Health IT from practicing physicians’ perspective (as opposed to the Ivory Towers’)

1. Health IT from practicing physicians’ perspective (as opposed to the Ivory Towers’) Joe Heyman, MD Chief Medical Information Officer Health Information exchange

2. Larry Monahan, MD, Internal Medicine, five physician practice, Virginia The IT investment of time and money (required by CMS, Insurance companies, Meaningful Use, Hospitals, CPOE etc) has simply been the most demeaning, discouraging, and belittling, series of events of my  professional life, and it is NOT THE PRACTICE OF MEDICINE.  EMR is NOT what honest doctors want, is NOT what appreciative patients want or need.   I have gotten to the point of saying, “if ‘THEY’ want to turn me into a typist (or data input device-operator), then I’m not going to be able to continue trying to be a physician any more (who enters a room, smiles, shakes the patient’s hand, sits down, faces THE PATIENT not the computer (for goodness sake!), listens and asks questions, stands up and EXAMINES THE PATIENT (for goodness sake!....touching the patient, palpating & percussing & auscultating!!), then sits down again, communicates WITH the patient about recommendations/considerations/testing possibilities/medications, finally stands up and shakes hands again with a kind/encouraging word of departure, etc.)   I cannot conceive of HOW this IT “God” can cease to be “worshiped,” unless one of the CMS/WhiteHouse/Insurance executives suffers or loses a life or a family member because the “provider” is doing clerical things at the computer . . .

3. Rand Study 2012-2013 • “Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy” • Sponsored by American Medical Association • 30 physician practices in six states: Colorado, Massachusetts, North Carolina, Texas, Washington, and Wisconsin • Initial six practices caused a rewrite of plan for study.

4. Rand Study • Physicians approved of EHRs in concept. Only 20% would go back to paper charts. • Better ability to remotely access patient information • Improvements in quality of care. • The potential of EHRs to further improve both patient care and professional satisfaction in the future, as EHR technology—especially user interfaces and health information exchange—improves.

5. Rand Study Some practices felt the current state of EHR technology significantly worsened professional satisfaction in multiple ways. Prominent sources of professional dissatisfaction: • Poor EHR usability • Time-consuming data entry • Interference with face-to-face patient care • Inefficient and less fulfilling work content • Inability to exchange health information among EHR products • Degradation of clinical documentation. • Too expensive threatening practice financial stability • Some of these problems were more prominent among senior physicians and those lacking scribes, transcriptionists, and other staff to support data entry or manage information flow. Physicians across the full range of specialties and practice models described other problems, including but not limited to frustrations with receiving template-generated notes (i.e., degradation of clinical documentation).

6. Rand Study Some practices have taken action to improve satisfaction: • allowing multiple modes of data entry (including scribes and dictation with human transcriptionists) • employing other staff members (e.g., flow managers) to help physicians focus their interactions with EHRs on activities truly requiring a physician’s training.

7. Lisa Egbert, Solo OBGYN, Ohio • I am in agreement with others that the absolute worst thing about EMR's is that they do not talk to each other, and they most definitely should. Given the proprietary nature of the business, however, I do not foresee it happening until they are legally forced to do so, which means the companies that make them should be penalized with significant financial burdens by the government until they comply. • The second problem with EMR's is the GOVERNMENT! The incessant creation of, changing of, implementation of, and inconsistent enforcement of rules and regulations related to health care is actually harming the advancement of EMR technology. For example, “XXXXXXXXX” has an entirely new and updated system that it was ready to launch to it's customers, but it has been put on permanent hold so that they could use their IT people to get “XXXXXXXXXX” itself ready for MU2 and ICD-10. Now that there are further delays, (ICD-10 delayed until 2015), do they go back to working on their new platform or do they continue to patch the old one so that they can be ready to comply?

8. Barbara Hummel, MD, Solo Family Practice, Wisconsin • I have an office EHR and have since I opened my private practice 17 years ago.  I just updated my computers because XP professional is no longer supported.  My medical management system does not function on windows 7 so I am now in the middle of implementing a new management system because the company that I purchased my previous system from sold out to a larger company and they had so many higher priced systems that they preferred to sell us so they dropped support and no longer sell the reasonably priced system - they wanted me to purchase their $35,000 system -- not doable for a solo family physician.  This has been a tough year because of all this and one thing that would help is stability of the vendors and their products.  This is the third time I have had to change systems because of vendor consolidation.   • I value my computers but I have control of what is in my EHR.  There is much in the hospital EPIC system ( that our hospital has) that is in the records that I don't put there and have no choice to have included -- some nurse inputs the information and it isn't always correct.  That is frustrating. The fact that the three different hospital systems In my area -- all with EPIC -- cannot even communicate with each other is frustrating.  As an independent physician I no longer get reports from the specialists who work for the systems because they direct everything to EPIC and that is not my system.  We need inter-operativity.  The lack of information when my patients come to see me after they see the specialist is frustrating and puts us all at a loss and a risk.  

9. Joe Heyman, MD, Solo OBGYN, Massachusetts I left a large group with lots of resources to start my little solo practice with a single employee in 2001.  I never would have been able to afford to do that without my EMR.  No chart pulls. No space needed for filing.  One person could do front desk job, get patients ready and there were no other filing needs.  She got next patient ready in an exam room while I finished interviewing patient in my office after her exam.  I never had a computer in my exam room and most of my entry was done while patient was dressing.  As my current patient left, my front desk person entered the codes I picked.  Two people managed a thriving practice where patients could spend a half hour with me.  It was a boutique practice without the subscription fees. That EMR has become less usable with lots of extra clicks interfering with workflow since the introduction of Meaningful Use requirements.

13. Advantage of a physician-owned HIE • Patients are in more than one network especially in rural areas (Lahey, BIDCO, Tufts, Partners, Steward). We never see a patient in a single network. Regional HIE is only way to have complete clinical information because networks only have their own information. • Patients need only a single portal. • Physicians avoid becoming prisoners of networks and hospitals.

14. What does this have to do with workforce? • Large healthcare systems and hospitals can afford more easily all the changes associated with system reform and IT infrastructure. • Small practice physicians (and their patients) prefer a different setting where they feel more like individuals and less like a number. They want a single doc seeing them rather than a “team” of midlevels.

15. What does this have to do with workforce? • Small practices present workforce challenges. • Fewer resources (people and finance) • Less technology know-how • More IT frustration • These are actually opportunities for new directions for workforce. • Scaling down systems • Scaling down costs • Scaling down HIE infrastructure (it can be done)

16. What does this have to do with workforce? • We need innovations that can direct at small practice physician organizations. • Treat them like large practices even though the members are financially independent. • There are about 500 IPAs with 120,329 primary care physicians and 144,080 specialists across the country, according to the Managed Care Information Center in Manasquan, N.J. (2011)

17. What does this have to do with workforce? • There is need for help with • Implementing better EMRs • Achieving MU • IT support (hardware and software) • Workflow design • Transcription • Scribes • Flow managers • Interoperability • New Apps

18. Joe Heyman Health Information Exchange Owned and Operated by the Whittier IPA, Inc. Joe Heyman, MD Chief Medical Information Officer 255 Low Street Newburyport, MA 01950 (978) 462-2345 Office (978) 807-5365 Cell joseph.heyman@verizon.net www.wellporthealth.net