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Curbside Consult with Dr. Jayne 2/27/12

February 27, 2012 Dr. Jayne 2 Comments

Over the past several years (and especially with Meaningful Use) there has been a fairly significant shift in the attitudes of ambulatory physicians who are making the leap to electronic health records. The hospital-based physicians (and ambulatory physicians who see patients in the hospital) are a different story. They’re a captive audience who has always been subject to hospital control and who has a long-standing history of adapting to things imposed by various Big Brother entities: the Joint Commission, the hospital’s formulary team, insurance and hospital case managers, etc.

Those physicians have done pretty well adapting to electronic documentation, computerized order entry, and the like while in the hospital. Hospitals have also tended to phase their implementations over the scope of years – deploying in a modular fashion with lab, nursing documentation, CPOE, and provider documentation all done as separate initiatives. Ambulatory docs who dislike the hospital’s conversion have been able to escape back to the relative safety of private practice and cling to their paper charts.

As ambulatory physicians transition to EHR, though, they tend to deploy more rapidly – wanting to get rid of all the paper immediately, but also with a strong drive to keep the revenue stream steady. When I started deploying EHRs some time ago, we worked with early adopters who believed in the promise of electronic recordkeeping and were more willing to staff up, reduce patient load, or work longer hours to realize their goals. These physicians are now mature users who are leveraging their EHRs to achieve advanced Patient Centered Medical Home designations, increase fee schedules through demonstrable quality, and improve patient satisfaction.

On the other hand, there are now thousands of physicians who previously found the idea of the EHR distasteful and feel forced to make the transition. Whether by peer pressure, payer requirements, or the threat of government-related penalties, they’re now implementing and with a significantly different strategy than may be prudent.

More often, I hear of physicians that want to implement a system fast, cheap, and easy. The rest of us who have done this for a while know that it’s very difficult (if not impossible) to do all three. Often these late adopters refuse to follow vendor advice, consultant advice, or frankly anyone’s advice. Convincing them to cut schedules or hire staff is a challenge. Ultimately, it’s the patients who suffer.

As the healthcare market consolidates, hospitals and health systems are looking to “align” (one of my least-favorite buzzwords) with community physicians to ensure profitable referral, ancillary, surgical, and inpatient revenue streams. Many are offering subsidies and other incentives to bring these providers onto EHR systems.

Often these practices don’t actually want to align, but are feeling cornered and desperate. Some have previously turned down acquisition offers from the same hospital and see taking a subsidized EHR as a way to be somewhat protected from burdensome federal requirements while maintaining at least some degree of autonomy. Others simply can’t afford an EHR without the subsidy. A last group is providers who’d like to be acquired but for various reasons aren’t suitable candidates, but hope that alignment (and sending a steady volume of referrals which of course cannot be spoken about) will result in being ultimately asked to the dance.

These physicians often deploy on an existing system-wide EHR. Since they’re late to the game, though, they haven’t been stakeholders in any of the decision-making that’s already occurred and often have less buy-in to the idea of group goals than those users who are actually part of the group.

Another angle is that even though subsidized, these physicians are paying customers with different expectations than employed physicians and different ideas about governance. Of course, this would have been true even if these subsidized physicians were early adopters, but the differences are magnified by them being late in the EHR game and feeling pressured to demonstrate Meaningful Use as quickly as possible.

I still go out on implementations and perform physician training on a regular basis. Until recently, most of the physicians I have worked with have treated me as a respected colleague who could assist them through the difficult transition. Some have even looked at me as some kind of EHR shaman, able to smooth their journey to the other side with mystical wisdom. Of course, there have always been a few docs who were borderline (or overtly) hostile, but they were few and far between and usually we could leverage their partners or peers to moderate their behaviors.

Lately I’ve run into more and more angry physicians who are completely resistant to the idea of the EHR transition even though they’ve agreed to go paperless. Some are passive-aggressive, but others are openly abusive. This manifests in a variety of ways – disruptive behavior, inappropriate comments during training (think middle school students with a substitute teacher), or refusing to be trained at all. I find the latter group the most frustrating because then they can’t figure out why the system is so hard to use and scream the loudest about lack of support.

Looking at the data on how many physicians are actually using EHRs in practice (let alone being robust users) we’re just approaching the midpoint. If what I’m seeing in the field is any indication, it’s only going to get tougher as the last-ditch adopters come through with increasingly unrealistic expectations and correspondingly difficult implementations.

I feel bad for the vendors and for the teams who have to support these folks (mine included.) I feel bad for the physicians who don’t want to transition to EHR and the staff members that have to work with them every day. But most of all, I feel bad for the patients who entrust them with their care. Regardless of what they think about the EHR, the IT team, or the government, I hope the angry docs remember that after all, it IS all about the patient.

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Currently there are "2 comments" on this Article:

  1. What about all the practices where they are adopting an EMR, kIcking and screaming, and they no longer document their own charts because of their resistance to the system. So their staff, including non clinical office staff, do their chart documentation for them. All I hear is ‘the docs aren’t going to do that, so they do it for them’ including documenting for MU. How is that good for the patient?

  2. >>> Looking at the data on how many physicians are actually using EHRs in practice (let alone being robust users) we’re just approaching the midpoint.

    According to the most recent CDC study, the total use of EMR has increased to 57%, but the proportion of those using EMRs that would qualify as “EHRs” decreased 4 points to 23%. Do the math- it’s quite simple. Subtract the total EMR/EHR number of 57% by the total “Basic EMR/EHR System” and you arrive at what would amount to the MU-ready EHRs. So it’s 57-34= 23% of users have a MU-ready EHR, DOWN from their previous report which was 26%. The use of a “fully functional system” which in 2010 was 10.1% probably dropped too, to closer to 9%.

    Read more: http://www.cdc.gov/nchs/data/databriefs/db79.pdf

    Another set of facts that show that physicians are NOT coming on-board with MU (I know, those pesky facts) is that although the figure now stands at 115,000 registered “meaningful use providers”, only 10,155 (9%) are successfully attesting to date, which is pitifully low. These “providers” include:

    •Doctor of medicine or osteopathy
    •Doctor of podiatry
    •”Other”

    The percent of actual physicians and podiatrists in clinical practice are approximately 600000. Again, if you do the math, 10155/600000, then the portion of physicians and podiatrists actually successfully MU attesting then can be calculated to stand at about 1.5%. This is a really, really, really bad thing and is why the CMS folks have had to push the “meaningful use” schedule back a year recently. If President Obama starts to implement the penalties for nonparticipation on over 98% of physician/podiatry providers, I see a riot brewing.

    Read more: https://www.cms.gov/EHRIncentivePrograms/Downloads/Monthly_Payment_Registration_Report_Sep.pdf

    I don’t see physicians “leaping” to EHRs at all- what I do see are physicians closing their practices and either joining large groups or becoming hospitalists or leaving the practice of medicine altogether. In the building where I practice medicine, next to one of the largest hospitals in Northern Virginia, according to a meeting 4 days ago, the hospital now owns 43% of practices that once were independent and thriving. There are 4 more practices for sale which will increase the hospital share to over 60% by summer. Once they reach 80% of ownership they can close my office and all remaining private practices down for good.

    This is why physicians are angry. Your characterization of those physicians who refuse to follow the HIT mantra/religion as somehow lame and bad is misguided. Show me good, prospective, balanced, 2 arm studies that MU/EHR run by nonbiased individuals and all of us luddites too may come on-board. On the other hand, I can show you studies that have shown the opposite- that the EHR will increase the cost of healthcare, increase errors, and decrease quality.

    Read my recent grand rounds presentation:: http://www.box.com/s/urr0eux55neet8bmgsgr







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