When it comes to implementing new technology, the healthcare industry traditionally lags behind every other industry sector. However, here in Southwest Washington, providers are on the cutting edge of integrating electronic health records (EHR) into their workflows.
In the hospital
Every hospital, lab and clinic in the PeaceHealth network (that’s 10 hospitals across three states) uses the same EHR system – patient records follow the patient seamlessly from physician visit to hospital procedure to follow-up visits. Legacy Health uses the same EHR system as PeaceHealth across all their hospitals, including Legacy Salmon Creek Medical Center, as does the Vancouver Clinic.
“The single patient/single record approach is a fundamental shift in the way we care for patients,” said Dr. Mark Adams, chief medical officer for PeaceHealth. “Records used to be provider-centric. Everyone uses one record now. It’s the first major step toward patient-centered care.”
In private practice
The experience of private practices is somewhat different than that of larger health systems. For example, Dr. Don Benz, a Vancouver-based independent physician, said that despite deploying an EHR system more than a decade ago, he still experiences difficulty exchanging digital information with area hospitals. He said for many physicians, EHR has not made their lives any easier. In particular, he finds that EHR systems have a “bean counter” focus instead of a clinical focus.
“The physician uses check boxes to get paid and stay out of jail,” said Benz. Plus, he said, the information is not in the familiar “SOAP” format (subjective, objective, assessment, plan).
But Bob Kellar, owner of the only independently owned pharmacy in Clark County, Mill Plain Medical and Pharmacy, said electronic prescriptions have simplified the prescription transaction.
“There are no legibility and forgery issues,” said Kellar. “It’s been a good thing for the profession.”
He admits that the electronic approach has not eradicated all errors. Sometimes the physician selects the wrong medication from the dropdown list or may fail to change the default directions for how to take a medication. Benz said that these types of errors are less likely to be caught at some pharmacies, because the “electronic” format engenders a greater level of trust.
“EHR systems don’t prevent errors, they just make them easier to read,” said Benz.
In the field
Community Home Health and Hospice (CHHH), which has locations in Longview and Vancouver, has dozens of staff in the field every day. CHHH CEO Greg Pang said his staff needs “real-time information to know what’s happening with a patient visit at any given moment.” CHHH used to use a laptop-based EHR system that had no remote-submit capabilities and required overnight synchronization. In 2012 they converted to a smartphone-based system which sends data to the office immediately, resulting in better communication with both the office and following-up physicians.
Pang said staff members find the new system more efficient and easier to use.
“They ‘have their lives back,’” said Pang. “They’re not charting at home after hours.”
Dr. Michael Geist, medical director of informatics for PeaceHealth Medical Group, stated that the industry isn’t struggling with technology so much as with “how to absorb all of this into the work we do.” For example, traditionally, a nurse or medical office assistant may have called in a prescription refill – but if they aren’t licensed to do that, the EHR won’t allow the transaction. Geist said that the implementation of EHR has crystallized a build-up of work-arounds, and is forcing change.
“What feels like ‘bother’ is really ‘best practice,’” said Geist.
Another hurdle is interoperability. Adams said that the sensitivity of medical information makes it challenging to freely share patients’ medical records, even between providers.
“We want to make information available so it can be used, but we are tasked to protect the information from people that shouldn’t be seeing it,” said Adams. “We’re all trying to navigate this.”
Karen Waske, chief nursing informatics officer for Legacy Health, said that Legacy is offering the Epic EHR system through a community connect program to affiliated providers (not employed by Legacy Health). In this way, providers can share a single record, which promotes collaborative care.
Legacy also participates in health information exchanges. Waske said that in 2016 Legacy has already exchanged 3.9 million records; 2015’s total was 11.4 million records. Legacy was one of the first seven Epic customers in the country to implement Care Equality, a national health information exchange.
Geist said that sharing medical information with smaller clinics was challenging.
“We don’t know if we can rely on the small clinic to comply with HIPAA rules,” said Geist. “Also, it’s harder for small clinics to share secure connections and networks, and to match the necessary data structures, file formats and patient identifiers.”
Pang made an analogy to national parks, where there is always tension between access and protection. The bottom line is that although vendors and the government are aggressively pushing for interoperability, “we’re not there yet,” Geist said.
Note-bloat is another problem. The ease of copy and paste, as well as documentation requirements for reimbursement, lead to the inclusion of redundant or unnecessary content.
“If you think about the number of people that interact with the patient and the amount of data that is generated,” said Waske, “it’s key for physicians to understand how to organize that data and customize reports so they get just what they need.”
She acknowledged that it might be time-consuming for a physician to customize a report, but said that it “pays dividends on the backend” through more efficient use.
Patients benefit through enhanced communication so they can get lab and test results faster, can become more engaged in their own healthcare decisions, and can go from one site of care to another without filling out new forms. Web portals with secure messaging, said Geist, make provider notes available to patients. PeaceHealth is running a pilot project where patients enter their own information such as blood pressure and health histories.
“The future direction is patients being able to see their records, make changes and be an active participant,” said Geist.
Waske said Legacy will be focusing on patient-entered data over the next 18 months. She said that “we need to be thoughtful” about what data patients to enter. For example, weight may be more relevant to heart patients, while blood sugar readings are salient for diabetics.
“We don’t want to overload physicians with data,” said Waske.
Adams said PeaceHealth is using EHR to standardize care based on evidenced-based practice, to reduce duplication of tests and procedures, and to increase quality and safety. Building “best practice advisories” (BPAs) into the EHR system enables a clinic to implement checks and balances such as alerts about patient allergies or contraindications.
“We’ve discovered things we might not have been aware of without these BPAs,” said Adams. “They help us look at care on a broader scale and resolve potential conflicts.”
Waske stated that Legacy’s core quality measures, such as heart failures and community acquired pneumonia incidents have improved as EHR have evolved. While these improvements can’t be solely attributed to EHR, she said that the automated nature of the system relieves caregivers from simply having to “remember” to tell a patient something or order a certain type of medication.
“EHR systems enable sophisticated decision support,” said Waske.
So, while EHR systems are not yet perfect, Geist was optimistic.
“The vision for the future is moving fast. If you had asked me five years ago what today would be like, I would have been more pessimistic. But, there’s a lot more work to be done to reach the ideal state.”