Taking the Pulse of EHRs

Medicine—particularly cardiology—has always been an early adopter. Even the mere mention of innovation seems to get a physician's heart beating faster, flush with the promise of new and better. And more often than not, new equals better for many patients; think stents, stem cells and statins, for example. Can the same be said for electronic health records (EHRs)?

While many cardiologists are just beginning a relationship with EHRs, for some, the bloom of excitement over EHRs has faded, the relationship rocky if not in a rut. Why? EHRs actually have been around for decades, lighting the lights of the national stage at least 15 years ago. As technology keeps advancing, will EHRs capture that old magic?

Good question. Many physicians look past the smoke and mirrors and see a valuable tool, but currently most consider EHRs "a necessary evil," said Cathleen Biga, RN, MSN, CEO of Cardiovascular Management, a cardiology physician practice management company. "There are massive benefits to EHRs and I think once most physicians are through that transition they can't figure out how they ever worked without it, but getting there is difficult for many."

According to data from a 2011 study that excluded radiologists, pathologist and anesthesiologists, the National Center for Health Statistics estimates that about 55 percent of physicians have adopted some sort of EHR system and they tend to fall into one of three groups.

"There are the 20 percent early adopters who love it and wish they had done it years ago, 20 percent of adopters who think it is an intrusion and added work, and the 60 percent in the middle work with it but wish it was faster and better," said Marc E. Shelton, MD, who has been using EHRs for more than 10 years as president of Prairie Cardiovascular, Springfield, Illinois.

Dr. Shelton is not alone in using EHRs: data from the ACC Cardiovascular Practice Census indicate that ~65 percent of respondents were participating in the 2012 Centers for Medicare & Medicaid Services EHR Incentive Program. This rapid acceleration of EHR adoption reflects the fact that cardiology frequently treks to the frontier of medical technology.

But more work remains. CardioSource WorldNews spoke to several experts in the areas of health informatics and EHRs to discuss where things stand now with EHRs, and where they are headed in the future.

Carrots and Sticks

When it comes to health care news, publications treat EHRs like A-list celebrities stirring up engagement rumors. One big reason why: The 2009 American Recovery and Reinvestment Act (ARRA) bolstered the economy to the tune of $787 billion. A portion of this act was directed at the health care industry, activating a series of reimbursement options to encourage physicians and hospitals to adopt EHRs in the hope that the systems would reduce medical errors, improve health care outcomes, and ensure quality, ultimately decreasing health care costs.

Without going into too many details—and there are a lot of details—ARRA made more than $17 billion available to those who adopted EHRs within prespecified timeframes, reimbursing hospitals up to $11 million and private practitioners up to $44,000 once they could prove that they were using these systems in a meaningful way.

"The American Recovery and Reinvestment Act moved us from the concept of EHRs as containers of information that can be presented to the clinician to ones that manage that information as data and can manipulate and analyze that data while care is being provided," said James E. Tcheng, MD, professor of medicine in the division of cardiology at Duke University School of Medicine in Durham, North Carolina, and chair of the ACC's Informatics Committee, who has been using one type of EHR or another for about 30 years.

Those practices that establish phase 1 of the meaningful use criteria, including electronic data exchange and reporting of clinical quality measures, would be eligible to receive financial incentives for patient claims to Medicare and Medicaid. This phase of the reimbursement could be called the "carrot." By 2015, these financial incentives will disappear, to be replaced by the "stick:" those physicians and hospitals not using products that meet meaningful use criteria will be penalized on their Medicare and Medicaid claims.

However, this incentives/penalty program may not be going exactly according to plan. Some note that a better carrot would have been getting the $44,000 first to implement EHRs, because fronting "costs and then meeting relatively difficult meaningful use requirements is not easy," said Ms. Biga.

For some, $44,000 simply isn’t a juicy enough carrot to alter performance. "We got about a 2 percent increase in Medicare money if we changed and to a small practice that may not be worth it," noted David C. May, MD, PhD, of the Texas-based Cardiovascular Specialists and chair-elect of the ACC's Board of Governors.

But instead of penalties, Dr. Tcheng believes that many cardiology practices are driven to adopt EHR systems because it is the right thing to do.

The Good, the Bad, the Ugly—and the Expensive

While the promise of efficiency and efficacy accompany EHRs, everyone acknowledges there exist many pain points when incorporating EHR systems due to certain realities of the process. Adopting a system is quite different for a large hospital system with more manpower, resources, and money than it might be for a small cardiology practice.

Getting an EHR system going means purchasing, installing, and (over time) updating software systems; storing data on servers; training staff; and, possibly, incurring an initial loss of productivity. For a two-person cardiology group, noted Dr. Shelton, that may cost $250,000 and "it is likely that you don’t have that type of buffer in your operations budget."

That's why many smaller practices are reaching out to hospital organizations that they are affiliated with to find out about opportunities available for private practices to leverage the EHR system of large health care organizations. "It isn't just a financial consideration, it is the burden of all the work that has to be done in order for an EHR system to become operational," Dr. Tcheng said.

Ultimately, though, the positives usually far outweigh the negatives. The first thing any cardiologist will notice: the promise of a paperless office and the advantages associated with instant data access. The inches-thick medical record of a patient with a chronic condition such as HF reduces down to electronic information that can be indexed and accessed instantaneously.

Cardiologists can also pull up images, access patients' full medication lists, and write prescriptions electronically.

"If a patient comes in on six or seven medications and says, 'Doc, I need all of them renewed,' in the old days I would sit there with a prescription pad and write each one out and tear it off and give it to the patient, spending 2 to 4 minutes total," Dr. Tcheng said. "Now, I can make three clicks, have them all renewed and on their way to the pharmacy."

Improvements in safety are also a big plus for EHR systems. Many modern systems have pop-ups that prompt physicians to ask questions or follow up with patients based on possible safety concerns, for instance, an MI patient whose ejection fraction shrank after the infarct who received an implantable cardioverter-defibrillator (ICD). If the EF is below 35 at an exam, "the computer will pop up and ask me if I have addressed the issue of the automatic ICD in this patient," Dr. Shelton explained.

Medication recalls are also easier to address with an EHR system. "With the analog system it was difficult to get to patients who were on any given medication," said Michael J. Mirro, MD, a cardiologist with Parkview Physicians Group in Fort Wayne, Indiana, and a member of the ACC's Informatics Committee. "With a virtually stored system you can sit electronically and do a search and find every patient on that drug within minutes."

Ideally, experts hope, EHR systems will one day take all of the current advantages they provide a step further, by interfacing with other treating physicians, such as endocrinologists and oncologists; allowing patients access to and management of their records; being interoperational with local hospital systems; facilitating automated data reporting to clinical registries; and more.

Improving the Q in QOL

"When you first adopt a solution, it slows everything down, but ultimately the gains are better with regard to improvement in quality of care," said Dr. Mirro, who equated not having an EHR to a bank that doesn't have a website and does not offer debit cards. In other words, an archaic institution doomed to go out of business.

Modern-day EHR systems that are capable of data mining allow physicians to take the pulse of their practice to measure quality among patients. Dr. May and Dr. Shelton both regularly get reports measuring quality, whether it is from their home-grown EHR systems or through participation in an external registry that mines data from an EHR system like the NCDR® PINNACLE Registry®.

"Using reports from PINNACLE each quarter, I can compare my performance individually and my global practice performance against national recommendations and other PINNACLE participants," Dr. May said. "We go over it page by page to make sure that we are hitting our quality targets."

Recent studies sought to quantify the effect of EHR on quality measures in health care, and so far, the results look good.

A study published in October in the Journal of General Internal Medicine indicated that four of nine quality measures used in the study were improved in physicians who had adopted EHRs, including glycated hemoglobin testing in diabetes and screening in breast cancer, chlamydia, and colorectal cancer.

Earlier in the month Kaiser Permanente published the results of a study in Annals of Internal Medicine that showed that use of EHRs improved drug-treatment intensification, monitoring, and risk-factor control among patients with diabetes.

Pretty soon patients may not even need doctors anymore, right? Well, not quite. Dr. May hesitated to say that the positive results out of Kaiser Permanente were a result of the EHRs as much as the health care system that uses them. Similarly, Dr. Shelton compared it to determining if it is gasoline that makes a car go or the engine. In reality, he said, it is both.

A Love Triangle

While physicians continue to revel in their relationships with EHRs for all the advantages discussed, it can come at a price for the person who is at the heart of a clinician’s raison d’être, the patient. Like many areas of medicine where technology is making inroads, the switch to EHR and computer stations in patient exam rooms means a loss of a certain level of patient-physician interaction.

Some systems require a lot of data entry at the point of care by physicians, said Dr. Mirro, and the result could be the computer screen gets more face-time with the doctor than does the patient.

What makes the matter worse is that EHRs are very demanding partners, echoed Dr. Tcheng, who noted that doctors have to pay close attention to using the system correctly. "There is a real need to improve user interfaces between the physicians and the computer system so that less effort can be spent on figuring out what the computer wants and more effort can be spent on caring for the patient."

How do patients look at this third wheel in the exam room? Feelings seem mixed. Anecdotally, the physicians interviewed said that some patients dislike the systems because they feel that the physician pays less attention to them during the visit. In contrast though, some patients appreciate EHRs because they feel that the physician has all of their information at hand and, therefore, has all of the information that they need to address their specific health needs. 

Get on the Bus, Gus

Although experts bemoan this loss of the human "touch" as a negative of adopting EHRs, they by no means think that it is going to stand in the way of the onward progression of EHR use and adoption.

What advice do they give to the cardiologists out there who are currently faced with this decision? According to Ms. Biga, physicians need to choose a system that will work well for them and their patients. Many have templates embedded specifically for cardiologists that provide metrics "important to workflow," she noted.

Additionally, she recommended spending a significant portion of your decision-making time assessing your practice, fellow practitioners, and patients. Be realistic about what type of technical support you have, she said, and be wary of systems that require constant updates. "I always encourage physicians to do a site visit with another practice. Look at their medical record and walk through their patient process."

Another key piece of advice: have an internal champion of the process as well as a thorough, strategic implementation plan. Resources on CardioSource (www.cardiosource.org/healthit) may help cardiologists struggling with the details and decisions inherent in adopting an EHR system.

All of the experts who spoke with CardioSource WorldNnews acknowledged that the transition is difficult, costly, time consuming, and disruptive, but they all also said that it is inevitable.

"It makes no sense to maintain a paper record," said Dr. May. "As a country, as a health care system, we should have integrated successful sharing of information where a patient's information is widely useable by all providers and the patient, because that is what makes the most sense medically, as a business model, as a research model, and as a patient care model. I think we will get there, but it is going to take some time."—by Leah Lawrence 


  1. Changing CV Practice Landscape. Findings from ACC Cardiovascular Practice Census. September 2012. Provided by the American College of Cardiology.
  2. Jamoom E, Beatty P, Bercovitz A, et al. NCHS Data Brief No. 98, July 2012. http://www.cdc.gov/nchs/data/databriefs/db98.htm. Accessed October 21, 2012.
  3. Kern LM, et al. J Gen Intern Med. 2012;doi:10.1007/s11606-012-2237-8.
  4. Reed M, et al. Ann Intern Med. 2012;157:482-9.

Note: The ACC's Cardiovascular Summit in January will feature in-depth discussions on many of the topics addressed in this article. Learn more and register at www.cardiosource.org/cvsummit .


Keywords: Medical Errors, Chlamydia, Stem Cells, Medicaid, Software, Breast Neoplasms, Health Care Costs, Medical Records, Stents, Glycated Hemoglobin A, Electronic Health Records, Data Mining, American Recovery and Reinvestment Act, Colorectal Neoplasms, Medicare, Diabetes Mellitus

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