EHR and EMR management – getting data and making sense of it all

April 27, 2015
by Lisa Chamoff, Contributing Reporter
The use of electronic health records has long been touted as a major way to improve patient care by preventing drug reactions and heading off costly diseases like diabetes and cancer. The reality has not been quite so positive, with the American Medical Association saying the expensive programs disrupt workflow, interfere with patient care, and impose an administrative burden.

Last year, the Centers for Medicare and Medicaid Services announced that 257,000 doctors, or about one third, had failed to achieve Meaningful Use of electronic health records, and would see Medicare payments cut by 1 percent in 2015. While CMS announced earlier this year that it intends to modify requirements for Meaningful Use in 2015, hospitals and physician practices are still being required to move down the path to recording and exchanging information in a meaningful way.

Health information technology companies are responding with new products that promise easier image sharing and workflows, time savings, and the holy grail of interoperability. Big health care networks and smaller physician practices are also getting some good results with technology that is helping to save them time and make the electronic records more useful.

The big picture
Storing and sharing images is a big part of interoperability and there are still challenges to overcome in image sharing between specialties. While there are many image sharing products on the market, Cleveland Clinic has been using Agfa HealthCare’s Enterprise Imaging solution in a years-long project to enable sharing of images among its many hospitals, emergency departments, and specialty centers.

Dr. Cheryl Petersilge, a clinical professor of Radiology at Cleveland Clinic, who also works in clinical informatics, has been working on the effort to add images from a wide range of departments, including radiology and cardiology, as well as ophthalmology, endoscopy, and dermatology, into a library that is integrated into the Epic Systems EMR.

Aside from radiology images, the focus is also on wound care photography, endoscopy and laparoscopy images, ultrasound for anesthesia, the emergency department, and women’s health. “There are just so many images,” Petersilge says. “We continue to actively enroll new service lines, but we’re just beginning to fully comprehend the full breadth of medical images that need to be archived.”

At the moment, there are no Meaningful Use requirements for viewing images in the electronic health record, but there are for sharing images electronically with the patient. “That’s not the main focus of our project,” Petersilge says. “We believe that having images incorporated into the electronic medical records should be considered a critical component of EMR evolution and should be recognized by some of the EMR certification and recognition of advanced deployment.”

There are images still stored on departmental systems, and if a physician needs access, he or she has to either go to the department to look at that system, or the information has to be printed out or stored on unencrypted portable media, which has security risks.

“We’re continuing to move toward that vision of your EHR as a single source of truth about the patient’s medical care,” Petersilge says. “We call it the comprehensive longitudinal medical records.” A critical part of this, Petersilge says, is that the system they have deployed offers a workflow engine that allows them to integrate the electronic storage of images into a variety of different workflows that are outside the traditional radiology workflows.

For example, a department that takes a photograph doesn’t necessarily place an order before they acquire the image, and would have to attach patient demographic information and the order description after the fact. “Every radiology PACS system was developed in a pre-EHR era,” says Charles Morris, Agfa’s director of enterprise imaging for North America. “Companies had to try to integrate them. It’s been a long road of trying to get those linkages.”

The fundamental problem is that imaging systems are typically purchased by the performing department and not the same team that sets up the health records system, Morris says. Radiography OEM Carestream Health is also getting into interoperability. At last year’s RSNA, Carestream launched its new Clinical Collaboration Platform, which provides physicians with a single view of patient records and information. It uses Carestream’s Vue Archive to archive and exchange clinical content in Digital Imaging and Communications in Medicine (DICOM) and non-DICOM formats. The release came before January, when CMS announced tentative interoperability standards for 2017.

Cristine Kao, marketing manager for Global Healthcare IT at Carestream, says this technology could be useful for oncology cases, with an integrated clinical team made up of oncologists, referring physicians and radiologists being able to share images in a collaborative way. “You have to have a way to be able to facilitate a diagnosis,” Kao says. “Access to clinical content is at the core of it.”

From PACS to HER
Radiologists are no strangers to software, and though practices have had to work around Meaningful Use requirements that may not always work for them — collecting patient demographic information and smoking status, for example — the radiology market is ahead of the rest of the market when it comes to electronic health records, says Steve Deaton, vice president of software for Viztek.

“All the articles saying EHRs are so horrible — that’s old news in the radiology world,” Deaton says. “That used to be RIS and PACS in the radiology world five years ago. The radiology market is ahead of the rest of the market.”

Radiologists do have a particular challenge when it comes to choosing an HER system with the best workflows. “A lot of people have been faced with the choice of getting an EHR and getting a RIS, and we can offer both,” Deaton says.

In December, Viztek received FDA approval to market its Exa EHR, which the company says enables a seamless exchange of information for radiologists and technologists, enhancing workflow with a user-friendly design and removing the need for doctors to log in to separate EHR and PACS systems.

This is Viztek’s first endeavor into non-radiology- exclusive EHR. Deaton says Exa could be a particularly good fit for multispecialty groups, such as an orthopedics practice opening its own MRI center. “The trend in the market is consolidating practices to compete with the hospitals,” Deaton says. “That’s where the compass needle’s pointing for most people now.”

Patients aren’t left out of the equation, and Deaton says Viztek worked to enhance Exa’s patient portal, with patient use being part of Meaningful Use requirements. Aside from being able to do simple things, like updating insurance information or paying bills, patients can use it to request a follow-up exam with their primary care doctor, or schedule a CT if a doctor prescribes one.

“The question was, how much can we drive exponential adoption of this product so now it’s a medical Google for yourself?” Deaton says. “We see there’s going to be a move to be patient-centered. It was a change for us because we’ve always looked straight to the doctor.”

Populating a patient’s medical record with a variety of information from insurance carriers and outside laboratories is also a big task. WESTMED Practice Partners, a multi-specialty group practice in Westchester County, N.Y., uses the Qvera Interface Engine to populate patient records. Merin Joseph, WESTMED Practice Partners’ executive vice president and chief information officer, says it provides a lot of time savings for doctors and helps to prevent ordering of unnecessary patient tests. The Qvera software accesses insurance claims databases for various carriers. If a doctor asks a patient if they’ve had an MRI and the patient doesn’t remember, the doctor can use Qvera to pull claims data for that patient. When laboratory reports come in from Quest Diagnostics, for example, the Qvera Interface Engine makes sure the information goes on the correct fields in the EMR.

“For medical practices, just having an EMR is not enough,” Joseph says. “There are easily 20 applications running besides the EMR. Our physicians are not going through those systems…From a physician’s standpoint, when they see a patient, they want all the information presented to them in the right format. The Interface Engine is bringing everything together into the EMR and the patient record.”

Speaking their language
Another way physicians are mitigating some of the productivity losses is through the use of clinical speech recognition software from companies such as Nuance. More than 500,000 clinicians and 10,000 health care organizations use Nuance solutions, like Dragon Medical, to support and expedite clinical workflows, says Jonathon Dreyer, Nuance’s director of cloud and mobile solutions. The software allows doctors to dictate patient notes into the system, while they’re with a patient or after they have seen them.

“As we’re looking at the general trends within practices and hospitals, we’re seeing a greater appetite for mobility,” Dreyer says. “Physicians want to be able to have instant and secure access, whether it’s on their smartphones or tablets, or at their office or workstations. This shift to a more virtualized environment opens up a lot of opportunities for new workflow configurations that can be tailored to meet the physicians’ specific needs.”

Nuance has partnered with EMR vendors, such as Cerner, Epic and eClinicalWorks, on dictation applications for iOS and Android platforms, and has also moved to further boost productivity with clinical language understanding, which parses the clinical documentation, whether it was dictated with speech recognition or taken via transcription, extracts the relevant information needed to meet Meaningful Use criteria, and populates it accordingly within the EHR.

“It takes a lot of the administrative burden off of physicians by allowing them to document their patient notes in free-form narrative, a format to which they are already accustomed, and lets them focus on their patients.” Dreyer says.

M*Modal provides similar speech recognition and transcription services, such as Fluency Direct, which integrates with the EHR. Dr. Juergen Fritsch, M*Modal’s chief scientist, says the company differs from Nuance in that it works within health care exclusively.

In the fourth quarter of last year, M*Modal released Fluency Direct with computer-assisted physician documentation. The service provides clinically-driven feedback to help with providing more detail that physicians can use for diagnoses and for reimbursement. Fritsch says the company is still fine-tuning it. “More and more health care providers and physicians benefit from this kind of feedback,” Fritsch says. “They have a strong incentive not just to be efficient, but also to create higher quality documentation.”

Quick turnaround
Health IT companies are also struggling to meet the federal government’s demands. Mark Segal, vice president of government and industry affairs for GE Healthcare, who also serves as the chair of the EHR Association, says companies have been struggling with creating products that are certified for Meaningful Use, but also meet customers’ needs.

“The process of standardizing things through Meaningful Use and certification can have that downside of changing the way people have been doing things in their practices,” Segal says. “We have to balance the regulatory requirements while being mindful within those constraints of the usability of our products.”

For example, GE is looking to streamline clinical visit summaries, which in some cases were not as usable as desired, or provided more information than the clinician or patient wanted included. Segal says the company is working on making the clinical visit summaries more usable; that is, briefer, and organized in a way that better meets physicians’ and patients’ needs.

CMS is expected to soon put out requirements for Stage 3 of Meaningful Use and Segal says EHR and other heath IT developers are looking to increase the time available to put out the best product. The general opinion in the industry is that companies should have 18 months from when the final regulations, as well as all associated guidance and certification test scripts, are out, to when the products need to be released. “In practice, it was much less than that for Stage 2,” Segal says.

That compressed timing, as well as extensive and prescriptive requirements, has an impact on usability, and what ends up getting prioritized by companies is what needs to be done to be certified for Meaningful Use, with less focus on what customers are asking for, including usability of the product. “Give customers time to really digest what has come out in Stages 1 and 2, and room for developers to focus on customer-prioritized functionality,” Segal says.