In their January 10th-11th meeting, the HIT Standards Committee Implementation Workgroup met to review progress toward adoption of Meaningful Use by clinicians and hospitals. Numerous perspectives were heard, from provider organizations, hospitals, vendors and others. Several consistent comments emerged, that are worthy of note, as we try to move forward with the envisioned widespread adoption of Electronic Health Records (EHRs). These themes can be summarized as follows:
Certification remains confusing. The Certification process, in an effort to encourage all forms of health IT, allows for both Modular and Complete EHR Certification. This is a good thing, acknowledging the reality that some providers – especially hospitals that are already invested in technology that won’t achieve all the Meaningful Use criteria as they are built – will need to mix-and-match a variety of tools in order to cover all the functions needed for access to HITECH incentive money. Some EHR vendors have Certified their whole suite of modules as a Complete EHR, but their deployment in the field may actually be uneven, and some customers may not have all the pieces that are part of the Complete EHR solution.
This issue is especially vexing for hospitals, where the “mix-and-match problem” is most frequent. For ambulatory practices, it is more likely that a single-source solution will be ideal. However, if a practice chooses to use a Complete EHR for almost everything, but uses some other external product for a specific Meaningful Use piece – e.g. a stand-alone e-prescriber – then that practice needs to make sure that all the parts are Certified as such.
Upgrading an EHR to a Certified version can be costly. For practices that have already invested in a locally-installed EHR, it is likely that this version is not the one that became Certified. Numerous enhancements and additional features needed to be built in order to meet Certification requirements. The Certified version of the product is not what is in the field, and an upgrade step needs to take place. This can be disruptive and costly. And the bigger the system – big installations at hospitals and large medical groups, for example – the more costly the upgrade will likely be. Further, the vendors of such EHRs may be quite strapped for manpower and resources, resulting in a real bottleneck for upgrade assistance.
Of course, this issue is not something that providers using a web-based EHR have to worry about. One of the beauties of web-based deployment is that the most-current version – the Certified one – is the one that everyone everywhere has. No upgrades are needed; they happen automatically.
Reporting Meaningful Use remains a problem. Identifying how one is doing with respect to Meaningful Use criteria, including which items may not be pertinent to one’s practice and how to report exclusion from that measure, is often not evident from the EHR being used. It may take some significant “digging around” in reports generated by the EHR in order to tally numerators and denominators for each of the measures.
In particular, the reporting of Clinical Quality Measures (one of the Meaningful Use criteria) can be daunting. Often (especially in hospital settings), this is done using tools that supplement the native EHR (and these CQM reporting tools need to be Certified as well). And – most importantly – if clinical performance is identified as being below-threshold, then changes in clinical behavior need to take place and re-measured in time for Attestation for EHR Incentive payments.
This is one place where a well-designed web-based EHR can shine. If at-a-glance reporting tools on some “Meaningful Use dashboard” can quickly and graphically show progress toward each Meaningful Use measure, then clinicians are dramatically helped by this. In particular, progress toward achievement of Clinical Quality Measure thresholds by built-in dashboards and reports, with identification of patients who need followup in order that the CQM item is achieved, will not only help Meaningful Use, but will also measurably improve clinical quality. This vision guides our product development efforts, as we create these elements over the next few months and deploy them in the web product (and therefore all users have access to them without needing any upgrades or supplements – for free).
Usability of EHRs is often poor. Poorly designed EHRs disrupt the workflow of an office. This can result in a significant drop in productivity (therefore, income stream) for a clinical practice – one anecdote reported at the Implementation Workgroup meeting described a drop in the pre-EHR daily visit volume from 35 per day down to 15 per day, rising only to 20 per day after 6 months, and eventually recovering to 30-32 visits per day. This is a common experience with many EHR users – the workflow disruptions and difficulty engaging with the computer interface slow one down.
As we have gone about designing our web-based EHR, usability (in addition to functionality) has been foremost. The result has been demonstrated in a recent large survey by Brown-Wilson’s Black Book Rankings of EHRs showing Practice Fusion as the top performer in customer satisfaction, overall performance, innovation, reliability, security, support and best-of-breed technology for primary care specialties. The experience of our users with respect to the impact on performance that adopting a web-based EHR has had is something we are also surveying.
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Numerous challenges stand before clinicians and hospitals in their adoption of EHR technology, and demonstration of Meaningful Use. This is particularly true for hospitals and large medical groups who have already invested in legacy technology that needs to be upgraded. The hope for the future, and a “best pathway” for ambulatory clinicians (especially small-sized and primary care practices) is through highly-usable web-based EHR tools such as the kind we are building and pioneering.
Robert Rowley, MD
Chief Medical Officer
Practice Fusion EMR
