Charting the course
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Physicians discuss adjusting to EHR when the choice isn’t theirs

Even among physicians with their own private offices and the ability to choose from a multitude of products, adapting to electronic health records (EHR) can be a painful process. So what happens to dermatologists in academics and larger group practices, whose record-keeping decisions are made by someone else? According to those who have experienced it, the process is very different, but equally fraught. Yet even dermatologists who ultimately need to adapt to an institutionally mandated EHR system can smooth out many difficulties for themselves through research, training, and clear communication with leadership and colleagues.

Adapting to processes

St. Louis University dermatologist Dee Anna Glaser, MD, likened the adoption of her academic center’s EHR system to a sudden and unexpected delivery. The big difference between buying an EHR for one’s practice and learning of a decision to adopt a new system, she said, is the lack of lead time for the kind of research most dermatologists do as a matter of course when selecting an EHR.

“A lot of times, in an academic situation, it can feel as though the decision happens quickly, and unlike a private practice doctor, you don’t have the time and luxury to go to the Academy meeting and talk to the different vendors and look at and choose from different options,” Dr. Glaser said. “There’s the worry that you’ll just get something on your doorstep without the exact training or tools you need to make it work. You need to find out all you can about the system and how you can make it work for your department.” [pagebreak]

According to Dr. Glaser, the experience of one’s academic or large group practice adopting EHR, even a widely used EHR, can vary greatly, depending on leadership’s ultimate decisions on features.

“It was interesting to hear one of our physicians talk about how different our system was than one she’d used before at a different university. It was because of the differing set of features they had purchased,” Dr. Glaser said. “We called several dermatologists in different academic centers that we knew were using the same system, but our experiences were so different because of the options we were using that it was hard to get any constructive feedback.”

Southern Illinois University dermatologist and former Academy president Stephen Stone, MD, saw his academic practice adopt in late 2011, and he said his department has faced many issues in adapting to the new system. Unlike Dr. Glaser however, he had time to use the software and receive training months before adoption. [pagebreak]

“We had the opportunity to use it for a little bit before the mandatory transition. We were able to use the system on a trial basis, both during our patient hours and in the off hours, before we all moved to mandatory EHR.” Dr. Stone said. “Starting with a new EHR system can reduce productivity, but at least the time we had with the system was helpful in the transition.”

In Dr. Glaser’s case, the department of dermatology greatly reduced the number of patients for its physicians just prior to launch, ramping up to full capacity only after months of both training and patient visits.

“We had several months where they were giving us different tasks to complete as part of the training. We worked with two vendor team leaders to produce templates and order sets that would work,” Dr. Glaser said. “We worked in the cosmetic division for a couple of months figuring out how to get photographs in there that we can document on. The system couldn’t always do what we wanted, so we had to come up with workarounds for some things.”

While advantageous to the speed of adoption, Dr. Glaser said that the amount of change needed to adapt to the EHR was ultimately difficult for physicians and staff. Preparing for this possibility, she said, is an often-overlooked aspect of changing the working processes of so many employees. [pagebreak]

“One thing that we were able to do was cut our patient load way down as the conversion process started. We tried to gradually increase the numbers over the ensuing three months, but it was still a big hit in the volume of patients,” she said. “It was detrimental to the morale of staff and physicians, and took a toll on the department. The staff didn’t get as much of an input as they do in a private practice. Afterwards, however, the staff had some very good ideas for some changes to help us function better.”

Both Dr. Stone and Dr. Glaser, while admitting to frustration with the transition, spoke of eventual benefits to having made the EHR transition, highlighting the importance of finding positive developments along the way.

“We created our own quick text, where you hit a couple of letters and it writes out the entire sentence. That was very helpful in saving time. Templates are also particularly helpful, because they remind us to ask the questions we need to be asking,” Dr. Stone said. “We have a template for isotretinoin return visits, and for methotrexate return visits, to guide us through the questions that we should be asking each time. The use of templates is helpful as a checklist. I fly an airplane, and even with years and years of piloting, you want to make sure you go through the pre-flight checklist every time. Patients on complex medications benefit from the checklist, and when you document that you’ve done everything on the checklist, you’re also sure you have adequate documentation.” [pagebreak]

Working with vendors

As Dr. Glaser delved more deeply into the EHR adoption process, she said that she was able to eventually approach the vendor for fairly significant changes to the system function. Her only regret, she said, was not having done so sooner.

“My advice to somebody would be to know that you can make changes. In academics, I think we get too used to being told we can’t do things, but these systems can be somewhat customized for your needs,” Dr. Glaser said. “Just put the time up front to make that happen to the greatest extent possible. Make templates that are going to be workable for you. Keep in touch with the IT team that’s implementing this. Make them come back and create adjustments to optimize the experience for you.”

Creating shortcuts and customizations, Dr. Stone said, should be done with the intent of greater effiiciency, but physicians should keep in mind the need to create a detailed, meaningful note that is clearly unique to the visit it documents. [pagebreak]

“When dermatologists think of customizing EHR, we think of the templates and quick text options, but that also raises the question of whether the referring physician actually did everything recorded on the template or used a standard visit template,” he said.

Dr. Glaser agreed, saying that notes generated with too many auto-complete options can make discerning relevant information more difficult.

“The notes are a little less detailed, even though they generate more words than a traditional record. That’s more palpable in an academic center where so many people are interacting with a given patient,” she said. “You read what a resident wrote, and it’s just difficult to tell it from those of the other patients that were documented. It hasn’t been quite as individualized and specific. I’m making sure my notes actually say what happened, which is what I’ve been focusing on with the residents. I’m starting to make some forward progress.” [pagebreak]

Pushing back

While it’s never optimal to have to raise issues with leadership decisions, Dr. Glaser said that for many smaller departments and specialties like dermatology, it’s vital to push back a bit and make oneself heard when processes are in the works that might negatively impact one’s ability to function efficiently.

“The transfer to EHR is so large that one particular department or practice type might not get as much time as it needs to form a cohesive workflow. When you’re talking surgeons, oncologists, pediatricians down the hall and you’re the small department, it’s very possible to get overlooked. You need persistence to make them help you and realize that your practice is unique,” Dr. Glaser said. “It took us a lot of effort to get our implementation team to understand dermatology. It was a few months of some uncomfortable discussions to make them work with us and help us. The vendor teams seem to think sometimes that dermatology is like any other practice.”

One area that saw a communication breakdown, she said, was in dermatology’s need to have heavy visual elements incorporated and the vendor’s apparent incomprehension of the importance of photo comparison and anatomic drawing. [pagebreak]

“Of all the issues we had to have addressed, the big one was having a method of being able to draw in the system, map lesions, insert photographs, and stuff like that. Initially, there was a lot of resistance, because the vendor hadn’t come across anything like that so far,” Dr. Glaser said. “It really took a lot of time with our EHR team and the university medical group to make them understand the importance of those features to us.”

The importance of advocating for one’s specialty during the selection process, according to Dr. Stone, cannot be overstated. The final product, he said, usually bears the imprint of those with the most influence in the decision.

“To benefit most from computerization, the system should be designed for dermatologists. It would seem to me that dermatology-focused systems would have features that aren’t important to most multispecialty groups,” Dr. Stone said. “I felt my training was adequate to use the system, but also adequate to demonstrate that it didn’t have all the features that I would want as a dermatologist. Because we’re part of a multispecialty faculty practice group, we didn’t get the degree of input that I think dermatology should have. I would love to have an EHR where it’s easier to upload photographs and document lesions without having to paint a verbal picture.” [pagebreak]

Adding on

In addition to making changes within the EHR system itself, dermatologists using systems they didn’t choose can consider add-ons from outside vendors to help manage their photos or integrate a photo database more effectively with an EHR. Such applications can prove invaluable to dermatologists for comparing pre- and post-operative images of a patient taken with the practice’s digital camera. These diagnostic tools also allow for encryption technology that meets HIPAA requirements.

  • FotoFinder Handyscope is an iPhone-exclusive piece of software that pairs with a special camera that slides on to the iPhone case. The app includes photo transfer and storage utilities, and works with a Web-based storage system hosted on the company’s servers.
  • tkDerm is an iPhone app that allows a physician to capture photographs and associate patient metadata with images, then send the images to a desktop computer for backup. The PC version is open source and free to download.
  • Mirror PhotoFile, from Canfield Scientific, offers comparative image viewing and unlimited user-defined data fields.
  • Profect Medical publishes two digital imaging software suites for organization and analysis of patient images.
  • DICOM-izer allows dermatologists to associate metadata with an image, then converts the image into a DICOM (Digital Imagine and Communications in Medicine, a security standard for medical images often used by specialists for X-rays and MRI images) compatible file. The images can then be retrieved on any DICOM-compatible server.

Fukuroi, Japan, dermatologist and professor Manabu Inuzuka, MD, developed tkDerm, which he said offers a three-pronged image database system, with a PC (or Mac/Linux) version integrating with an iPhone or iPad tablet and a software suite for one’s server. The add-on approach, Dr. Inuzuka, said, offers a few distinct advantages especially for dermatologists who find themselves with an orphaned system after a vendor goes under.

“The software can support multiple users and multiple devices due to its client-server architecture. In addition, you can add a PC or Mac as another client,” he said, adding that the server software is written in an open-source data format that helps to future-proof it. “Data format as well as the way photos are stored are open to everyone,” Dr. Inuzuka said, arguing that data portability is of critical importance. “Even if the software is not supported by a vendor in the future, porting data to new database software is relatively easy provided that the data format is kept open.”

(To see a demonstration of how tkDerm works, read the online-only sidebar about it.)

Rollin Read, who works as the director of surgical imaging for Canfield Scientific, said that for dermatologists and plastic surgeons, additional imaging software used in conjunction with one’s EHR can realize significant time savings over most built-in EHR photo management systems.

“In our experience, what visual specialties want from their software is the ability to import multiple images into a patient chart with one click and assign procedure and diagnostic information en masse,” Read said. “If I take 30 pictures of one patient, I could import those all simultaneously and assign data to them and have them stored in a specific patient record or a patient chart and be able to recall that that information based on any number of recorded criteria. Something that would typically take a considerable amount of time is broken down to a minute or two.”

For more discussion of add-on photo storage software and available options, read Dermatology World’s October 2012 Technically Speaking column.

 

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Adding on