PracticalDermatology

Before presenting a talk in Chicago at the recent AAD summer meeting, I was struck by an email I received regarding a recent AAD video roundtable (Dermatology World, June 18, 2014), in which a panel of dermatologists considered the question, “What is the one thing you wish your Electronic Medical Record could do for you?” At the end of that portion of the discussion, Dr. Brent Moody summed up many dermatologists' feelings about EHRs, saying: “I would love for the medical record of the future to be the medical record of the past, and by that I mean: solely to help me take care of patients.” He further stated, and I will paraphrase, that he did not want it to be a billing document, not a legal document, and not something you have to worry about whether you checked enough boxes because you are going to be audited. I whole-heartedly agreed and have felt that way ever since the government began promoting EHR through its Medicare payment provisions and Meaningful Use criteria. There are definite positives and there are definite negatives, as were discussed at this roundtable.

Over the last several years, many physicians have bemoaned the unneeded hassles associated with implementing and using EHRs. However, one thing is certain: EHRs are here to stay, and we must face this and adapt if the quality of medical care is to be maintained and constantly improved. Struggles vary depending on the physician's comfort with technology, but even the most adept users have growing pains. The reality is that a series of small delays in workflow ultimately results in a loss of efficiency, which impacts the quality and quantity of care provided by physicians. For instance, if using an EHR adds an extra two minutes per patient (just for data input), that's an extra 40 minutes for every 20 patients you see. Therefore, no matter what system you select and use in your practice, preparation and teamwork are arguably the most crucial aspects of efficiently and effectively operating an EHR.

EHRs IN THE DERMATOLOGY SPACE

A recent Medscape survey indicated that despite increased levels of comfort with EHRs (81 percent of respondents report being more comfortable with their EHR “over time”), just as significantly, fewer than half of physicians surveyed reported that their EHR allowed them to more effectively manage staff. These numbers point to a gap between how physicians use EHRs in the examination room and the overall utility of EHRs in a medical practice. Indeed, while physicians seem to be learning the grammar of EHRs, they have not been able to fully integrate EHRs into the practice of medicine/dermatology to achieve its promises without an incredible burden of time and energy that weighs clinical practices down.

Preparation. When establishing an EHR system, preparation is worth its weight in gold. To optimize the system, it is important to perform workflow analysis in order to better understand how, exactly, the system would affect all areas of practice—not just patient examinations and e-prescribing. Training is another essential component to implementing an EHR, particularly by the Information Systems Personnel/Vendor. You should have an initial training upon installation and hands-on guidance with implementation. Moreover, frequent return trips over a two- to fourmonth stretch would further support a better chance for success. These training visits should require significant time durations, so that physicians and staff can learn defaults, macros, dot phrases, smart phrases, prescription preferences, smart sets, and any other means to save time yet add important data. It is critical to emphasize to the EHR vendor that you and your staff require significant help in order to maximize the potential of the system.

It is one thing to have classroom-type instruction, where you “follow the bouncing ball,” so to speak, as the instructor quickly moves from click to click through the process (constructing your initial intake, recording the history and physical exam, and finishing with diagnoses for the visit), marks that you have reviewed everything, and finally enters correct charges with procedures and modifiers. It is quite another to make your way through these steps on your own. There are simply too many steps that are not intuitive, and if you do not know where to click, you will be stuck forever. As Yogi Berra once said, “If you don't know where you are going, you could end up some place else.” Aside from adding time to completing the documentation, this sense of being lost can be a very frustrating feeling and paralyzing to the flow of the entire practice.

Teamwork. As important as preparation is, there is no question that teamwork will be the grease that keeps the well-oiled machine working. This affects the patient from every aspect of care. The team must work together from the phone call, arrival at the front desk, the initial intake process, the visit by the physician/provider, to final instructions. Even after all that is accomplished, there must be “true interactive” teamwork in handling phone calls and lab work (ordered as well as when results are received). We must not let things “get lost” in this wonderful huge databank. As mentioned above, training is extremely important at all levels of patient care but we must spend just as much time and effort in the implementation strategy for total cooperative interaction. This is not only important in how the office flows but to insure patient safety.

We may have to make some changes in the culture of medicine that Dr. Peter Pronovost discusses in his book Safe Patients, Smart Hospitals. We depend on our office staff to point out anything that does not seem right on the record just as importantly as reminding us if something is missing in the record. This becomes of paramount importance because there is a growing consensus that survival with EHRs is increasingly dependent on using scribes so that we can efficiently see what would approach a reasonable number of patients in each clinic session. Even with smart sets, macros, dot-phrases, and all other kinds of defaults, I feel it is imperative to have a well-trained team to help one manage the Electronic Medical Record.

ADAPTING FOR THE FUTURE

As physicians, our many years of training are meant to prepare us to care for patients, not to be the recorder of data. It is important to have a thorough record to document who, what, where, when, etc. for our use as, well as others' use. But we are also responsible for the flow of operations in the practice, which means we must invest ourselves into various other aspects related to practice management, particularly EHRs. However, just like any other aspect of practice, the best investment a physician can make toward implementation of an EHR is spending the appropriate time and money to allow the execution of the system to run smoothly and allow everyone from the most junior staff member to the physician to do their jobs efficiently.

Along the same line, physicians must invest in the appropriate assistance, both from the EHR vendor and from staff within the practice to help ensure smooth transition and peak workflow. This is all part of a larger preparation effort that's required of all phases of practice. EHRs require a great deal of work, but with the appropriate preparation, teamwork, and finally a willingness to learn and adapt, physicians can optimize their use in practice and thereby hopefully improve the experience for staff and patients, as well.

Stephen E. Helms, MD, is a Professor of Dermatology at the University of Mississippi Medical Center in Jackson, Mississippi. He uses the EPIC system.

This article is based on Dr. Helms's presentation at the 2014 Summer Meeting of the American Academy of Dermatology.