BRADENTON -- At Blake Medical Center, the prognosis for pen and paper is poor: Doctors’ traditional tools for tracking cases and ordering medications and procedures are being phased out in favor of computers.
To Dr. Joe Pace, a cardiologist, it’s a tremendous boon.
“It works great for us,” he said. “One of our biggest problems is that in the cath lab, things happen rapidly. The computer ties it all together. Notes, dictation, orders -- it’s all right there.”
To Dr. Barbara Wagner, a family practice physician, that same computer is more of a bane.
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“It may be fine for a cardiologist, who does 20 procedures 90 percent of the time,” she said. “As an internist, I may be juggling 10 or 15 different medical problems, and I don’t have the leisure of cookbook medicine.”
The two doctors see the pros and cons of a trend sweeping though medicine. Electronic health records, known as EHR, are at the core of the health-care reform effort. Computerized records, supporters say, will mean fewer mistakes and less money wasted on duplicated tests.
Blake, which has been building its EHR system for years, launched a feature in April for doctors to enter their daily progress notes electronically. In June, it added a feature for ordering medications and procedures via computer. It’s part of a national push, called hCare, by Blake’s parent company HCA.
But many doctors were reluctant to give up their pens. More than 100 staff physicians signed a letter asking for the computerization project to be put on hold, saying the system is cumbersome and likely to induce errors.
The project’s supporters acknowledge doctors and nurses have made mistakes as they learn the system, though they are unaware of any resulting in harm to patients. But they contend that, in the long run, an electronic system will be safer than using paper records -- something critics grudgingly admit.
Still, even as a $27 billion federal program is encouraging hospitals and doctors to launch EHR systems, no regulatory agency tests or regulates them. So a crucial question remains unanswered: Does it truly improve care?
How it works
In a first-floor conference room, Blake staffers demonstrate the system, called Meditech from Massachusetts-based Medical Information Technology. Over the next 30 minutes, the walkthrough reveals both what pleases Pace and dismays Wagner.
The initial screen, the “physician desktop,” has a utilitarian, Windows 95 feel, with many clickable menus and boxes. But an experienced user can quickly call up patients’ vital signs or jump to menus for ordering procedures -- the integration Pace appreciates.
Some areas of the desktop are streamlined templates and seem inflexible. But users can call up areas to type unlimited notes, and Blake staff works with doctors to customize the interface for their preferences, said Andrea Smith, director of clinical applications.
The ability to see a patient’s long-term treatment and medication record can be helpful, Wagner concedes. But the system, she says, limits both her time with patients and what she can track.
“The more you can describe a condition, the better, but this is a check-box,” she said. “If you want to do more, you have to type it in. When we dictate, we can rattle off a note pretty quickly. So we’re not being as descriptive. We’re trying to make people fit into boxes.”
Wagner, who describes herself as a hunt-and-peck typist, says she is now spending time entering notes that she used to spend with patients. “If I spend three minutes on a chart instead of one minute, that’s two minutes less a patient gets, she said.
“I’m spending less time at bedside, and that’s not good.”
Dr. Robert Subbiondo, Blake’s chief of staff, says many doctors share Wagner’s concerns. In their letter, Blake physicians expressed concerns that the system would be slow, cumbersome and result in medical errors.
“They want to spend time with their patients. They feel like this is an intrusion,” Subbiondo said.
He advised doctors to essentially stay calm, test the system and report specific concerns in writing.
The physicians appear to be heeding his advice. About 70 percent of doctors are entering their progress notes directly into the system, he said. About 20 percent are using the computerized ordering system for medications and procedures, according to Smith, the clinical applications director.
The hospital is allowing doctors to use paper records during the transition. The system also allows doctors to dictate notes, then have a service type them into the computer.
To date, there have been “a couple of potential issues,” Subbiondo said, but no one has sent him documentation of any mistakes.
“I’m sure that mistakes happen,” he said, noting that they also happen in the system being replaced. “We all know the paper system of written records, the inability to interpret physicians’ handwriting and the errors that generates is not perfect.”
State records show regulators have investigated one complaint at Blake since the EHR expansion, and found problems with nurses documenting cases, but did not fault the computerized system.
Blake physicians’ experience has been typical, according to Dr. Ashish Jha, an internist and expert in quality and EHR systems at the Harvard School of Public Health.
“I understand where the physicians are coming from. Everyone is very resistant to change if they think it’s not going to help,” Jha said.
And at first, that’s how it seems. Doctors are 10 percent to 20 percent less efficient for the first six to 12 months after they switch to electronic records, Jha said.
That’s in part due to the many clunky EHR systems that desperately need improvement: “I was hoping that when Steve Jobs stepped down from Apple, he was going to head an EHR company,” he joked.
But Jha believes physicians nonetheless need to change.
“It’s an untenable position,” he said. “Paper is a lousy way to keep medical records. Paper records can hurt and kill people.”
Wins and losses
The question is, can electronic records do better?
The federal government certainly thinks so. The HITECH act, a health care reform measure folded into the economic stimulus package, has set aside $27 billion over 10 years as incentives to get doctors and hospitals to adopt EHR systems.
While the formula is complex, hospitals can receive a base payment of $2 million starting this year, adjusted by how many Medicare patients they handle and how it long it takes them to hit usage goals. Doctors can get as much as $44,000 a year through 2015 for using EHR in their practices. Doctors and hospitals that do not go electronic will see reductions in their Medicare payments in 2015.
But even as the technology rolls out in hospitals nationwide, several studies question its efficacy.
From 2008 to 2010, the federal Food and Drug Administration received 257 reports of health information technology errors via its voluntary reporting program. Most were related to radiology images, but 63 were listed as relating to “medical computers and software,” according to an internal memo. And unlike devices like pacemakers and hip implants, the agency does not evaluate or approve EHR systems.
Researchers’ work has started to find faults as well.
Most research focuses on computerized physician order entry systems, or CPOE. Many studies have found it reduces common medication errors -- for example, automatically flagging a medication order that has a harmful interaction with a drug the patient already takes.
But a widely cited 2005 study in the Journal of the American Medical Association found CPOE also introduces new types of errors.
Researchers from the University of Pennsylvania looked at a major hospital that had used CPOE for several years. They found it created 22 classes of errors, like the computer failing to automatically cancel a medication order if an associated surgery had been cancelled. “CPOE systems can facilitate error risks in addition to reducing them,” they wrote.
For example, Harvard’s Jha said, EHR systems’ click-boxes usually offer a default dosage for common medications, though doctors can change it manually.
“If that’s wrong on a paper record, you hurt one patient,” he said. “Set the default dose wrong for an electronic system and you hurt hundreds of patients.”
The flip side, Pace said, is that a default dose can eliminate a common error where a practitioner misses a decimal point in a medication dose, making it 10 times too strong -- a mistake known as “death by decimal.”
A more definitive assessment is expected soon, notes Jha, who served on the committee conducting a study by the Institute of Medicine. The institute’s report should be released by early 2012.
At Blake, hospital pharmacists are reviewing every medication order as the CPOE system rolls out, Subbiondo said. The medical staff sees the potential for EHR, but also is watching its limitations.
“A lot of what’s talked about with electronic records sounds great,” Subbiondo said. “Some of it’s not there yet. But in the long run, it’s going to be better for the patients.”