By Jan Bowers, contributing writer, December 01, 2011
While one of the primary purposes of an electronic health record system (EHR) may be to streamline a physician’s recordkeeping and billing procedures, it also has other far-reaching implications, including an impact on patient care. Technology has paved the way for new built-in, customizable features like drug interaction alerts that can help avert serious events, and electronic exchange of notes and lab results between dermatologists and other physicians that can help ensure vital information is communicated quickly and accurately.
However, as with any new technology, grappling with a new system may also take a toll on physicians’ attention to patients during visits and on their ability to see patients in a timely fashion. Being aware and proactive about patients’ needs in EHR transition will serve dermatologists well.
Customized advisories and patient safety
“In our system, one of the key features in terms of improved patient care is the Best Practice Advisory (BPA),” said Julie Lin, MD, assistant professor of medicine in the division of dermatology at the University of Vermont. A dermatologist with a special interest in biomedical informatics, Dr. Lin helped to organize her university hospital’s transition from a paper system to an EHR two years ago. “Physicians in each specialty can build these [BPAs] into the system in a way that’s specific to their needs,” she said.
“For example, we give a lot of biologics for psoriasis, and the recommendation is that patients on biologics get a PPD test for tuberculosis once a year. You can set it up so that any time a physician or other provider orders a biologic, if the patient hasn’t had a PPD test within the past year, a flag will pop up to warn you. In addition, an order set will be called up so you can just order the test with one click. You can do the same thing for a patient on isotretinoin that’s due for a pregnancy test. We’re trying to automate more processes like that.”
BPAs can be designed to reach all providers in the health system or just those within a specialty, Dr. Lin explained. “You have to use BPAs judiciously because otherwise you get alert fatigue,’” she said. “If too many alerts and pop-ups appear, people want to ignore them. So we try to keep it at the level of the specialty; within our group of seven dermatologists, decisions about what prompts a BPA are made by consensus.”[pagebreak]
Other features commonly available on EHR systems that dermatologists cite as advantageous in improving patient safety and quality care are patient allergy alerts and drug interaction alerts, e-prescribing, and having a single electronic record available to all physicians across a health system that can’t be lost or misfiled.
“Aside from providing a legible, organized record for the physician, the EHR helps us coordinate care across our system, where most of our patients see their primary care doctor and other specialists,” said Matthew Evans, MD, chair of dermatology at Dreyer Medical Clinic in west suburban Chicago. “The patient has one chart that all physicians share, with the exception of psychiatric information, which is open to psychiatrists only because of privacy concerns. So we can all easily see diagnoses, medications, allergies, and when patients had their last physicals and immunizations.”
Clinical decision support and order sets
EHRs include a variety of tools that help the dermatologist reach a diagnosis or take the next steps following a diagnosis. However, not all systems offer the same range of features. EHR systems developed for dermatologists and targeted to solo practitioners or independent groups are the most likely to contain a wealth of built-in templates and decision trees specific to dermatology. Philip Mills, MD, who has a private practice in Blue Ridge, Ga., recently implemented a dermatology-specific system he saw demonstrated at the American Academy of Dermatology’s 2011 Annual Meeting. “I tried this product and thought, this is the future,” he remarked. “When a patient comes in with a particular lesion I don’t see often and I’m doing a biopsy, I’ll look at the differential diagnosis and may see something I hadn’t thought of. With almost every biopsy, I’ll put down my diagnosis but I’ll also choose from among the differentials that I think are reasonable for the dermatopathologist to consider.”
The system includes clinical decision trees for more than 850 dermatologic conditions. For any given condition, it provides a list of morphologies, treatment options, surgical procedures, cosmetic procedures, and diagnostic testing where appropriate. Peter Lio, MD, assistant professor of clinical dermatology and pediatrics at Northwestern University Feinberg School of Medicine, and an advisor to and investor in Modernizing Medicine, said he uses that system’s tablet interface and rarely needs to type anything during a patient visit. “If you have an acne patient, you touch acne’ and it prompts you for the questions you should ask,” he said. “Then it shows you a picture of the body and you can just touch where the acne lesions are. You can choose from among treatment plans, touch a button, and it e-prescribes for you and prints out information for the patient right away.”
Physicians using a system not already customized for dermatology can usually create their own templates if they have the need and the time to do so. “You have to physically make the templates yourself,” said Dr. Lin. “We have a lot of patient instructions for common diseases and a lot of common order sets. The system is only as good as what you build into it,” she said.[pagebreak]
Enhancing patient communication
In addition to streamlining the exchange of information between dermatologists and other physicians, pharmacies, and labs, EHRs can facilitate communication to patients in ways that enhance their care. “Our patients can access certain lab tests and results and contact their physician directly through a secure Internet portal,” said Dr. Lin regarding the systems at University of Vermont. “Anytime you get a blood test, you can view the results on your smartphone, iPad, or laptop, usually within 48 hours. You can also update your contact and insurance information. The patient portal helps us make sure that when we have a patient scheduled for Mohs surgery, for example, we get the necessary information about blood thinners, pacemakers, and whether they’ve had previous problems with anesthesia or surgery. If patients have activated access to their electronic record, you can simply route the electronic survey and it will go directly into the chart.”
Information provided to the patient through the EHR system during and after the visit can help ensure the patient understands the diagnosis, what tests and medications have been ordered, proper care of a biopsy site, and other pertinent instructions. The after-visit summary can be printed or accessed by patients electronically, but a printout can be helpful, “especially when the patient is going to see another provider outside this health system; the paper record shows what transpired,” said Dr. Lin.[pagebreak]
Some dermatologists who have made the transition to an EHR warn that there may be some repercussions that affect the doctor-patient relationship. Sasha Kramer, MD, an Olympia, Wash. dermatologist in private practice, said the time required to implement a new EHR system severely restricted her ability to see patients. “In an area that’s already experiencing a shortage of dermatologists and long wait times, this just exacerbated that problem,” she said. In addition, many dermatologists reported that use of an EHR system during the patient visit may be a distraction, particularly when the physician is learning a new system. “It definitely takes some attention away from the patient, and that’s a balance you have to learn entering information and paying attention to the patient at the same time,” said Dr. Kramer. “I have to remind my office staff that we may be frustrated with the new system, but we don’t want to convey that to the patient; they don’t want to hear about it.”
Longtime EHR users have suggested that one solution to this situation may involve implementing and optimizing EHR in a time-sensitive manner that involves as little disruption to daily operations as possible (see additional information in “Lessons learned”).
Given careful consideration and time, changing EHR systems can actually improve patient care. “With my old system, I was spending so much time looking at the computer, and I hated that because I wanted to look at the patient,” said Dr. Mills. “Patients and their care are key; I like patients. Now I can walk into the room, glance at the computer screen so quickly the patient isn’t aware of it, sit down with them and hear their complaints without feeling like I’m rushed. I can see 40 patients a day comfortably, as opposed to 32 with the old system.”
EHR emerging as powerful research tool
As data on dermatologic conditions and treatments are collected, analyzed, and published, EHRs have the added potential to improve the care of patients within a single health care system or nationwide. For example, Julie Lin, MD, assistant professor of medicine in the division of dermatology at the University of Vermont said physicians could use the EHR system to track outcomes for cutaneous lupus as measured by the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI). “That outcome measure becomes part of the EHR in the form of a flowsheet, which is essentially a chart that looks like a simplified Excel spreadsheet,” she said. “Each time the CLASI is measured, it is a column of a table, and disease activity can be tracked over time, graphed, and exported for statistical analysis.” Dr. Lin added that the University of Vermont has the capability to recruit patients for clinical studies by sending an invitation to participate directly to eligible patients through the patient portal in the EHR.
The EHR of the Department of Veterans Affairs (VA) health care system, used in 150 medical centers and more than 1,000 outpatient clinics, has become a powerful tool for research and quality assessment. “The VA, in many ways, pioneered EHR. It’s been in place at my medical center for more than 10 years,” said Martin A. Weinstock, MD, PhD, chief of dermatology at Providence VA Medical Center and professor of dermatology and epidemiology at Warren Alpert Medical School of Brown University. Using data from the electronic records of six VA centers, Dr. Weinstock’s team published several studies involving the use of topical tretinoin for chemoprevention. “We had informed consent from the study participants to access their prescription records; we didn’t have to depend on their recall of what medicines they’d received,” said Dr. Weinstock. “We found that those veterans who were on angiotensin-converting enzyme inhibitors had a 40 percent lower risk of getting another basal cell or squamous cell carcinoma. We also looked at statins, non-steroidal anti-inflammatory medications, and prednisone. You can do all kinds of research using an EHR — but the system has to be set up in a way that allows researchers to gather the data.”