of documentation, i.e., what kind of data is presented and how it’s presented. Stage 2 began in 2014 and focused on advanced clinical processes, such as secure transport of clinical information from one system to another and the ability of patients to access their information.

The steps physicians have to take to meet these goals involve what can be a confusing blend of “core requirements,” “menu requirements,” and “clinical quality measures.”

Stage 3, which may be rolled out as soon as 2016, focuses on improved outcomes.

Whether you’re in a single-physician environment or a multi-specialty practice might affect what you can and can’t report on, and physicians need to “take a very critical look at that,” Dr. Scher said.

In April, President Obama signed into law the merit-based incentive payment system (MIPS), which will base physician payments on quality of care, EHR meaningful use, the use of healthcare resources, and clinical practice improvements. Meaningful use requirements might continue to morph, added Dr. Scher.

“I think it behooves all of us to look at this, gripe about it as appropriate, but gripe toward making meaningful changes that benefit us and our patients rather than just requiring us to push more buttons on a computer screen,” he said.

Professionalism

Sujana Chandrasekhar, MD, director of New York Otology and president-elect of the American Academy of Otolaryngology-Head and Neck Surgery, said that the use of EHRs can strain the professionalism of doctors, largely when it comes to the in-office visit. Physicians might face sideways toward a computer screen or even sit with their backs to patients, which can take the patient “completely out of the equation,” she said.

Dr. Chandrasekhar said she types during office visits but has the screen and keyboard situated so that she is still facing the patient, and she tries maintain face-to-face contact while doing so.

Research shows a divide between how patients would like to communicate with their physician’s offices—via cell phone, text, or web—and how physicians prefer to communicate, via face-to-face, letter, and telephone conversations.

“When I’m e-mailing a patient or texting to a patient, which sometimes happens, I don’t really know what they’re getting from what I’m saying, and I think that’s a real issue for a lot of us,” she said. “We need to learn how to adapt to the new reality…. We just need to become better suited to the new environment.”

There is also a difference of opinion about EHRs she said. Almost 80% of patients say they have no problem with EHRs and note-taking in the exam room, and most prefer them over paper charts (Software Advice. 25 April 2015). “However, about half of us [physicians] think that EHRs are making healthcare worse,” she said. “So there’s that divide between us.”

“I think the way we maintain professionalism while using EHRs is you keep the patient at the center of the interaction,” Dr. Chandrasekhar said. “You design your office space so that the computer is not interfering with your ability to actually be a good doctor. And, the leaders in your field need to enable the physician to do their best work and therefore maintain professionalism.”

Thomas Collins is a freelance medical writer based in Florida.