Where EHRs Fall Short

When electronic health records (EHRs) were first introduced, they were touted as being the answer to managing all patient data. An easy way to keep all medical data in one central location, accessible by all medical providers, and beneficial to patient care overall.

That was the initial intent, said Rena Zimmerman, MD, a radiation oncologist at Olympic Medical Center in Sequim, WA.

“Electronic health records should be intuitive to use, improve efficiency, reduce administrative responsibilities, not interfere with patient relationships, and be interoperable,” Zimmerman said. “They must be fully supported by your IT department, be completely secure, and improve patient outcomes and the health of the nation.”

But, that’s not what’s happened, she said at this year’s RSNA. Instead, EHRs are rife with challenges that make full, effective implementation difficult.

Medication Reconciliation: Under Meaningful Use guidelines, you’re required to review medication lists with 50% of your patients, including all prescription medications, herbal supplements, and over-the-counter medicines. Based on existing data, though, more than 60% of medical records contain errors of omission, addition, or both, even though providers have had several years to figure out how to manage medication records correctly.

“At this point, the learning curve isn’t the problem,” she said. “Most physicians feel the system is so cumbersome that they’ve sort of given up. There’s a belief that they don’t believe the medication record anyway, so they just put something, knowing that it’s probably not right.”

Medication Errors: Simply not knowing which medications a patient is taking isn’t the only problem that arises from mistakes in the record. Not only is a medical error nearly impossible to completely erase from an EHR, an incorrect medication listed or an inaccurate diagnosis recorded can affect whether a patient receives the safest care, she said. It can also impact what type of insurance coverage a patient might be able to secure.[[{"type":"media","view_mode":"media_crop","fid":"44507","attributes":{"alt":"Rena Zimmerman, MD","class":"media-image media-image-right","id":"media_crop_8706422039739","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4987","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 270px; width: 180px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Rena Zimmerman, MD","typeof":"foaf:Image"}}]]

Patient Access: Meaningful Use guidelines also mandate that you give 50% of your patient’s access to at least some of their medical records within four days’ time. The difficulty arises, Zimmerman said, because there’s no guidance about how much and what information to make available. In addition, most EHRs have a default setting that automatically sends patients records after you indicate you’ve reviewed them, opening up the possibility that patients receive information they don’t understand without anyone to help them interpret the findings.

Knowing Patients: Although EHRs are intended to keep track of extensive amounts of patient information, using them has actually impaired physicians’ abilities to get to know and remember their patients, she said. Existing research revealed that college students who take hand-written notes retain information far better than those who take notes on a computer.

Through a personal experiment where she took hand-written notes on a patient, Zimmerman said she remembered far more about her patients than when she typed directly into the EHR.

Usability: EHRs were intended to make physician’s lives easier, but they lack some fundamental functionality, she said. Currently, physicians can’t edit orders or receive questions about appropriateness from referring physicians.

Additionally, there’s very little standardization in how physicians enter orders in an EHR, and there’s currently no way to search for open orders or to check order status, she said. Adding that capability would make it easier for you and your referring physicians to make a phone call to change an incorrect order or to submit additional requests.

Improving EHR Use: There are ways for you to improve how you use EHRs now, however. One tactic, Zimmerman said, is called LEVEL: let patients look over your shoulder, eye contact with patients, value the computer as a tool, explain what you’re doing, log off and say you did.

When you use your EHR, place the computer between you and the patient, creating a triangle shape. That way, she said, you can still look at the patient while inputting information or discussing a diagnosis.

If you can, Zimmerman added, consider discussing serious diagnoses in a less clinical environment. For example, to make patients more comfortable and provide more privacy, she brings them into her office that’s decorated in therapeutic colors and indirect lighting with aroma therapy.

Ultimately, she said, EHRs have provided a broader, more accessible vault of patient information than the previous paper-based system. But, there’s still extensive room for improvement.

“Nearly all physicians believe in the promise of electronic health records, but you can’t buy and install a promise to help deliver better patient care,” Zimmerman said.