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Community clinics are stuck in a painful wrestling match with electronic medical records

Community clinics are stuck in a painful wrestling match with electronic medical records

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Most doctors could write a dissertation on the shortcomings of electronic medical records.
Most doctors could write a dissertation on the shortcomings of electronic medical records.

In 2009 Congress passed a huge stimulus bill that included incentives for doctors and health systems to do away with paper charts and adopt electronic medical records.

Fast forward nine years and $40 billion in incentive payments, and what have we achieved? Physicians are spending two hours on electronic health records (EHR) for every hour of patient care — often taking work home. And lawsuits have targeted the vendors who make these computer systems, including Cerner and eClinicalWorks. Likewise, Allscripts faces a class-action lawsuit after a ransomware attack disrupted service for its 1,500 clients — providers who rely on the EHR system to care for patients.

This shouldn’t come as a surprise, according to Dr. Uli Chettipally, the chief technology officer for Kaiser Permanente’s CREST research network. In his view, most EHR systems were designed with neither patient care nor provider ease-of-use as the primary goal. They focused instead on what he calls the three Rs: reimbursement, regulations, and risk of malpractice. Health care organizations want to get paid, stay compliant, and avoid legal trouble.

By crossing their T’s and dotting their I’s, health care organizations can back up claims of medical necessity and boost revenues by entering codes for every billable service. As a result, EHR vendors developed systems geared toward documentation.

But more detailed medical records don’t necessarily translate into better clinical practice. Nor have they improved patient outcomes or reduced administrative costs. Instead, errors from copied-and-pasted data are common. We hear about allegations of improper “upcoding.” We hear complaints about eroding physician autonomy. Both patients and physicians see their relationship compromised.

“Looking at computer screens hinders us from building rapport with our patients,” said Dr. Bryan Choi, an internist at AltaMed, a nonprofit network of clinics serving low-income patients in Southern California. He believes that strong patient-doctor relationships lead to more effective care, an opinion long-supported by the literature.

“I try to do my computer work before or after the (patient) encounter,” Choi said. “However, there are tasks that require patient input.” His main complaint, echoing a sentiment shared by many physicians, is that EMR systems are inefficient: “It takes too many steps to do simple tasks, like refilling a medication or sending a referral.”

EHRs have come to embody what doctors hate about modern medicine. A growing body of literature links EHRs to physician burnout — a topic receiving lots of attention from health systems, government agencies, industry groups, and the media.

Community health centers like AltaMed have faced three challenges that have made the transition to electronic records even harder.

First, community clinics see higher patient volumes than private practices. They are required by law to accept all patients, regardless of ability to pay. In California, the expansion of Medicaid has led more people to seek care. As a result, physicians are already pressed for time — time increasingly spent documenting electronic health records.

Secondly, major EHRs were not designed for community health centers. Features such as sliding fee scales are absent from most record systems. When available, these features appear to have been afterthoughts.

Lastly, community health centers tend to have limited IT budgets. Upgrades are delayed. Customizations must wait. Clinics make do with what they have. Most do not have the capital to switch to new vendors. 

Sometimes necessity is the mother of invention.

“When they mentioned building our own EHR system, I was ready,” says Dr. Charles “Bart” Smoot, assistant medical director at Family Health Centers of San Diego, a community health center. Unlike most providers, the network of clinics developed its own EHR system, which the organization uses to run its 24 primary care clinics and a host of other services.

“Physicians want two things from EHRs,” said Smoot. “Save me time, and help me avoid mistakes.”

He has an advantage: Prior to medical school, Smoot was a software engineer. That dual-experience helped him develop a system that better meets the needs of the clinic and its doctors.

Whether bought or homegrown, EHRs are here to stay.

“I remember transitioning from paper records to EHR during residency, and it was a welcome change,” recalled AltaMed’s Choi.

Like most doctors, he cannot imagine going back to paper. But also like most doctors, he’s still waiting for better software than what’s available today.

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