by Robert Fulton, California Health Report
September 11, 2013
When the South Central Family Health Center adopted electronic health records last year, physician David Noya was keenly aware of the need to not get too engrossed with note taking and maintain a connection with the patient sitting in front of him.
“I always keep myself in check personally when I'm with a patient,” said Noya, speaking by phone from the Los Angeles based federally qualified health center. “You want to be as efficient as possible, but you still want to have that patient contact, patient interaction.”
Under the standards and incentives of “meaningful use” established by the Centers for Medicare and Medicaid Services, electronic health records are expected to play a key role in bettering health care in the United States. The Affordable Care Act, or Obamacare, stresses the implementation of electronic health records to reduce costs and increase efficiency.
Many of the benefits of turning to electronic health records have become obvious, including better access to and sharing of information, but the challenges in using EHRs are also becoming clear. These include an initial decline in productivity, adapting to new technology, time-consuming data entry, hardware and software costs, digitizing paper charts, and maintaining a balance between focusing on a computer and a patient.
South Central Family Health Center started adopting EHRs in March 2012, rolling the system out in waves. The clinic used a $655,000 Health Resources and Services Administration grant to purchase its health record system, and $30,000 in grants from L.A. Care for hardware upgrades and consulting services.
According to Noya, productivity dropped from four to two patients an hour while the providers learned the new NextGen system. He added that the myriad options EHRs offer can lead to over documenting a patient's visit.
“Because there's so many different screens that you can go to, sometimes you can get caught up into that too,” Noya said. “You're over documenting, and that can sometimes slow you down.”
Dr. David Engel of Eisner Pediatric and Family Health Center possesses a degree in computer science and spearheaded that clinic's transition to electronic health records. Like South Central Family Health Center, Eisner implemented EHRs in steps starting in 2011. He explained that one of the challenges with EHR software – Eisner uses NextGen as well – is that it is not designed by clinicians but programmers. The free-flowing nature of a patient-clinician conversation doesn't always mesh well with clicking between pages to input information.
“The software desires to put a real hard structure on things which is very difficult for the clinician to do,” Engel said. “The work flow that it creates is much more structured and makes it more difficult for you to be able to do it in the course of a conversation with a patient.”
Engel added that inputting of some data such as labs has fallen on the provider and away from medical assistants. He said that the additional time spent is small, but adds up.
Dr. Yolanda Rebollo, a pediatrician at Eisner, said that her clinic's EHR software allows for more documentation, but “is quite labor intensive.”
“Many of our patients have multiple medical problems, so we have many diagnosis, so each one of those you have to go step by step,” Rebollo said.
Providers take different approaches to inputting information into EHR software. Some enter information during the consultation while others choose to finish back at their office after the exam, time and workload permitting.
The exam rooms at South Central Family Health Center are too small to include workstations, so providers bring in laptops to the exam, and outside the exam rooms are computer stations used by medical assistants. At Eisner, each of the exam rooms includes a computer with a monitor on a swing arm that extends out of from the wall, providing a comfortable triangulation between provider, patient and workstation.
Mary Franz is the executive director of HITEC-LA, a non-profit funded by federal grants through L.A Care that helps small private practices and federally qualified health centers adopt EHRs. HITEC-LA was one of the consultants on South Central Family Health Center’s implementation.
Franz said that any decline in productivity is expected when new technology is adopted. Productivity eventually returns and improves with the implementation of EHRs. She recommended that providers only digitize active patients, go back no more than two years, and avoid dated items like old labs. She added that impacting the patient-clinician relationship was a concern initially, but no longer.
“In the very beginning there was a concern that there would be less of a relationship because a doctor couldn't look at the patient,” Franz said. “Now what we're seeing is actually the patients like the fact that their doctors have their medical records online, and what we often see is that the doctor will turn the screen towards the patient and have them look right on the screen with them. Now they're using this tool to engage the patient directly, which patients are finding very positive. So we don't hear that much any more.”
Lourdes Romero, 31, has been coming to Eisner since January. She said through a translator that electronic records quickly provide more and accurate information.
Jonathan Carillo, 23, also a patient at Eisner, said he hadn't even noticed the computer in the exam room. The Paramount resident said that the print out received at the end of a visit helps explain what was discussed.
“Of course it helps out,” Carillo said. “Especially when you don't know what's going on too well in the room, all you have to do is look at your paper and there's instructions right here. I believe it definitely helps out.”
Eisner has added a computer station in each of its 76 exam rooms and dental chairs at its main location, and more at mobile and satellite locations. In addition to more computers, Eisner must pay a software licensing fee for each provider on staff.
And not all clinicians are computer literate. Noya spoke of an older provider who wasn't computer friendly and now has a scribe accompany him to visits, and Franz said that some older providers are more comfortable using a tablet or dictation software.
But despite the costs, shortcomings and challenges in navigating the world of electronic health records, Engel said that overall they're a plus.
“I think we do a better job with the electronic medical records,” Engel said. “I think that people, physicians and the other providers as a whole want to do a good job, and the electronic health record kind of requests of you to do a better job.”
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