Cardiologists ‘Wary’ of Inadequate EHR Systems
At the beginning of 2014, a key component of the American Recovery and Reinvestment Act of 2009 came into effect that will transform the everyday workload of physicians in the United States by shifting records from paper to electronic databases. The law requires the adoption of electronic medical records (EMRs) and allows the Centers for Medicare and Medicaid Services (CMS) to incentivize the implementation and “meaningful use” of electronic health records (EHRs).
In interviews with numerous clinicians practicing across the country, TCTMD has learned that cardiologists are both hopeful that the technology will prove to be revolutionary and frustrated with its limitations.
According to John Rumsfeld, MD, PhD, chief scientific officer of the American College of Cardiology’s National Cardiovascular Data Registry (NCDR) and director of the Clinical Assessment, Reporting, and Tracking (CART) program of the US Department of Veterans Affairs (VA), cardiologists “are wary of what they are getting into, or being forced to do, but they have a positive curiosity about whether or not EHRs can become clinically functional enough to improve care.”
Once solely completed with pens and paper during an office visit, documentation is now more likely to be input electronically by physicians either with patients in the room or, for many, during off-hours. Physicians across specialty lines have reported decreased productivity, inadequate information exchange between different EHR programs, and the need to complete tasks for which they are overqualified—among other issues—as undesirable side effects of EHR implementation.
Penalties, Incentives to Shape Adoption
CMS reimbursement will not change for eligible providers who implement an EHR system by 2015. Eligible providers who do not demonstrate “meaningful use” before the first day of 2015, however, will be subject to an annual, cumulative reimbursement penalty for each year they remain noncompliant. 2015 is the last year to begin participation in the Medicare EHR incentive program, and 2016 is the last year to begin participation in the Medicaid incentive program.
According to a report from the CMS’s Health IT Policy Committee in September 2014, 89.87% of individual providers and 94.95% of hospitals eligible for the CMS incentive programs, respectively, have registered. Additionally, 75% of eligible professionals had made “financial commitments” to implement an EHR. Under the CMS programs, about $24.9 billion was distributed to 410,688 unique providers from the beginning of the program to July 2014.
A Perception Problem for EHRs
Creating an electronic record system has been perceived by physicians as expensive and difficult, reports a nationwide study commissioned by the American Medical Association and conducted by the Rand Corporation between January and August 2013. Moreover, the process was associated with a reduction in physicians’ professional satisfaction and quality of life.
The study also found a connection between overall professional satisfaction and EHRs. Increasing EHR program complexity (more features and functions) independently predicted professional dissatisfaction, and clinicians were less likely to report high satisfaction if they perceived EHRs as slowing clinical work or interfering with face-to-face patient care or if they indicated a preference for paper records over EHRs.
Much like other physicians, “cardiologists have been struggling with how to meet the requirements for implementing an EHR, choosing which EHR, and then altering how they have always delivered care in their practices to fit around EHRs,” Dr. Rumsfeld told TCTMD in a telephone interview.
Data Collected May Not Work for Cardiology
One area where EHRs have so far failed to reach their potential is in the format of data entry, observed Dr. Rumsfeld. Much of the documentation takes place in narrative or text boxes, he said, noting, “Therefore, you can’t extract that key clinical information from any given EHR, and you can’t compare that information with other EHRs.”
James E. Tcheng, MD, of Duke University Medical Center (Durham, NC), described the systems as “very broad but not particularly deep.”
In contrast, “interventional cardiology and the entire cardiology spectrum tend to be very data intensive and data rich,” he said, adding that rather than acting as “managers of data,” EHRs currently function as “repositories of blobs of information.”
The more cardiology-specific systems, explained J. Jeffrey Marshall, MD, of Northeast Georgia Medical Center (Gainesville, GA), “won’t work for an orthopedic surgeon or an ophthalmologist.” As such, they will not necessarily be able to communicate with other EHR systems or show data in a way that is relevant for other specialties, he explained.
Inadequate Information Exchange
Another primary issue, according to Henry S. Jennings III, MD, of Vanderbilt University Medical Center (Nashville, TN), is the “lack of intercommunication and connectedness” between EHR programs. This discrepancy, present not only when patient data are shared between cardiology departments at different hospitals but also when different specialties communicate within the same organization, puts many doctors in a position where records need to be printed out and faxed, he noted.
Admitting to perhaps speaking “more on the dramatic side,” Dr. Rumsfeld stated, “I think you can flatly say… that there is currently no interoperability between EHRs in the American healthcare system. Period.”
The NCDR’s early attempts to extract data from the new systems has proven “that EHRs are extremely heterogeneous in terms of what data they have in them and what data can be extracted. A lot of the key clinical data that is so important to understand quality is missing,” he said.
Decrease in Productivity, Face-to-Face Communication
With the transition to new EHRs from paper charts or even from older but noncompliant electronic records, many interventional cardiologists have experienced productivity declines.
“Something has to give,” Dr. Tcheng said, estimating that productivity is down 10-20% at most hospitals. “You can either spend more time to see the same amount of patients or the same amount of time and see fewer patients.”
Dr. Jennings, for example, related that it now takes 13 out of every 15 minutes he has allotted for an existing patient’s appointment to handle EHRs. “So I get 2 minutes with a patient and then move to working on a computer,” he said. The problem is exacerbated for cardiologists practicing in rural outreach clinics with unreliable internet connectivity.
However, 2 cardiologists interviewed by TCTMD, Dr. Marshall and Anthony J. Minisi, MD, of the Medical College of Virginia Campus at Virginia Commonwealth University/McGuire VA Medical Center (Richmond, VA), both said that after a challenging initial learning period, they were able to match or improve time efficiency.
In addition, many physicians question the wisdom behind their new role as digital documenter. “Doctors are now doing what in the past was completed by clerks or medical assistants,” said Dr. Marshall.
“[Cardiologists] are not functioning at their highest level of training,” stated Dr. Jennings.
Some facilities and physicians have begun to use transcriptionists, voice-recognition technology such as Dragon (Nuance; Burlington, MA), and/or outsourcing to countries such as India.
Adding a computer into the patient-doctor equation also has resulted in a “depersonalization” of care, Dr. Jennings argued. “The clinician is glued to the computer rather than sitting back trying to talk to patients, look in their eyes, watch their expression, sense what they are feeling.”
Dr. Minisi, however, said that physicians can adapt. “Over the years, I have been able to interact with patients as I type,” he noted. “Patients don’t seem to mind it, and it doesn’t slow me down much.”
Better Access to Data
There seems to be consensus among physicians and cardiologists that EHRs do enable access to patient data, with less dependence on physical charts. Lost charts are no longer an issue, Dr. Marshall suggested, noting that quickly being able to view images and reports is “useful in a workflow standpoint.”
Additionally, Dr. Tcheng attested that EHRs have eliminated some redundancies in procedures and “improved the management of care.” They can also facilitate medical ordering and interactions with pharmacies, said Dr. Rumsfeld.
In addition, electronic records are less physically vulnerable than paper. Dr. Minisi related hearing that “of all of the hospitals down in New Orleans, the only hospital that didn’t have their medical records destroyed [after hurricanes Katrina and Rita] was the VA because it was all electronic, no paper.”
VA CART a ‘Powerful’ Example
One electronic record system that seems to be fulfilling its potential is the VA CART program. CART is an application within the VA’s computerized patient records system designed to generate reports/office notes without increasing the time spent by cardiologists, explained Dr. Rumsfeld.
“It brings all of the data from the previous EHR to the point of the record, so [cardiologists] just have to fill in the extra clinical fields,” Dr. Rumsfeld said. The clinical fields, from the NCDR CathPCI Registry, are the same throughout the VA, allowing for large-scale quality assessment, he explained. “I think that is why CART ends up being so powerful.”
Many of typical problems for EHRs do not seem to be much of an issue at the VA, including the electronic exchangeability across the system’s hospitals, Dr. Minisi noted.
Improvements on the Horizon
Imitating the VA CART program in other healthcare systems would require the commitment of EHR vendors, which have thus far focused more on market share than on making the programs work for clinicians, Dr. Rumsfeld stressed.
The ACC also is getting involved, he noted. As part of its Strategic Plan the organization is working toward the development of a “digital platform” for education and decision making that would dovetail with EHRs and the creation of more standardized data fields that would be clinically meaningful to cardiologists.
Changes are coming, Dr. Rumsfeld stressed, reporting that the vendor Epic (Verona, WI) is slated to begin releasing software with structured data fields for the PINNACLE Registry in 2015.
Whether vendors will learn from the VA CART program to optimize EHR programs is unclear, but Dr. Rumsfeld said one thing remains uncertain: “In reality, current clinical practice and the future practice of cardiology in this country is going to be centered on the use of electronic health records. There is really no going back on this.”
For now, however, many cardiologists remain frustrated. “We’re doing all this stuff for the government, jumping through their hoops, when a lot of this stuff is just not ready for prime time,” Dr. Marshall said.
1. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. RAND Corporation. http://www.ama-assn.org/ama/pub/news/news/2013/2013-10-09-rand-study-physician-satisfaction.page. Published October 2013. Accessed July 1, 2014.
2. Centers for Medicare & Medicaid Services: Health IT Policy Committee. September 2014 HITPC Presentation. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/DataAndReports.html. Published September 3, 2014. Accessed September 25, 2014.
- Drs. Jennings, Marshall, Minisi, and Rumsfeld report no relevant conflicts of interest.
- Dr. Tcheng reports acting as an unpaid advisor on the cardiology steering board of Epic.