Whether you've adopted electronic health records (EHRs) in your offices or not, most of you have begun to use them at your hospitals or will soon do so. That's because, like eligible professionals, hospitals will be subject to Medicare payment reductions beginning in 2015 if they have not met the criteria for meaningful use of EHRs. And as early as this year, eligible hospitals may qualify for federal funds, beginning with a $2 million base payment, if they have.
This incentive to train providers to use hospital systems has created a new liaison role for many physicians in hospital systems, neurologists included. Neurology Today spoke to two of them — Gregory J. Esper, MD, MBA, associate medical director for information services at Emory Healthcare, and associate chair of the AAN Medical Economics and Management Committee, and Allison L. Weathers, MD, medical director in the department of information services at Rush University Medical Center, to gauge physician reaction to the new wave of training and to ask what neurologists can do to make the process as painless as possible.
HOW DO YOU RESPOND TO COMPLAINTS THAT NEUROLOGISTS ARE LOSING THE ART OF THE NOTE, AND THAT REPORTS LOOK LIKE THEY HAVE BEEN CUT AND PASTED?
Dr. Allison Weathers (AW): I agree fully, and I don't have a good comeback. In many cases free text is still the right answer; we specifically did not build templated HPI [history of present illness] or A/P [assessment/plan] sections because we did not want to discourage the use of free text (printed words). I feel that voice recognition-EHR hybrids may be an ideal solution. Although we did not have a voice recognition option for my department to use at the time we went live, some of my providers went out and purchased the software on their own, and it seems to work well. As far as the issue of notes filled with useless information, this is a problem across specialties and across EHRs. For some reason, EHRs breed the ‘quantity is equal to quality’ mentality. We just keep reinforcing the concept that the information is one click away — there is almost no valid reason to bring in an entire MRI report into a clinic note — what matters is the clinician's interpretation of that result and the images.
Dr. Gregory Esper (GE): Both criticisms are correct, but there are ways around this. As Allison said, the impression and plan can always be free-texted, and these are the most important parts of the note, in addition to the HPI. Though the HPI in most systems can be a point-and-click, there are areas for free texting that I advocate using, especially for complex cases. The same advice applies to the impression and plan — just as the point-and-click may be needed for billing purposes and ICD9 (10) identification, use of free text is both needed and justified for the clarity of the note.
WHAT CAN NEUROLOGISTS DO TO MAKE THE LEARNING PROCESS EASIER?
AW: Don't skimp out on training. At our institution we mandate at least eight hours for ambulatory training. This amount of training sounds excessive and daunting, but it is really crucial. Physicians will never gain back the efficiency and productivity lost from not having adequate training and instead learning “bad habits” — for example, doing time-consuming workarounds such as poor charting techniques. Become involved in the build process. Speak up and make sure that you are communicating what is important to you, including unique workflows to your clinic. For practices larger than one or two physicians, make sure one physician is elected to be the “super user,” the person who not only really represents the practice at the build meetings, but also gets trained earlier and more in-depth, so that when the implementation team leaves, someone with a little more expertise is left behind. Finally, reduce your clinic schedule on the “go live” day [the first day you use the system]. We recommend to our practices a 50 percent scheduling reduction for at least the first two weeks, then 75 percent for week three and possibly four. I am not minimizing the impact this makes on a clinic's bottom line and RVUs [relative value units] for the month, but it really is impossible to keep up a full schedule while trying to implement a new EHR.
GE: Set up your own templates, specific to your encounters. Learn to use computerized shortcuts and autocomplete features so that you can save time and keystrokes, and template chunks of text. Create libraries of orders for tests, labs, and medications. Practice during time that is not directly related to patient care so that you can gain familiarity with the tool in a non-stressful environment. If voice recognition software (for example, Dragon) is available and can be incorporated, learn to use this tool along with the EHR.
WHAT HAS BEEN YOUR GREATEST CHALLENGE?
AW: While many physicians are accepting and even eager for this change, there are certainly those who are resistant. A large part of my current role is as a physician leader for a large number of ambulatory implementations that we have completed over the past year. I act as a “translator,” sitting in build meetings with the information services team and the physicians from the individual practices and trying to make sure that both sides are truly hearing each other. I also provide at-the-elbow support for physicians once their practice goes live and am now involved in our efforts to have all of eligible professionals attest to meaningful use. I'm kind of a traveling help desk — colleagues will call, page, or e-mail me if they have any Epic-related questions or issues.
Different strategies are needed in training depending on the mood of the room, the ability of the physicians who happen to be in that particular training session, and their acceptance of EHRs. Sometimes I can be the good cop, other times the bad cop: “You will sit down right now, you will be quiet, you will participate in training or you won't be able to see patients and you will get fired!” I've had to learn to express that with authority, but in a polite and convincing manner. I've also had to occasionally resort to calling their boss, and in very bad situations, having the chief medical information officer reach out to their chair. I understand why physicians get upset when they feel they're being asked to do something that is a waste of their time; fortunately, they seem to take advice better when it comes from a colleague.
GE: There's a general wave of resentment among many physicians, seasoned and green, about the use of the EHR in practice. This is because of the disruption in workflow that is either perceived or real, depending on how the person has tried to implement the EHR into his or her own practice. Frustration around e-prescribing was especially high, particularly given the push from the administration to “avoid penalty” in 2012 by performing 10 electronic prescriptions by June 30. We embarked on a multifaceted communication campaign which tried to emphasize not only how to e-prescribe, but also how to add the G8553 code to their billing forms. When doctors were shown how easy it was, their anger changed to quick acceptance. Many doctors also suggested that the pharmacies be prepopulated by clinic staff, and once this was done, adoption skyrocketed. Lessons learned: robust communication, real-time support, and allowing the doctors/staff to be part of solutions increase adoption of an electronic tool.
WE ALL KNOW WHAT A NEUROLOGIC CRISIS IS, BUT WHAT ARE THE EHR CRISES THAT KEEP YOU UP AT NIGHT?
AW: We hold emergency meetings when critical issues arise. One recent example of this took place after a patient brought to our attention that his insurance information, including psychiatry coverage information, was showing up on every printed order. While this had been done to facilitate processing of orders, it was a potentially significant patient privacy issue which was immediately rectified. One of the core objectives of meaningful use is providing patients with an after-visit summary that includes the patient's active problem list. This has led to inadvertent disclosure of sensitive diagnoses, such as when a patient hands the document to a family member not realizing what information is contained on it. As many hospitals are in the process of interpreting the final CMS rules to attest to meaningful use, we are all struggling with new issues like these that have never arisen before.
GE: I worry about what will happen if the system goes down and we can't see patient data, medications, or prior notes. What will happen if new regulations that occur overnight threaten the practice? For instance, the Georgia Board of Pharmacy has now mandated that all narcotics scripts be printed on state-approved security paper; the question is how to make this operational for all of our physicians at multiple clinic sites as e-prescribing of narcotics is currently not an option in Georgia.
HOW DO NEUROLOGISTS STACK UP WHEN IT COMES TO IMPLEMENTATION?
AW: According to the Epic consultants, the neurology department at Rush was one of the best groups they have worked with in terms of acceptance and rapid adoption. However, it's difficult for me to answer this question fairly, as my department always felt able to speak freely about their concerns and fears as I am “one of them,” and I certainly encouraged and welcomed their feedback.
GE: Neurologists at Emory are among the leaders in sections who have developed structured documentation for neurologic problems for Cerner's EHR in the in-patient and outpatient settings. More neurologists use EHRs to document their notes than not. All are using CPOE [computerized physician order entry] for medications. We have standard clinical messaging and results management through the EHR as well.
Dr. Avitzur, a neurologist in private practice in Tarrytown, NY, holds academic appointments at Yale University School of Medicine and New York Medical College. She is an associate editor of Neurology Today, as well as the editor-in-chief of the AAN Web site,AAN.com,and chair of the AAN Practice Management and Technology Subcommittee.