Electronic Medical Records: Promises, Pitfalls, and Pearls for Pain Physicians
Among physicians today, few topics are as controversial as electronic medical records (EMRs). The opportunity to improve medical care through digital records is almost universally recognized, but the reality often falls short of the potential. In all facets of life, advances in technology have made the way we communicate, access information, and consume entertainment more convenient and efficient. The current state of the EMR, however, stands in stark contrast, presenting the pain physician with many potential hazards.
The medical record is the cornerstone for providing care to patients. As scientists, we use the data from prior documents to formulate a hypothesis and subsequent results to guide our treatments. For decades, fax was king for sharing this information among a patient’s many treating physicians, at the cost of immense manpower and resources. Much as the Internet supplanted the Yellow Pages, GPS the atlas, and translator apps the pocket dictionary, the EMR promised to replace an antiquated analog system with lightning-fast access to a complete summary of a patient’s health. Most important, the EMR was touted as a way to provide better care: Barriers between silos of care would fall, duplication of expensive testing and interventions would be avoided, and physicians could leverage the power of patient data to become better doctors.1
Since the turn of the century, physicians have swiftly heeded the call to modernize. In 2001, only 18% of physicians used an EMR; by 2013, that number ballooned to 75%.2 This rapid implementation was largely driven by financial incentives from the federal government as part of the Meaningful Use program, a component of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009; by 2014, three-quarters of eligible providers and 90% of hospitals had received funds as part of the program.1
So what has been the effect of bringing the EMR into the clinic? A recent Medical Economics survey found that more than two-thirds of physicians were dissatisfied with their EMR’s functionality, and, more troubling, nearly half said that patient care was worse since implementation.3 These findings have been echoed by countless studies associating EMRs with physician burnout, early retirement, and, ironically, poorer care.4 Having already invested vast amounts of time and money into their systems, many physicians now find themselves married to a toxic EMR and unable to file for divorce.
Luckily, the news isn’t all doom and gloom. Strategies exist for the busy pain specialist to harness an EMR to improve practice workflow, patient outcomes, and physician satisfaction. No single approach can overcome the significant challenges EMRs present, but enterprising doctors can reap a multitude of benefits by incorporating some novel approaches, already in use by others, into their own practices (Figure 1).
Some of the most poorly used resources already at the physician’s disposal are the training and information technology support included with many EMR systems. Much like medical education involves continuous learning, ongoing training with your EMR can reap the rewards of increased efficiency and overall improved physician satisfaction.5
Another highly touted approach is the designation of a “Physician Champion,” a tech-savvy colleague who can act as liaison between physicians and the EMR vendor to communicate evolving needs and problems, customize templates to the practice, and ultimately improve the interactions between a practice and its EMR.6
From travel to shopping, modern consumers are adept at turning to technology to organize their lives, so why not let them do the same when it comes to your practice? Using online scheduling, electronic intake forms, and digital refill requests frees up staff and resources that can be better used elsewhere. In addition, these tools have been shown to increase patient satisfaction with physicians.7
Because the EMR can be accessed at multiple locations by different staff members at the same time, an opportunity exists to maximize team members and streamline an office visit, freeing the pain physician’s time for only those tasks that require their expertise.
One option that has paralleled the adoption of EMRs is the use of medical scribes. Scribes are currently present in almost 20% of practices that use an EMR, and their numbers are expected to increase as more practices adopt the technology.8 While there are concerns that scribes could negatively affect a practice’s bottom line, a study of scribes in a cardiology clinic reported a 59% increase in patients seen per hour and a 57% increase in work relative value units per hour. This resulted in improved physician productivity and practice revenue that offset additional costs to employ scribes.9 Importantly, doctors reported improvements in physician-patient interaction and increased work satisfaction.
In between appointments, patients can take an active role in their care by using smartphone applications that track their health. More than 125 million people in the United States own smartphones, and their ubiquity allows for the use of apps such as Manage My Pain and My Pain Diary to record diary entries between office visits and allow pain specialists and their staff to send them tailored messages.10
Patient portals, included in many modern EMRs, offer another medium for physicians to interact securely with their patients. As payment models transition from fee-for-service, requiring an inoffice visit for reimbursement, to value-based payments that pay for the entire episode of care, communicating nonurgent issues with patients through a patient portal offers a more convenient venue for both the patient and physician.
Physicians report spending several additional hours each day documenting in their EMR, long after the last patient has left the office.11 One solution is to incorporate documentation into the patient visit. A recent article in the Journal of General Internal Medicine recommends physicians and patients navigate the chart jointly during the appointment.12 The benefits are suggested to be threefold: Patients can offer corrections and updates to their information, they feel more engaged in their care, and the bulk of documentation is completed once the doctor leaves the examination room.
1. HealthIT.gov. A robust health data infrastructure. Available at: https://www. healthit.gov/newsroom/robust-health-data-infrastructure. Accessed October 12, 2016.
2. Hsiao C-J, Hing E. Use and characteristics of electronic health record systems among office-based physician practices: United States, 2001-2012. NCHS Data Brief. 2012;(111):1–8.
3. Verdon DR. Medical economics EHR survey probes physician angst about adoption, use of technology [slideshow]. Medical Economics. Available at: http:// medicaleconomics.modernmedicine.com/medical-economics/content/tags/ ehr/slideshow-medical-economics-ehr-survey-probes-physician-angst-abo. Accessed October 16, 2016.
4. Friedberg MW, Chen PG, Van Busum KR, et al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Santa Monica, California: RAND Corporation; 2013. Available at: http://www.rand.org/pubs/research_reports/RR439.html. Accessed December 8, 2016.
5. Jalota L, Aryal MR, Mahmood M, Wasser T, Donato A. Interventions to increase physician efficiency and comfort with an electronic health record system. Methods Inf Med. 2015;54(1):103–109.
6. Luchetski JE. Physician Champion Role in an Electronic Health Record Implementation, a Case History. Fort Worth, TX: University of North Texas Science Center; 2010. Available at: http://digitalcommons.hsc.unt.edu/cgi/ viewcontent.cgi?article=1093&context=theses. Accessed December 8, 2016.
7. Kruse CS, Argueta DA, Lopez L, Nair A. Patient and provider attitudes toward the use of patient portals for the management of chronic disease: a systematic review. J Med Int Res. 2015;17(2):e40.
8. Gellert GA, Ramirez R, Webster SL. The rise of the medical scribe industry: implications for the advancement of electronic health records. JAMA. 2015;313(13):1315–1316.
9. Bank AJ, Gage RM. Annual impact of scribes on physician productivity and revenue in a cardiology clinic. ClinicoEcon Outcomes Res. 2015;7:489–495.
10. Mehta N, Inturrisi CE, Horn SD, Witkin LR. Using chronic pain outcomes data to improve outcomes. Anesthesiol Clin. 2016;34:392–408.
11. Kuhn T, Basch P, Barr M, et al. Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2015;162(4):301–303.
12. Schiff GD, Zucker L. Medical scribes: salvation for primary care or workaround for poor EMR usability? J Gen Intern Med. 2016;31(9):979–981.
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