Efficient or obtrusive? Exploring the controversy over electronic health records

Dr. Peter Lueninghoener sits in his office at Elkhorn Valley Family Practice in O'Neill, Neb. (Photo by Hilary Stohs-Krause, NET News)
An example of electronic health record software; this is from Allscripts Professional, one of the most common programs used by Nebraska health care providers. (Courtesy image)
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September 11, 2013 - 6:30am

Electronic health records are one of the most controversial aspects of healthcare reform. While some Nebraska experts said they’re a lifesaver – literally – others argue they’re cumbersome and actually hinder healthcare workers instead of helping them.


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Dr. Peter Lueninghoener chats on the phone with a nurse in his office at Elkhorn Valley Family Medicine in the north-central town of O’Neill. His desk and a peg board are littered with calendars, printed articles, scribbled post-it-notes and stacks and stacks of file folders and documents. Two mounted deer stare down from the wall. 

For more of the NET News in-depth report on health care and technology in Nebraska, visit the series page.

The plethora of paper might not seem strange, at first, until you realize that Lueninghoener’s practice uses electronic health records, and so istechnically paperless. He laughs when a visitor point out the seeming inconsistency.

“There are a lot of things that were a lot easier with paper,” he said, chuckling. “The old paper way, I sure can’t knock it, because it worked very well. But there are so many advantages to the electronic, and we’re just beginning to touch the tip of the iceberg.”

Providers take the leap

As of 2010, a quarter of office-based physicians in Nebraska were using at least a basic electronic health record program, or EHR, according to a federal report.

When it comes to hospitals, last year Nebraska ranked 20th nationallyfor EHR use. Nebraska matches the national rate of electronic health record use in hospitals – about 44 percent. And that number has tripled nationally since 2009.

But why the rapid increase? What do electronic health records even do?

GRAPHIC: ELECTRONIC HEALTH RECORD USE BY STATE


WHAT IS 'MEANINGFUL USE' ?

Meaningful use refers to a specific set of criteria for electronic health records defined by the federal government that eligible health care providers must meet in order to qualify for incentive payments. There are three stages so far:

Stage 1 (2011 - 2012): This stage is essentially just adopting an EHR - getting your feet wet, as Todd Searls with Wide River TEC put it. He said 80 percent of primary care providers are projected to have an EHR by the end of 2013; prior to 2001, that number was around 18 percent. 

Stage 2 (2014): The focus in stage 2 is on interoperabiltiy, Searls said, such as health information exchanges and allowing providers to share data seamlessly. 

Stage 3 (2016): Searls said this stage is all about patient engagement - online portals will allow patients to fully participate in and direct their care, and will give them control over their records. 

“It saves a lot of time,” said Kayleigh Johnson, a registered nurse and the assistant director of nursing at Family Practice Associates in Kearney, Neb. “It’s helped our patient care quite a bit. Everything’s right there at your fingertips - you don’t have to spend hours digging through charts. So I think a lot less gets missed.”

Johnson, who worked at the Kearney clinic during their switch from paper to EHR, said digital medical records help providers keep better track of patients: when they need check-ups, giving them lab results sooner, and providing easy access to information on their allergies and medications. For more advanced EHRs, it also allows for patients to review their medical information and correct any errors. That can be huge – according to a 2005 study, one in seven hospitalizations results from missing clinical information.

It also helps patients better keep track of themselves.

“You know, the doctor tells you a million things,” Johnson said, “and by the time you leave, you don’t really remember any of it.”

Essentially, proponents say, electronic records cut down on human error. But the transition from paper to PC can be tough.

A 'painful' process

“You have to be patient with it,” Johnson said matter-of-factly. “It takes a while. Everybody’s going to get frustrated.”

Todd Searls agreed.

“It’s definitely something that has been painful for a lot of providers, and understandably so. Especially in Nebraska, where we’re predominantly a rural state. There just aren’t a lot of resources.”

Searls oversees Wide River TEC, a statewide program to help primary care providers, small clinics and rural providers transition to EHRs. He said the cost of that transition is often a big concern.

“Then we talk about staffing concerns, in terms of getting their staff up to speed and trained, and then it goes more into the practice and workflow disruption that occurs.”

According to a 2012 report from the U.S. Centers for Disease Control, 85 percent of physicians who have adopted an EHR system reported being somewhat (47 percent) or very (38 percent) satisfied with their system. About 75 percent reported that using their EHR system resulted in better patient care.

Debating the impact of EHRs

But not everyone agrees. The 2012 National Physicians Survey, for example, found that roughly equal numbers of physicians said EHRs will cause patient care to deteriorate, will cause it to improve or will cause it to stay the same.

“EHR probably is the single most disruptive element in today’s healthcare,” declared Dr. Dmitry Oleynikov, professor of surgery and director of minimally invasive and robotic surgery at the University of Nebraska Medical Center in Omaha.

“The perceived benefit is that somehow all this information, all this data, will enhance or improve patient outcomes, which is untrue,” he said. “Because it’s not designed for that. EHRs are designed to meet guidelines that are created by individuals that frankly do not understand what matters when it comes to good or bad patient outcomes.”

Oleynikov is referring to “meaningful use” standards created by the federal government. The stages of meaningful use – there are currently three – are like mile markers for clinics and hospitals. Eligible health care providers can earn incentive payments by meeting these mile markers.

ADVICE FOR HEALTH CARE PROVIDERS SWITCHING FROM PAPER TO ELECTRONIC HEALTH RECORDS

Dr. Peter Loeninghoener from O’Neill, Neb. recommended the band-aid approach – just get it over with.

“You can’t put your put in the water and wade up to your knee, and then up to your waist, and then up to your chest, and finally, you know, get in,” he said. “If you do that, you run into a lot more problems, because paper and electronic (systems) do not transfer very well.”

Registered nurse Kayleigh Johnson from Kearney, however, disagreed, saying her clinic transitioned one department at a time, and that the piece-by-piece method allowed the staff to slowly acclimate to the software.

Todd Searls from Wide River TEC, a statewide program that helps providers make the switch from paper to EHR, said to expect disappointment your first time around.

“Doctors who didn’t know what questions to ask have now purchased software, and once their three-to-five-year contract’s up, they know they’re not happy with it, and they’re going to rip and replace it. And it’ll be better for them,” he said, estimating that 60 percent of providers they’ve worked with end up switching to a different EHR.

“To me, I use the analogy that it’s like a first-time home buyer,” he continued. “You buy this nice, cute little bungalow, and then you get in there and you realize, ‘Wow, I really need something that has X, Y and Z, so my next home, I’m going to make sure it has all that.’” 

Apart from misguided, mandated goals, the other major complaint with electronic records is that they’re cumbersome.

“I’ve heard that from multiple doctors that use EHR software,” said Christopher Novak, vice-president and director of operations for MacPractice, an Apple-based EHR and medical software company.

“The term I’ve heard is ‘click happy,’” he said at the company’s Lincoln headquarters. “You have to click here, click there, click here, do this, and it takes you twice as long to fill out your patient health information in EHR as it would to fill it out on paper.”

Novak said this stems in part from federal reporting requirements, but that it’s an aspect of electronic records software the industry is trying to improve. Kearney nurse Johnson said much of that lag time is also attributable to the complexity of EHR programs - and their frequent updates. 

“There was a huge learning curve with it (at the clinic),” she said. “I would say it took us a year to get fully comfortable, and two years later, we’re still finding new ways to make things easier.”

EHR as a recruiting tool

But despite the initial hurdles, Johnson said she would hesitate to return to a paper clinic.

“Everything in there is so organized, and … each person can kind of map it the way that they want,” she said. “It just makes it so much easier.”

She’s not alone. Especially for younger health care workers, having an EHR system can be a big draw, said Deb Bass with the Nebraska Health Information Initiative, a state network of medical data.

“They’re very used to using technology to do all their activities of daily living, personal and professional,” Bass said. “And you send them out to a rural community that is completely paper-based … that’s a frustrating experience.”

Jennifer Rathman with Wide River TEC agreed, recalling a young physicians at a clinic in Atkinson, Neb. who insisted on switching to an electronic record system before the other, older physician retired.

“She knew to get a new (medical doctor) right out of school, they would have to have an electronic health record or they would never get anyone to switch,” Rathman said. “Because all the doctors coming out right now, that’s all they use – they’re not going to convert back to paper their first year out of medical school.”

UNMC’s Oleynikov works with many of those students, and he acknowledged that digitizing records is valuable; it’s the current methods of doing so that are inadequate, he said, turning physicians into “glorified data-entry specialists.”

But, for better or worse, more and more healthcare providers in Nebraska are choosing that method.


Editor’s note: This story is part of a weeklong in-depth report on technology and healthcare in Nebraska, “Giving Nebraska’s Health Care the Digital Treatment.”

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