By John Carruthers, staff writer, February 01, 2013
Though rates of electronic health record (EHR) use remain highest among hospital and multispecialty practice physicians, more small practices are adopting the new technology each year as the government and payers put increasing pressure on physicians to fully adopt. While the numbers in the American Academy of Dermatology’s 2012 Dermatology Practice Profile Survey continue to show increasing adoption of EHR (see sidebar), satisfaction with one’s chosen system can vary widely. Satisfaction with one’s EHR, according to electronic records consultant Margret Amatayakul, MBA, is associated with a number of factors, but often comes down to one’s expertise with and efficiency in using the system to document patient visits. By taking a comprehensive view of one’s workflow practices and tailoring them to the strengths and weaknesses of one’s EHR functionality, she said, it’s possible to attain a level of EHR expertise that will benefit not only the dermatologist, but the practice as a whole.
Whether critics or supporters of the technology, every physician can agree that EHR fundamentally changes a doctor’s workflow. Even with mobile and touchscreen technology, most EHRs offer a very different experience from that of documenting a visit with a traditional patient chart. The most successful adopters, according to Amatayakul, realize and work around this fact early in the adoption process.
The goal, Amatayakul said, should be to make documentation of a patient visit with EHR as natural and effortless as using the paper charts most dermatologists came of age using. [pagebreak]
“The ultimate goal is when your workflow processes are in place and you really know your system, the EHR is so easy to use and fundamental to the way you work on a day-to-day basis that it just becomes a natural part of your day as a dermatologist,” she said. “It becomes completely intuitive, no more thought about using it than picking up a pen. Using it without even thinking is the point [doctors] need to get to with EHR.”
Rachna Chaudhari, the American Academy of Dermatology’s practice management manager, said that when tailoring one’s processes to an EHR system, it’s important to know from the outset that your workflow will have to accommodate steps required to meet meaningful use measures. For example, she said, the clinical summaries measure in stage 1 of meaningful use requires dermatologists to provide a clinical summary to at least half of the patients within three days of their office visit, something that may require alterations to the practice’s usual workflow.
The financial incentives for successfully participating in meaningful use are significant, but should not, Amatayakul said, be the sole motivator in implementing EHR. If the frustration and disruption to workflow lead to revenue losses that exceed the bonus payments, she said, the practice will have taken a step back. [pagebreak]
“Physicians need to think about this not just financially, but in terms of finding a system worth the effort it takes to learn and use, and finding a vendor that will guide you through the first-time adoption process and address your concerns,” she said.
That’s why Amatayakul reminds her clients that choosing a system solely for meaningful use compliance can be a potentially disastrous mistake. The features that many shopping for EHR write off as unnecessary — such as follow-up scheduling built into the practice management side of the software that syncs a patient’s note with the physician’s calendar for optimal scheduling and built-in reminders for patients and dermatologists — can, in time, prove to be time-saving boons to both front- and back-office operation.
“It’s not just about learning how to do more with the system, but knowing how to change the workflow in your office to do better all around. Not just to accommodate the EHR, but to make that EHR work for you,” Amatayakul said. “For example, creating a follow-up schedule for yourself, one that coordinates your calendar with the patient’s follow-up schedule and availability, is something that EHRs offer that increases efficiency over paper charts, but not every vendor takes the time or effort to sit down with the physician and staff and show them how to incorporate it. That’s really the workflow process that for a lot of physicians has been missing in action and continues to be.” [pagebreak]
Olympia, Wash., dermatologist Sasha Kramer, MD, who began her practice five years ago with an EHR system after using paper records with her previous group practice, said that learning the features available in her system eventually won her over as an EHR user.
“I love that I can pull up a patient and have all of their labs and paths in front of me,” Dr. Kramer said. “At the end of the day, my notes are done and my charges are already sent to the clearinghouse. There’s definite efficiency there.”
In addition to follow-up scheduling tools, some EHR systems offer better ease of use during the visit, which may appeal to physicians who claim that the technology places a barrier between them and their patients. Some systems allow for different presentations of information depending on the levels of access that are allowed for different tiers of users. Nurses or physician assistants can see the levels of detail and software features appropriate to their skills, training, and place in the continuum of care, while billing and administrative staff may have a simpler interface that only encompasses the fields they need to see, rendering the rest invisible. The resulting cleaner, simpler interfaces for each user can help increase efficiency at all levels of the office/patient interaction. [pagebreak]
Touchscreen and mobile
A touchscreen interface, especially for dermatologists who make extensive notation on photographs or body diagrams, can offer an experience closer to traditional paper charts than earlier systems offered. As the popularity of tablet computing increases and the ability of smartphones to offer secure, powerful record technology improves, due both to the leap in processing power and improved ability to handle more stringent security protocols, a touchscreen-compatible system will allow the EHR to grow with the practice hardware. Manhattan Research’s May 2012 survey results show physician adoption of tablet computers at 62 percent, with just over half of those doctors using the device at point-of-care.
“Not only is touchscreen technology amenable to dermatologists’ workflow, but some dermatologists have had success in integrating Bluetooth transcription into their EHR so that they mainly speak and revise their medical note accordingly rather than using point-and-click methods,” Chaudhari said.
Dr. Kaufmann agreed, and added that the use of mobile technology among physicians is only going to increase, which should ultimately be of benefit to the patient. In learning to use EHR systems integrated across an array of traditional and portable devices, Dr. Kaufmann said, dermatologists will be able to better interact with patients and transfer care records to colleagues seamlessly.
“There are new devices for access to patient records now that we would never have considered in the past. Cloud server technology allows us much more ability to access a patient’s records and provide quality care [wherever we are],” Dr. Kaufmann said. “We need to know how to integrate them into practice properly, because it’s going to become the prevalent technology.” [pagebreak]
On the patient side of EHR, the second stage of meaningful use will hold physicians responsible for encouraging patients to interact with their records through a secure online portal. Under stage 2, physicians will be required to provide patients with a portal to access their records for printing, transmitting, or downloading. In addition, 10 percent of a practice’s patients must get reminders via the portal for preventive follow-up care. The portal will also enable secure email communication between patients and physicians. In some portals, patients are able to request refills and pay their bills through the system, and physicians can schedule appointments and send lab results confidentially. Physicians, Amatayakul said, should be able to demonstrate and feel comfortable interacting with patients through the EHR’s portal. In addition, many systems have built-in satisfaction surveys that can measure both patient and staff satisfaction with the care process or practice workflow.
“Patient portals allow the patient greater autonomy in their health record. They also provide an additional communication channel for patients to access their physicians,” Chaudhari said. “Dermatologists should be aware that patient portals can be advantageous with respect to administrative efficiency as well as strengthening the doctor-patient relationship by allowing patients greater access to their health information. Physicians, however, should be prepared for increased communication from patients as well.”
For more discussion of how patient portals work and how their use will be measured in different stages of meaningful use, see the Technically Speaking column in the February issue of Dermatology World. [pagebreak]
Interaction with patients
Even with differing systems, settings, and workflow processes, the fact remains that EHRs do a great deal to define the physician/patient relationship for every visit. Physicians should be sure to evaluate how EHR-driven processes impact the ordinary visit. Many physicians, according to New York dermatologist and EHR expert Mark Kaufmann, MD, feel that the use of a computer while talking to a patient impedes the relationship and leaves patients less satisfied with their visits.
“When we talk about EHR, there’s always that one statistic that stands out. Patients whose doctors talk to them face to face perceive visits as being longer than they actually were and have higher satisfaction scores,” Dr. Kaufmann said. “And on the other side, when you see negative feedback from patients, it sometimes has to do with the doctor being on the computer during the visit. Patients can feel that you’re not paying attention to them. When you’re bringing EHR into your practice, it’s really important to keep the focus on the patient.” [pagebreak]
It should be noted, he said, that while the visit and interaction with the physician has a great deal of impact on eventual patient satisfaction, EHR use is not necessarily a limiting factor. A 2009 cross-sectional study in the Journal of the American Board of Family Medicine found that in the available literature, patient satisfaction was either positively or neutrally correlated with physician use of EHR. More recent studies by family physicians have found that patients not only prefer them to use EHR, but perceive an increase in quality of care when their physician utilizes it.
Amatayakul agreed, saying that while it’s an often overlooked factor when designing one’s processes, patient interaction during EHR use is the most important factor in one’s success with the software. Physicians who are able to have comfortable, familiar interactions with patients under the new system are far more likely to persevere through the growing pains of EHR adoption. More vendors, she said, would do well to take up the issue and integrate it into their training. “Another thing that vendors don’t all address, but should, is the issue of where and how to sit and interact with the patient [while using their EHR system],” she said. “That can change the patient’s entire perception of the visit.”
Dr. Kramer has been through two different EHR adoption processes since leaving her group practice and its paper charts five years ago. The key to progressing to the next stage, she said, is having the familiarity with the system to feel comfortable trying new changes with the confidence that one’s practice will ultimately benefit.
“When you’re in the throes of adoption, staff and even physicians can sometimes think that it’s never going to get any easier. It’s important to persist and know that it’s going to get better through time and work,” Dr. Kramer said. “I wanted to integrate photographs, I wanted very individualized notes, and I wanted to not have to do a great deal of typing. I have all that now with my system, and I could never go back to paper charts.” [pagebreak]
EHR use in dermatology
The AAD’s 2012 Dermatology Practice Profile Survey demonstrated that electronic health records (EHR) have been widely adopted in multispecialty and academic practices, while solo practices and dermatology groups follow behind.