State Gets Mixed Reviews on Electronic Health Record Use

December 12, 2013

Khine Khine Win, a Kaiser Permanente doctor of internal medicine, reviews a patient's electronic health record. Photo: Chris Richard

Khine Khine Win, a Kaiser Permanente doctor of internal medicine, reviews a patient’s electronic health record. Photo: Chris Richard

By Chris Richard

To make the Affordable Care Act work, one tool is critical: the electronic health record.

These digital forms, known in the medical community as EHRs, can help doctors identify and offer preventive treatment to illness-prone patients, instead of waiting for a crisis and hospitalization.

And EHRs are crucial to such Affordable Care Act goals as treating Medicare patients with closely integrated medical teams and curbing hospital readmissions.

“We often describe the EHR system as the road upon which new care delivery systems, better care, can be provided,” said Kimberly Lynch, director of the federal government’s Regional Extension Center program, which assists providers in getting EHR systems established.

But according to a recent report, that road still has some potholes in California.

The California Healthcare Foundation study ranks the state among the weakest in the nation in providers’ use of electronic prescriptions. Only Alaska and the District of Columbia did worse.

The other shortcoming concerns California doctors’ response to the federal “Meaningful Use” program, financial incentives to help qualified Medicare and Medicaid providers make the transition to electronic records systems. The program sets such requirements as an ability to take clinical notes, generate a list of the patient’s allergies and send and receive digital information from other doctors who are also treating the person.

More than half of doctors in the state said they wanted “Meaningful Use” financial aid. But when the Healthcare Foundation surveyed physicians who actually had EHR systems, only 30 percent complied with all 12 federal requirements that the Foundation checked.

Lynch noted that the push on incentives is still underway, and Medi-Cal providers aren’t due to start declaring their EHR commitments until 2014. That could make it appear that caregivers are adopting the digital tools more slowly than they are, she said.

Doug Hillblom, a board member and former president of the California Pharmacists’ Assn., attributed part of the state’s low ranking on e-prescribing to California’s size and its wide variety of providers. A smaller state might have a more homogeneous record-keeping system, he said.

California has a number of large health networks that developed their own computerized systems for internal records and communications. As those systems seek to adapt to the need for out-of-network communications, they’re running into compatibility problems, Hillblom said. He likened the confusion to the difficulties in making Eastern and Western railroads conform to a uniform gauge necessary to the establishment of a transcontinental rail network.

“To top it off, now we have many practitioners who are independent, and they are now trying to get onto that railroad track also. Some of them don’t know what the gauge is. They don’t know what type of railroad car they use. They don’t know where that switch is to get onto the right track,” Hillblom said.

Finally, the financial aid extended to doctors for help setting up digital communication hasn’t been offered to pharmacies, he said. That means the pharmacies have to try to process the varying EHR forms out of their own pockets, and it’s expensive, Hillblom said.

Lynch said communication problems between different software systems are starting to resolve themselves.
“We have a market-based economy, and I think that’s what you’re seeing,” she said.

“We have faith in the market, and we have faith that by partnering with the providers directly and helping them get enabled on the system, that they can help the market leap forward.”

In describing where that leap might take the medical community, experts often refer to Kaiser Permanente.
Kaiser made the transition to an entirely digital system beginning in 2004. The Oakland-based nonprofit has the world’s largest nongovernmental database of medical records, used for everything from scheduling appointments to ordering prescriptions.

“Because of this amazing connectivity, we’re all sharing the same information,” said Kaiser family physician Joel Hyatt, assistant regional director for quality in Southern California.

“If, as a diabetic, I’m overdue for a blood sugar test or a lipid test, everybody knows that, even the pharmacy, and we’re in a position, no matter where you are in the organization, to advise the patient, ‘You’re overdue for your blood sugar test. Go to the laboratory. Right now.’ And that lab test is already there. It’s ordered. So, we leverage everybody to deliver chronic care.”

Last year, a Kaiser research team published findings that after doctors switched from paper to digital records, diabetic patients made 5.5 percent fewer trips to the emergency room and were hospitalized 5.3 percent less frequently.

Kaiser allows patients virtually unfettered access to their own health records, Hyatt said. A survey published in March by the management consulting firm Accenture found eight out of 10 U.S. doctors want patients to be able to contribute to their records. But only a third of those surveyed want completely open access.

Kaveh Safavi, managing director of Accenture’s North America health business, called the hesitancy part of a cultural shift. The Open Notes Project, an experiment in completely open health-care sponsored by the Robert Wood Johnson Foundation, found that some doctors hesitated to grant access because they feared patients would get enough information to make to make them waste time on irrelevancies.

“What they found out was, it wasn’t like that at all. The reality was, it wasn’t a burden, and in fact it was a benefit.,” Safavi said. “So my view is, there’s an experience thing that has to happen here.”

Susan Hogeland, executive vice president of the California Academy of Family Physicians, said such digital synergy is much harder to achieve for medical groups of less than 50 doctors, to say nothing of sole practitioners.

“A lot of it is, they don’t have the time to do it,” she said. “The incentives were great, and we’re delighted that they were offered, but a lot of it comes down to the pressure of keeping the wheels spinning in the office and not have a financial disaster on their hands while they adopt EHRs.”

Overall, the Healthcare Foundation report shows a mixed picture.

In addition to the state’s lackluster performance in some areas, study author Jodi Simon also pointed to signs of progress. In 2007, just 13 percent of the state’s hospitals used EHRs. Last year, half did. In 2005, a scant 3 percent of community clinics used the computerized forms. The most recent records available in that category, for 2011, show that 65 percent of the centers now use them.

“There’s been progress,” said Jodi Simon, author of the Healthcare Foundation report. “You kind of balance the fact that community clinics’ growth has been through the roof, versus the fact that e-prescribing has been abysmal. And the other sectors have made steady but not striking progress.”

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