If you aren’t familiar with AMC’s television series The Walking Dead, I would suggest you catch up before the start of the next season in October. For fans of the show, Season 4 ended March 30th, and the next few months will be filled with anxious anticipation for the Season 5 premiere, which will reveal the fate of the show’s characters who are trying to survive in the midst of a full-blown zombie apocalypse.
While a show about zombies may seem a far cry from learning how to use an EHR meaningfully (or maybe not), there are some surprising lessons from the show that EHR Meaningful Users may find helpful (or at least interesting).

1. There is no escape for anyone.  One thing that the characters learn quickly in The Walking Dead is that zombies are everywhere. Private homes or public buildings, underground or underwater, in the light of day or in the light of the moon — it doesn’t matter where the survivors seek refuge, zombies have a knack for showing up, and, frankly, it’s unnerving. For many healthcare providers, they feel the same way about “meaningful use”— it’s all consuming. Learning how to document in an EHR is tough enough, let alone having to document a certain way as to not alert the chomping mouths of the administrators and their weekly reports. So if there’s no escape, how do you survive? Mostly, surviving requires assimilation. The characters learn what it takes to kill the zombies while at the same time studying what triggers their attention and what it takes to hide from them. That’s not saying healthcare providers should learn how to kill or to hide from the administration (even if it does seem tempting at times). More along the lines of accepting your situation, studying what it takes to document correctly, and developing strategies to do it faster.

2. Even a prison can be a refuge.  At the beginning of Season 3,  after a long, hard winter of running on empty, Rick Grimes (the male protagonist of the series) and crew finally find a place to rest and refuel (and perhaps even reside?). And where else but a prison?! While we discover later in the series that the prison isn’t the perfect sanctuary, it does provide them with a temporary refuge where they have time to recover. Likewise, Meaningful Use may seem like a prison sentence for providers who have never had to document in an EHR before now, but in some ways, Meaningful Use has provided EHR users a means of protection in an industry that demands high standards be met for quality patient care. At least healthcare providers can be assured that when purchasing EHR hardware and software, the vendors must design them to meet Meaningful Use criteria in order to be a certified product. Additionally, while the Meaningful Use program isn’t perfect, participants do receive funding from the program, which should help them pay for the cost of implementation. For a time, their HIT initiatives are covered (or at least partially); every now and again a zombie sneaks into the prison.

3. We must have hope.  If my favorite characters keep dying (in very gruesome, dismal ways) and the zombie apocalypse apparently has no end in sight, why do I and millions of other fans keep watching every Sunday night, glued to our sets for the full hour, the only show that, as one friend pointed out, is watched in real time versus hours or days later on the DVR (yes, we actually sit through the commercials)? Perhaps it’s because we still have hope—hope that those who are left will find a safe haven, a place to “live” once again rather than just exist. Better yet, hope for eradication of the virus that started the whole apocalypse and continues to be a constant threat to the survival of the human race. Perhaps the best lesson healthcare providers can take away from the show is they must have hope—hope that all of their efforts, that all of their struggles, that all of their time and money invested will pay off in the end and that patient care will be improved. 

In a recent Medscape Family Medicine article by Brandon Cohen, “Making EHRs Less Intrusive and Annoying for Patients,” Cohen points out an all too obvious fact, that some physicians see electronic health records (EHRs) as “a giant headache” and “a barrier to good relationships with patients.” Cohen adds, however, that other providers see the EHR as a valuable tool that helps with “efficiency and accuracy” and doesn’t have to impede the doctor/patient relationship. Some of the comments shared by frustrated physician EHR users may be echoed in your office:

• "EHR has turned us from MDs into data entry clerks! We have gone from being a medical practice to an IT firm." 
  
• "I feel less satisfied at the end of the day now. When patients are all gone, I'm typing, spell-checking, and doing autocorrections." 
• "The measures of quality [in EHR] are based on checked boxes, not real outcomes. They have to be, or it fails. Simple is always better!"
• "The most important keystroke is to push the PC aside and face the patient directly."
• "I live in a town that has passed legislation criminalizing texting and driving. A driver is more impaired and distracted when texting than when intoxicated. EHRs and the practice of medicine should be no different. Do you really believe that your physician is actually concentrating on the patient in front of them while their attention is primarily focused on entering data in a computer?"
• "It's time to tell the practice managers, insurance companies, and efficiency consultants that patients expect and deserve a real physician who is a caring human being and is able to take the time and provide the human element that is a major dimension of healing."

These sentiments of frustration are obviously felt nationwide, but what makes the difference for those physicians who appreciate having an EHR? Is it a different generation of users or a different specialty? Could it be the difference in the EHR system or the workflow set up? It may be that all of these factors affect attitudes, but Cohen shares some suggestions from other physicians for making EHR more patient friendly, and, to that end, more tolerable. 

Improving the EHR Experience
Doctors who have found satisfaction with their EHR product offered suggestions to their frustrated colleagues for making the EHR less intrusive. 

Let the patient interact with the computer, too. "[Older] patients feel much more comfortable with the computer when I pull up their actual scans on the monitor and use them to explain their disease...For many patients, the computer is not only an accepted but welcome presence." (Oncology)

Identify the benefits of using an EHR and what works well. "I have a lot of stuff in the current note that used to be buried in the chart (or omitted). Every patient gets a printout of today's interim history and the proposed plan, as well as a list of meds and diagnoses." (Psychiatry)Bigger might be better. "I have a 32-inch monitor screen on the wall and wireless keyboard and mouse. It sucks the patient into their record and is unmatched for patient education." (Primary Care)

Switch the workflow and take notes. "I leave the computer out of the exam room and take notes as necessary, then complete the EHR after the interview, while my assistant is performing her tasks with the patient." (Gastroenterology)

Enter what’s necessary first, then use pen and paper.  "I inform the new patient, 'I'm just going to get some background information, and then I will talk to you about why you are here.' Once the database is completed, I print off the sheets and conduct the history and physical in the same manner I have done for the past 38 years." (Internal Medicine)

Learn to touch-type. "I touch-type, which I highly recommend learning. I can maintain eye contact while entering their history." (Internal Medicine)

Cohen noted that most physicians are not completely satisfied with current EHR technology, but many users are hopeful about what the future will bring to healthcare technology, especially as improvements are made to free up the physician to interact with patients.  
Of course, as one physician pointed out, there is one generation of patients that probably aren’t bothered at all by the presence of the computer:
"They [teenagers] won't notice you looking at a screen because their peripheral vision isn't that good, and they never break their texting trance. ...This EHR [problem] may be a transient issue; it certainly doesn't bother the younger generation."
Perhaps the issue is transient, as the provider above suggests, especially as computers and other technologies saturate our society and lives, but insights from successful users may be beneficial as we transition to this new way of medical record keeping and documentation.  

You may have already heard more than you care to about the topic, but like it or not, secure exchange of protected health information is required for HIPAA compliance. Not surprisingly, some of the required measures for achieving Stage 1 and Stage 2 Meaningful Use involve the secure electronic exchange of  patient health information.  Stage 2 Core Measure 17 “Use Secure Electronic Messaging” is a prime example:

The Objective is to use secure electronic messaging to communicate with patients on relevant health information.  A secure message must be sent using the electronic messaging function of the provider’s CEHRT by more than 5 percent of unique patients seen by the eligible provider (EP) during the reporting period. 

A Secure Message is defined as  “Any electronic communication between a provider and patient that ensures only those parties can access the communication. This electronic message could be 1) email, 2) the electronic messaging function of a PHR, 3) an online patient portal, or 4) any other electronic means. An EP or staff member can follow-up with a telephone call or office visit if deemed more appropriate to address the concerns raised in the patient’s e-message. And don’t get too panicking just yet if you’re thinking what a lot of other providers are thinking, “Yikes! Email from patients?!”. . .There isn’t a requirement that the EP must personally respond to electronic messages to the patient. Designated office staff can manage the email under the supervision of the physician.
As Quillen ETSU Physicians prepares to meet the requirements of this measure and to comply with the HIPPA Security Rule, we have started the process of registering our users in the Direct Project.  If you’ve been asked to send us your driver’s license and ETSU ID, then you’re on your way to being registered. The Direct Project offers providers a secure way to send protected health information, including clinical summaries, continuity of care documents (CCDs), and laboratory results, to other providers who also have a Direct address. Presently, we are participating in the most basic implementation of the Direct Project, a secure email system via an email client, which works just like regular email, but with an added level of security required to transport sensitive health information.
Over the next few weeks, some of our users will be receiving an email much like the one you see below. Once you receive it, you’ll be asked in another email by the EHR administrator to forward it to her. She’ll be providing you with additional information for using it later.
Admittedly, there are many changes going on in healthcare right now, which may have you feeling overwhelmed. But, what I keep reminding myself—as I try to muddle through and stay current in serving our users—is that these changes are being implemented for improved quality of patient care and, eventually, to make providing that care to our patients more convenient for everyone.
It wasn’t too long ago that we all heard the chime, “You’ve got mail!” as we logged into our AOL accounts through our dial-up modems (can you remember how slow that connection was?). Now we are blazing across the internet on our smart phones and tablets, with instant access to almost any information we need, including patient health records.
Healthcare technology’s day will soon arrive and all of the changes that are being implemented now will seem routine and outdated as we continue to move forward. Rather than having to leave voicemails, send faxes, call the pharmacy again and again, or wait on a patient’s return call, wait on a fax, or wait on the pharmacy to call you back, the exchange of secure information will be at your fingertips and as fast as you can say, “You’ve Got Secure Mail.”

Ever feel like the government is one big bully, forcing you to  click a box or else? If so, you aren’t alone. At a recent conference presentation I attended on EHR use, the presenter* revealed that a good portion of the providers at his practice feel bullied into using an EHR. Their comments included

•  “I don’t really care what the government wants me to do.”
• “I want to tell my story in my own way, in my own words.”
• “An EMR can never tell me how to practice medicine!”
• “I don’t really care what’s in the note so long as you leave my narrative alone.”
• “I’m not going to use it.”
  

Many of our Quillen ETSU providers have made similar comments, and who can blame them? Change is never easy, and when that change is implemented with the consequence of “or else,” it’s no wonder that many providers feel bullied into using an EHR.

But what strategies do we encourage our children to use when faced with a bully?  The most common strategy, but one that’s effectiveness has recently been questioned, is to “walk away.”  And questioned rightfully so. A child who walks away from a bully doesn’t make the bully go away. And doctors who walk away—well, they’d just need to find another job, right? —because the EHR isn’t going away.

So what bully strategies do work?  Most experts encourage children to get involved with a another group. With positive peers around, the bully finds it harder to isolate the victim, and, often, the group’s positive influence becomes contagious, even to the point of affecting the bully.

To apply this same strategy to our EHR scenario works as well. Rather than providers giving up, walking away,  and joining the unemployment line, working with the EHR can have some positive outcomes on  our patient population.  With the entire staff on board, and negative attitudes put aside, consider the benefits of using the EHR:

• Patient lists can be generated for better tracking of patient populations, for instance, identifying cardiology patients with low ejection fractions but no ICD.
• Candidates for clinical research trials can be quickly identified.
• The accuracy of medication lists is improved. 
• Order tracking is improved and the cost savings from duplicate orders are passed along to the patient. 
  

Although this is a short list, there are many more benefits that can be added to it. So for those users who  have taken the attitude “If you can’t beat it, join it” or better yet, “I love it,” pass along your sentiments. 

And for those “victims” out there, adopt a new strategy and let  some positive peer pressure affect  you.

*Presentation by Scott Tuning, Clinical Information Systems Manager, New Mexico Heart Institute, Albuquerque, NM

One of my very favorite pediatricians (and she knows who she is) made the comment a couple of weeks ago that she thought her clinic should be winning a pizza party for something other than clicking a box to document education. She suggested that they should be winning for something like, well, quality patient care.

I absolutely agree with her. They should be awarded for quality patient care.

As I mentioned last month, I am a parent who truly appreciates the quality of care my children have received from them. And as an EHR analyst, I’ve been able to work with the clinic to help set up templates to document some of the grant initiatives they’ve been awarded recently (Ever heard about the ReadNPlay books?)  And when it comes to residency training, this group has really demonstrated their commitment to medical education and making sure that their residents are well prepared, not only for providing excellent patient care, but for also documenting excellent care in an electronic health record.

I say all of this—not to brag on the clinic again this month—but to suggest that checking a box and providing quality care can go hand-in-hand. Maybe we could’ve rephrased our award to be “Highest Percentage of Quality Care Education Documentation.” I little wordy, perhaps, but do you see what I’m getting at?

The Meaningful Use initiative wasn’t created to demean or devalue the care providers are already giving; it was designed, in part, to help document that care in a meaningful way, or, more specifically, in a way that can be pulled as data later—for research, for quality improvement, for education. It was also implemented to ensure providers are equipped with EHRs that are designed to be a secure tool for them, not just another database.

Admittedly, it isn’t a perfect program, and what new quality health initiative is? Yes, providers do have to spend more time clicking boxes, and, yes, the system freezes up sometimes, and, yes, there are “bugs” that creep around the system, just to get under our skin.

Not that these imperfections are directly Meaningful Use centered; in fact, most of the things users complain about are technology centered. How many times have you found yourself grumbling about your Smartphone being too slow or forgetting your online banking password? In fact, just a few days ago, I had to call my credit card issuer because their website locked me out…imagine that! But, I also can’t imagine not having my Smartphone, or not being able to check my bank account balance, or not being able to pay my bills online. I never want to balance a paper checkbook using canceled checks again. And I would guess that none of our users can imagine using a paper chart again.

But as we start preparing for the next stage of Meaningful Use, it’s interesting to look at how this next stage is trying to improve from the first stage of the program and really make use of developing technologies. According to CMS, Stage 2 Meaningful Use was designed to support “the aims and priorities of the National Quality Strategy. Specifically, Stage 2 meaningful use criteria…encourage[s] the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible." As part of the Affordable Care Act, the National Quality Strategy is a national endeavor to “align public and private interests to improve the quality of health and health care for all Americans.”

It’s guided by three aims to provide better, more affordable care for people and communities, as well as six priorities:

• Making care safer by reducing harm caused in the delivery of care.
• Ensuring that each person and family is engaged as partners in their care.
• Promoting effective communication and coordination of care.
• Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
• Working with communities to promote wide use of best practices to enable healthy living.
• Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.
  

Let’s use patient education to illustrate how these priorities work. For Stage 2, core measure #13 requires using a certified EHR to identify and to provide patient-specific education for more than 10% of unique patients. As an improvement upon Stage 1, our EHR will be required for Stage 2 to identify appropriate educational resources for the patient, based on either his or her problem list, medication list, or laboratory test results.

Although the material doesn’t have to be produced from the EHR, the EHR will be required to become a useful tool for the practitioner, rooted in the third and fourth priorities mentioned previously: he is assisted with, one, effective communication and, two, effective prevention and treatment practices. With Quillen’s next major upgrade to Allscripts, our users won’t just be clicking a box to say they provided education; our system will alert them that patient education might be appropriate and is available for the patient. 

This is not to say that my favorite pediatrician needs to be reminded to educate her patients; she has been practicing long enough that patient education is second nature to her. But the convenience of having the education available from within the system and available in an electronic format that can be sent to a patient portal is a tremendous advantage of an EHR. 

Some of our providers are already taking advantage of the patient education tool now. For instance, rather than just click “Education provided,” one of our internal medicine providers selects a diet plan (when appropriate) that is loaded in the system and prints it out for the patient before he or she leaves.  

Another great example, one of our surgeons orders and then prints education about laxatives so that patients can understand the different options. The EHR Team can also add educational material if a clinic or provider requests it. 

Kudos to these providers for attempting to use the system’s tools. It’s definitely not the easiest system to use, and, again, the system is far from perfect. But why not take advantage of the benefits it does offer? 

I have written about workflow, proper documentation, and clinical quality measures over and over, but my perspective has always been a little one-sided until recently.  Always writing from the clinical staffs’ viewpoint, I never really considered how the patient might perceive the implementation of our EHR and all of the workflow changes that have come about as a result of our EHR incentives programs, like Meaningful Use or PQRS.  However, with the recent illness of my middle daughter, I’ve gained a lot of valuable patient insight (albeit not from the best of circumstances), and I’m very appreciative of the learning opportunity.

So exactly what have I learned?

1. Computers can be glitchy, but they provide a lot of valuable information. While at the hospital and at follow-up appointments with Anna, there were a few times that the computers froze or caused a problem, but, honestly, not that often. And given the alternative —of not having Anna’s information readily available and having to wait on records to be faxed—I’ll take the occasional glitch. Anna has seen multiple providers during the past few months, and with all them having access to her electronic chart, it put my mind at ease.

2. Computers do get in between the provider and patient, but it isn’t all that bad. I have heard several clinicians say that they feel like the computer gets in between them and the patient. And I have also heard patients say the same thing. But from what I observed during Anna’s experience, it’s not really that intrusive. Sure, you have to spend some time entering information, but once the information was entered, all of her providers spent time examining her and talking to her directly. It definitely wasn’t any different than writing down the information on paper. I discovered that most everyone who saw her has developed a balance in using the computer and seeing the patient.

3. An EHR saves the patient money. As mentioned in #1 above, when providers share the same record, it’s time gained, but it’s also money saved. All of Anna’s orders (labs, imaging, etc.) were shared by all of her providers, and no duplicate tests were unnecessarily ordered, saving me money.

4. The Clinical Summary is nice. First of all, let me say that Crystal, one of the check-in staff at Pediatrics, does an awesome job. She never forgot to ask us if we wanted a clinical summary of our visit. Although I didn’t need her to print it for all of Anna’s visits, the document has come in handy at other times. With so many medications and orders and diagnoses, it’s difficult to keep track of all that information, especially during a stressful acute illness. Thank you, Crystal, for always asking, because there are times when this mom forgets things. 

5. Quillen ETSU Physicians are wonderful physicians. Although I’ve taken advantage of Anna’s illness for inspiration to write, I hope everyone will indulge me. The most valuable perspective I gained during this experience is how wonderful our physicians and staff are. Anna has received the best of care, and I can’t say enough how appreciative I am for everyone who has helped her. To everyone at ETSU Family Medicine in Johnson City, ETSU Pediatrics, and ETSU Surgery, thank you so much for providing the best of care. You rock (the EHR, too)! 

Rhonda Cole has worked for ETSU Physicians for 34 years. Hard to imagine, huh? And for most our pre-EHR employees, when the computer programs screwed up, bit the dust, or became inoperable by some other clichéd demise, Rhonda was a phone call away. She still is the go-to for many of our practice management computer programs, but with the implementation of the Allscripts EHR, a whole new team, with a dedicated line just for EHR issues, was formed.

Now, when someone has computer problems, they usually aren’t singing “Help Me, Rhonda,” more like “Help, I Need Somebody … who will help me with this #?!*&%^ EHR.”   It’s not that they prefer the Beatles over The Beach Boys, or that they don’t like talking to Rhonda. It’s just the tune we have to play now. Rhonda’s computer program issues may be a nuisance to many that have to call her, but most of the issues don't keep providers from seeing patients. More often than not, though, when someone calls the EHR Helpdesk, they can’t continue to work because they are frozen or have received an error message. Without access to the chart, they feel powerless to help the patient.

So, I probably just validated all of the negative thoughts you’ve been having about using an EHR, but what about the positive aspects of the system? What makes it better than all that paper? What makes it meaningful?

For a while, Rhonda was one of the few people who could pull data for ETSU. She was the person to see for reports on codes and charges, or else, clinic personnel would have to take the time to manually pull data—a very time consuming and expensive task. Now, a call or task to the EHR Helpdesk can provide users with meaningful data that we could never easily gather before. For instance, we regularly run reports on Controlled Drugs that are prescribed in some of our clinics for quality assurance. We are also currently generating a report on patients with HIV and CAD for providers heading up a research study. We can also generate patient lists by request for providers wanting to keep track of a specific patient demographic or diagnosis.

There is also the convenience to the patient of providers being able to send prescriptions electronically so that the medications are waiting at the pharmacy, or the quick access to last week’s or last month’s or last year’s labs. 

The patient’s accessibility to results and medical data is also greatly improved. As they leave the clinic, a clinical summary is easily generated if desired, and very soon, an electronic portal will be available to the patient. 

And what about provider accessibility? The patient’s record is now accessible from home, from the hospital, even from a smart phone. That kind of convenient accessibility has never been a option—on-call providers had to fly blind.  

Obviously, EHR isn’t perfect and probably never will be. Ask Rhonda. She’s been working with computers and software that still need buggy problems fixed. She’s heard the song before: “And I can give you lotsa reasons why/ You gotta help me, Rhonda.”  (The Beach Boys, Help Me, Rhonda)

But since we have a new program, and a new team, a new number to dial, how about we try singing a new song: 

“(Now) But now these days are gone (These days are gone), I'm not so self assured/
(I know I've found) Now I find I've changed my mind and opened up the doors.”  (The Beatles, “Help!”)

According to the TennCare website, the definition of Meaningful Use involves using certified EHR technology to

· Improve quality, safety, efficiency, and reduce health disparities,
· Engage patients and families in their healthcare,
· Improve care coordination,
· Improve population and public health, and
· Maintain privacy and security.

Remarkably, we have already seen first-hand examples of Quillen ETSU providers and clinical staff using our EHR to each of these ends. 

Addressing health disparities has been the primary  focus of the patient lists generated for each provider. Many of the family medicine and internal medicine providers now have access to a list of all their diabetic patients with records in the EHR. 

These lists help providers and clinics manage this patient population, who, in Tennessee, had a 19% higher risk of dying from diabetes than the national average.  The Tennessee diabetes death rate of 30.2 per 100,000 was ranked 10th highest in the nation in 2002. In 2004, the age-adjusted diabetes death rate for black Tennesseans (61.1 per 100,000) was over twice the rate for whites (27.8 per 100,000).* 

*Information from tn.gov. 

Each of the Quillen clinics has also been offering  Clinical Summaries to patients and/or their family members at check out.. While not every patient asks for the summary, some patients have found these summaries very beneficial, such as parents wanting the most up-to-date immunization record, or simply patients who are on multiple medications.  

As we look toward adding a patient portal, patients will gain even more access to their health records, and, hopefully, this will prompt many of them to become more engaged in their own healthcare.

Improving care coordination has been one of the biggest benefits of using the system. With multiple providers and specialties having quick access to the patient’s chart, duplicate labs and medications have significantly decreased, saving patients money and time.

The referral process to providers within ETSU clinics has also  been significantly improved. Faxing records is no longer necessary, and clinics can use tasking rather than phones and faxing to make the referral.

With the system’s ability to track and report data, we are now able to run reports on various population and public health initiatives. In the Department of Pediatrics, data has been requested to track abnormal labs, the Read N Play initiative, and reflux diagnoses. In the Department of Family Medicine, various information is being tracked for improvement of their Patient-Centered Medical Home designation, as well as monthly reports on Controlled Substance prescriptions.

The system is also designed to generate reminders based on either input from individual providers or as system-generated reminders based on recommended screening and diagnostic guidelines, such as colorectal cancer and mammography screenings. Recently, reminders have been set up for CSMD checking  for patients on controlled substance prescriptions.

Maintaining privacy and security has always been a top concern for EHR users, no matter what the system. With retail electronic security breaches being reported regularly, many healthcare providers questioned the security of electronic health records when EHR systems were first introduced into practices. However, with quickly evolving technologies, and the stringent requirements on systems in order to be certified for Stage 1 of Meaningful Use, EHR systems are exceptionally secure. Eligible providers need to “attest” that they have met certain measures or requirements regarding the use of the EHR for patient care. 

EHRs are more secure than most paper charts ever were, especially within organizations where chart audits are frequently performed. In the paper world,  if an employee wanted to access a health record without reason, most likely, no one would ever know if he or she  had been in the record. With electronic records, anyone who accesses a chart is trackable, resulting in a more secure health record.

As we all become better users, the possibilities for how the system can be used in more meaningful ways will be illuminated.

What makes a medication meaningful? I suppose that ANY medication that is prescribed to a patient should be meaningful, but what happens when a patient’s medication list is maintained on the EHR, but the list isn’t accurate? Would an incomplete or inaccurate list be meaningful to anyone?

Let’s for a moment suspend the idea of a medication’s “usefulness” to the patient and examine the “meaningfulness” of the medication’s inclusion on the medication list. Perhaps the best way is to present a few patient scenarios:

Patient Scenario One

Patient One, “Mary Meaningful,” visits a clinic because she has allergy symptoms. She currently takes an over-the-counter decongestant, as well as a few vitamins and supplements. She also takes an anti-anxiety medication that she asks not be included on her medication list. Not wanting to cause Mary any distress, the nurse records her medications in the system (absent the anxiety medication) and sends her on to see the provider. Mary doesn’t mention anything about the anxiety medication to the provider because she feels embarrassed that she is taking it. The provider feels sure the medication list is accurate because it has been reconciled by the nurse and prescribes Mary an antihistamine.

Do you see the potential hazard here?

Dangerous interactions can occur when antihistamines and anti-anxiety drugs are taken together.

Patient Scenario Two

Patient Two, “Mike Meaningful,” shows up for his annual Medicare visit. He reports to the nurse that he has been seeing one of the cardiologists for some heart-related issues and that he was prescribed some medications a few months ago. She pulls up his chart and doesn’t see any medications on the list. When she questions Mike, he tells her that the doctor was too busy at his appointment and didn’t have time to put them in the system.  He just wrote them out on prescription paper.

How meaningful is the medication list now?

One provider’s responsibility has now been pushed off to another provider’s clinical staff, and, consequently, takes more time and is potentially less accurate than using the system the way it was designed.

Patient Scenario Three

Patient Three, “Misty Meaningful,” was originally prescribed 25mg of a blood pressure medication by her primary care physician, which was ordered through the system correctly. A few weeks later, Misty’s blood pressure hasn’t improved so the clinic calls in a higher dosage—50mg—but doesn’t record the change in the patient’s chart. Misty visits her specialist, who sees the dosage is 25mg but knows she is taking 50mg, as she reported to him. He decides she needs to take 100mg, and renews the medication at the higher dose. Unfortunately, Misty has a bad reaction and files a malpractice suit. When the defense attorney reads the specialist’s note, it appears that he upped her dosage by 75 mg because no one recorded the 50mg.

Where does the fault lie? 

Obviously, no one could have predicted the bad reaction, but how can we rely on the accuracy of a medication list and the system’s ability to accurately reflect a provider’s plan when no one takes the time to document in the EHR?

Meaningful Medications = Better Patient Care

I could describe many more patient scenarios in which the lack of accurate medication documentation has caused problems, but I think you get the point. Even when clinics were on paper, keeping an up-to-date medication list was very important for good patient care, but now, with the transition to an electronic health record, and with multiple providers using the same chart, each user must be particularly careful to accurately document. If we strive to make the medication list truly meaningful, the end result can only mean better patient care.
 

A recent survey conducted for the American College of Physicians and Doctors Helping Doctors Transform Health Care (published October 2012 ) in collaboration with the Bipartisan Policy Center (BPC) revealed some interesting findings concerning physician views about the adoption of electronic health records (EHR).

One of the most encouraging findings is that 80% of physicians surveyed believe that the adoption of EHR is having a positive impact on the quality of patient care. Additionally,

· 80% see EHR as improving the ability to coordinate care;
· 69% believe EHR is improving efficiencies in their practice setting;  and
· 57 % see EHR as reducing health care costs.

The same survey was fielded by the American Academy of Pediatrics in September 2012 with similar results. A majority (80 percent) of those surveyed believed that the electronic exchange of health information across care settings will have a positive impact on improving the quality of patient care as well as the ability to coordinate care.

While these percentages suggest an optimistic attitude about the EHR implementation, other findings reveal that there are still areas that need improvement, namely in the ability to exchange patient information among providers. 71% of the physicians surveyed said that the inability of the EHR to communicate electronically with other systems (or lack of inoperability) was a major barrier preventing them from exchanging information, as well as the lack of an exchange infrastructure (71%) and the cost associated with exchanging information (69%).

Fortunately, Stage One of Meaningful Use includes measures for tracking transition of care information exchange, and Stage Two emphasizes the clinical exchange of information electronically. According to CMS, “the Stage 2 criteria place an emphasis on health information exchange between providers to improve care coordination for patients. One of the core objectives for both EPs ... requires providers who transition or refer a patient to another setting of care or provider of care to provide a summary of care record for more than 50% of those transitions of care and referrals.”

Other changes to Stage 2 that demonstrate this objective include: 

· EPs that transition or refer their patient to another setting of care or provider of care must provide a summary of care record electronically (>10%)

· EPs that transition care must either a) conduct one or more successful electronic exchanges of a summary of care record with a recipient using technology that was designed by a different EHR developer than the sender's, or b) conduct one or more successful tests with the CMS-designated Test System during the EHR reporting period.

Although the extra documentation may seem time consuming at first, the more familiar systems become and with more feedback from users and providers, the future of EHR looks promising.