Neurologists Experiences with EHRs: The Texas Perspective The Texas Neurological Society surveyed its membership about their experiences with EHRs. Results show generally moderate to low satisfaction. By Stuart Black, MD and Randolph W. Evans, MD Electronic health records or EHRs are gaining prominence in healthcare, largely due to the current government incentives (and future dis-incentives) associated with their use. Medicare-participating practices that implement EHRs stand to earn bonuses on their Medicare billings over the next several years. With time, bonuses go away and practices will face penalties for failure to use EHRs. Practices implementing EHRs must make a number of important decisions, starting with the selection of an EHR platform. This can be a costly proposition for a practice and represents just one of many potential expenses associated with EHRs. Other costs may include the purchase of new computer hardware, staff training, and the development of an on-line patient information portal, one of many requirements of meaningful use. There are multiple criteria for achieving meaningful use, but CMS summarizes the concept in three steps: 1. The use of a certified EHR in a meaningful manner, such as e-prescribing. 2. The use of certified EHR technology for electronic exchange of health information to improve quality of health care. 3. The use of certified EHR technology to submit clinical quality and other measures. For full information on Meaningful use visit the CMS website at https://www. cms.gov/ehrincentiveprograms/30_meaningful_use. asp#bookmark1 An additional important consideration for anyone investing in EHRs is the certification status of the software. Both the brand as well as the specific version of the software should be ARRA-certified. Some vendors may be certified, but only specific versions are compliant with the certification guidelines. These overview points are meant to provide some context to the issue of EHR implementation, especially as it relates to specialties like neurology. The purported benefits of EHRs are numerous, ranging from environmental (paperless), to cost saving (for example, clinicians should have easy access to existing studies), and of course, life-saving (with better diagnoses based on more information available, less likelihood of prescribing errors, etc.), however the degree to which these benefits are actually realized remains to be seen. Furthermore, there is not a good deal of research addressing the experiences of neurologists with particular EHRs and/or their satisfaction with them. 20 Practical Neurology march/april 2012
The Survey and Findings In order to access neurologists experiences with EHRs, we surveyed members of the Texas Neurological Society (TNS). Prior to the February 3 5, 2012 TNS 15th Annual Winter Conference in Austin, an EHR satisfaction survey was mailed to the membership. A total of 416 surveys were mailed to TNS member neurologists in Texas. At the meeting, an additional 300 surveys were distributed to attendees. There was obvious overlap with some of those attending the meeting having already received the survey by mail; however, the intent was to be certain that TNS neurologists received the survey and to obtain as many responses as possible. In total, 127 neurologists filled out the TNS EHR survey. The survey focused on comments, demographics, satisfaction, and overall use of EHR. In addition, members were queried regarding meaningful use certification. The questions were presented on a 1-5 Likert scale: 1. Strongly disagree, 2. Disagree, 3. Neutral, 4. Agree, 5. Strongly agree. It was also A Perspective on EHRs In recent months, I have started using an EHR. The process has been initially frustrating and perhaps unduly wasteful of time as many EHR veterans told me it would be. The complaints I have with my particular software are many (despite lots of research beforehand), and not many of us are completely satisfied with any of the 200 products available. For example, I didn t know that I would need dual monitors to view prior records and to type in the current note. Where is there room on a little desk for dual monitors? Is this Tower of software Babel we ve constructed, unable to communicate with other users, a step forward? Some of you working in different settings have to learn different EHRs. Medical students rotating with me tell me they ve been exposed to six different EHRs. As we stare intently at the screen entering data, the patient can get lost in the encounter as we can become just as concerned with E&M and ICD-9 coding and meaningful use documentation as actual medical care. Although there are many advantages, EHRs in the exam room are resulting in less eye contact, less dialogue, and less interaction with our patients as we are too busy entering data like the clerks and health care providers we have become to have the discussions with our patients about their diseases and their lives like the physicians we used to be. Complying with meaningful use criteria appears to be an exercise in going through hoops rather than improving patient care. It seems akin to the recertification process which has been almost universally disdained as a waste of time and money by every type of physician I ve spoken with. I review my meaningful use dashboard and wonder if this is the future of medicine! In several years, will we all have new dashboards on our EHRs evaluating our quality as providers (i.e., cost to the system) with dollar demerits for poor quality. How about two of the 25 objectives that I use? As I click the mouse on fields to indicate that I ve briefly counseled patients to lose weight and stop smoking, is our collective intervention really effective? Or are we engaging in wishful clicking or clicking for dollars? However well-intended, are the interventions evidence-based to justify such a large scale intervention in physician behavior? A review of weight loss counseling by PCPs concluded, None of the four studies in which PCPs provided low- to moderateintensity behavioral counseling alone resulted in clinically significant weight loss. (J Gen Intern Med. 24(9):1073-9). Of course, everyone with a BMI of more than 25 is not overweight, but the EHR does not make this distinction in counting compliance. What about counseling for smoking cessation? There is a consistent relationship between more intensive counseling (with respect to both the duration and number of counseling sessions) and abstinence from smoking. According to a meta-analysis of 35 randomized trials, six-month abstinence rates increased significantly with minutes of total counseling contact: about 14 percent for one to three minutes of counseling, 19 percent for four to 30 minutes of counseling, and 27 percent for 31 to 90 minutes of counseling, versus 11 percent for no counseling. (N Engl J Med. 365(13):1222-31). (You may wish to read this article for a discussion of different counseling techniques. ). So perhaps we can achieve a three percent short-term cessation from the brief counseling which most physicians are likely to provide? Long- term abstinence rates are not provided. If you are striving for meaningful use, you can refer your patients to these adjuvant treatment resources: 1-800-QUIT-NOW, a national tobacco-cessation quitline or online smoking-cessation resources, including www.smokefree.gov. Randolph W. Evans, MD Excerpt from Broca s Area, the newsletter of the Texas Neurological Society march/april 2012 Practical Neurology 21
requested that current users of electronic health records write comments about their experiences with their EHR. The results of the TNS EHR survey are included here. (Tables 1-3) Nearly three-quarters (73.8 percent) of respondents currently used EHRs. Among those who did not currently use EHRs, 42 percent indicated that they planned to implement them during 2012. When looking at the data, it is apparent that a majority of physicians already using electronic health records do not seem to be entirely satisfied with their system. Overall, there was no clear unanimous enthusiasm expressed for EHR. It also appears that meaningful use is still not well understood even among neurologists using EHRs. Discussion and Implications To date, except for the recent TNS survey, it does not appear that any recent neurology EHR surveys have been conducted. In 2007, the AAN Electronic Health Record Work Group convened at the Boston meeting where five EHR vendors were invited to participate in a presentation designed for the work group. The goals of the presentations were to provide AAN members with a report of the capabilities of each EHR system. However, several years later, neurologists are still finding it challenging to identify the proper EHR for their practice. This was exemplified in the current TNS survey. Although there have been various national EHR surveys done in other specialties, there are still no definitive studies which provide reliable estimates of the adoption or satisfaction of EHR by US physicians. In neurology, it seems to remain difficult for the average neurologists to obtain updated peer reviewed information as to which electronic health record system may be best for their individual needs. For this reason, in the TNS survey, upon request, a number of colleagues currently using EHR have also provided their contact information for potential dialog with their fellow TNS members. Table 3 (next spread) provides an overview of respondent rankings for specific EHRs. While the number of respondents is low for each system, the responses nonetheless provide some insight for a neurologist contemplating any of these systems. n The authors have no relevant disclosures. Randolph W. Evans, MD is Clinical Professor of Neurology at Baylor College of Medicine in Houston. Stuart Black, MD is founding member and Medical Director of the Dallas Headache Clinic. He is Chief of Neurology and Co-Medical Director of the Neuroscience Center of Baylor University Medical Center in Dallas. Table 1. The Respondents Age 32-39: 13 40-49: 42 50-59: 37 60-69: 27 70 and Older: 7 Gender Female: 38 Male: 88 Practice Size Solo: 51 2-5: 44 6-10: 10 Larger than 10: 21 Practice Setting Academic: 12 Private: 101 Veteran: 2 Public: 1 Other: 10 Currently Using EHR I attested for Stage I of CMS Meaningful Use in 2011. Table 2. EHR Experience Yes: 93 No: 33 If yes to the above, which EHR will you be using? E-clinical Works: 1 American Med Software: 1 Amazing Charts: 1 Lytec: 1 : 1 Do not know/haven t decided: 9 Yes: 42 No: 49 If no, are you planning to purchase and implement one during 2012? Yes: 14 No: 19 Weigh in on this topic now! Log on to take our brief reader survey on EHRs. https://www.research.net/s/pneuro1 22 Practical Neurology march/april 2012
User Comments Some respondents offered feedback on specific EHR systems they had used or are currently using. These comments are those provided by the users and are not intended to replace careful research and assessment of a system prior to purchase. However, much like many on-line rating systems so popular today, these comments shed some light on individual user s experiences. EMR Software Athena Athena Centricity CPRS E Clinical Works Comments I m not so much negative on Athena, but just the whole concept of EHR. It causes us to become secretaries, and it is not particularly intuitive, but it is the current state of the art, so I will suck it up! Athena is an incredible EHR and I love it. I ve received my meaningful use and CMS e-scribing already for 2011 It is absolutely worth the money. I love this EHR it has improved quality of care. It facilitates organization records, things do not fall through the cracks. Also in our practice, it is very easy to communicate with other doctors in the practice at other locations not just in my office. CPRS is very heavy in personal data entry into system. EClinical Works is the best platform we evaluated. It is more intuitive than others. It is designed for a general, primary care practice (as are all of the EHR systems), but with lots of time and effort, it can be customized. The system is expensive. It offers a patient portal, but patients cannot enter info for the HPI via the portal. SH, PMH, PSH, ROS can be entered. Templating is awkward, and we elected to add medical dragon for letters and for the HPI. Coding, Billing, Order Sets, and E Rx work well. Easy to navigate. You will need someone in your practice to understand the system administration. We put one of our staff on EHR full time for ~ 8 weeks to get ready to go live. The EClinical staff will not customize the system or get you ready to go. They offer basic training to introduce the system and its options, but you need to be ready to do all of the customization yourself. Very capable system, but lots and lots of work to get it right. E-clinical works Highly satisfied with E-clinic works; have used it since July 2006 Epic ICC Next Gen Practice Fusion Valant We have had a previous EHR that was very good. Use Paragon at hospital, would not recommend at all I am part of a large group and started with this EMR. I used three different systems in my training, all of which are better than the current one I am using. EHR generally slows down patient care and efficiency. Happy with my EHR I believe that in theory the use of EHR is an effective means of communication and data storage. I felt the expense to benefit is too high. Practice in very large group. This EHR is extremely cumbersome, slow, frequently down, and turns simple tasks into a multi-step process. Hate it, but had no input in implementation or use. This EHR is internet based and free! Good support with YouTube, email, and phone. This is an EHR designed for psychiatric practices. I am board certified in pediatric and run a practice specializing in ADHD for children and adults. I do not contract with insurance companies, Medicaid or Medicare march/april 2012 Practical Neurology 23
Table 3. Program # of users Average Length of time used I am highly satisfied with this EHR If I were in the market to buy a new EHR now, this is the EHR I would buy. This EHR is worth the expense My EHR vendor provides excellent training and support during implementation. My EHR vendor provides excellent support and service. My EHR allows individual userspecific customization AHLTA 4 More than 5 years 2.75 1.75 2.25 2 3 3.25 Allscripts 5 More then 5 years 2.2 1.8 1.6 1.6 2.8 2.4 Amazing Charts 2 6 months 3.5 4 5 4 3.5 3.5 Aprima 1 More than 5 years 5 5 5 4 4 5 Athena 6 1 year 4 4.17 4.33 3.83 4.17 3.67 Catalis 1 2-5 years 2 2 4 2 5 4 Centricity 9 2-5 years 3.67 2.89 2.78 2.22 3.33 4 Centrix 1 1-2 years 4 2 2 2 2 3 Clear Practice 1 6-12 months 3 3 3 3 3 3 CPRS 1 6-12 months 3 3 3 3 3 4 CPRS 1 More than 5 years 4 3 3 3 5 5 E-Clinical Works 15 2-5 years 3.67 3.73 3.53 3.07 3.2 3.2 E Health Live 1 2-5 years 4 4 5 5 5 4 Eclipsys 1 0-6 months 4 1 3 4 1 2 Exlipsys 1 1-2 years 3 3 2 3 3 4 Epic 8 2-5 years 3.13 3.25 3.13 2.88 4 2.88 ICC 1 2-5 years 4 4 4 4 3 3 Intellidox 1 More than 5 years 4 1 4 4 4 3 Lytec 2 6 months 3.5 3 3.5 4 4 4 MacPractice 3 6 months 3.67 3.67 3.67 4 4.67 3.33 McKesson 1 2-5 years 1 1 1 1 1 1 MD-IT 1 6-12 months 4 4 5 5 5 5 Medisoft 1 0-6 months 1 1 1 1 1 1 Medware 1 2-5 years 3 1 4 3 3 4 11 1-2 years 2.45 2 2.18 3.09 2.82 2.55 Practice Fusion 3 6-12 months 4 4 5 5 5 5 Praxis 1 More than 5 years 4 2 4 4 5 5 Sevocity 4 2 years 3.5 3.5 4 33.75 3.75 3.75 Soapware 2 1-2 years 3 2.33 3.33 2.67 3.33 2.67 Valant 1 2-5 years 4 3 5 5 5 4 24 Practical Neurology march/april 2012
Documenting care is easy and effective with my EHR. Finding and reviewing information is easy with my EHR. E-messaging and tasking within the office is easy with this EHR. Overall this EHR is easy and intuitive to use. My EHR provides easy to use and excellent information to help me meet requirements for meeting Stage 1 of CMSMeaningful Use. I clearly understand the requirements for meeting Stage 1 Meaningful Use. Other than the routine use of an EHR, Stage 1 Meaningful Use is clinically meaningful to the practice of neurology and improves patient care. Other than routine examination and management documentation, Stage 1 Meaningful Use documentation is a good use of my time. 3.5 2.5 2.25 2.5 1.75 2.75 2.5 2.25 2.8 2 3.2 1.4 2.8 3 2.8 2 3.5 3.5 3.5 3.5 4 3.5 3 2.5 5 3 5 4 3 3 1 1 4.33 4.5 3.83 4.5 3.67 4.17 3.17 3.17 4 2 2 3 3 4 4 4 3.44 3 4.11 3.22 3.11 3.89 1.89 1.78 4 3 3 2 4 3 3 2 4 3 3 3 3 3 3 3 4 4 4 4 3 3 3 3 4 4 5 3 3 3 1 1 3.6 3.27 4.27 3.47 3.73 3 2.53 2.07 4 5 4 3 4 5 4 2 3 4 1 3 3 1 3 3 3 3 3 3 1 1 1 1 3.5 3.25 2.63 2.75 2.88 2.63 2.38 1.88 4 4 4 4 4 3 3 3 4 2 5 5 1 1 2 1 3.5 2.5 3 4.5 4 4 2 2 3.33 4 4.33 3.67 4.33 2.67 1.67 1.33 1 1 1 1 1 1 1 1 4 5 5 4 4 5 5 5 2 3 2 1 1 1 1 1 4 2 1 3 1 5 3 3 2.45 2.73 3.09 2.27 2.73 2.91 2.73 2.36 4 3 5 5 5 5 3 2 5 4 5 4 3 3 3 3 3.75 3.75 3.5 3.75 3.75 4 3 2.5 2.67 2.67 2.33 3 3.33 3.67 2.33 2 2 5 2 2 3 4 2 3 march/april 2012 Practical Neurology 25