October 20, 2014

A Physician’s Perspectives on EHR, ICD-10 and Healthcare Reform

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When it comes to healthcare I wear many hats that have broadened my perspective on the transformation we are currently experiencing in this industry.  

On most days I lead a physician training software company, on others I care for patients as a physician, and in yet others I mentor about a hundred high school children each year who dream of becoming doctors one day. This past month I put on a hat I haven’t worn in some time, having accompanied two family members on two separate ER visits varying from a simple fracture to an unfortunate death.  I was impressed by the care delivered in these two very different ER settings and care scenarios.  I always try to reflect on my experiences across these varying roles, frequently centering myself on the perspective of a very important stakeholder in healthcare, physicians. 

 

From the electronic health record (EHR) to a radically changing healthcare system, physicians have too much on their plate, and in all scenarios are ultimately responsible for the outcomes of their patient. Medscape recently reported that 70 percent of the 18,575 physicians they surveyed said the EHR decreases their face-to-face time with patients. In social media this past week, a physician commented that we should blame the Texas Health Presbyterian Hospital Emergency Room Physician for not directly asking the patient about his travel history, instead of relying on the EHR which was flawed according to hospital representatives. 

Although ultimately it is our responsibility as physicians to catch every detail and of course talk to the patient, the fact is that in addition to less time with them, we have other challenges that can compromise our ability to adequately care for them.  I am a major supporter of the EHR, and easily mastered systems I have used in the past, including voice recognition.  However, I also recognize that I am not your typical physician, and the majority of physicians practicing today didn’t learn to program computers in elementary school.

Although tech savvy is a variable directly related to the adoption of an EHR, all physicians are very capable of learning to use these systems, if taught appropriately.  A study conducted by the Agency of Healthcare Research and Quality (AHRQ) in 2010 showed that on average, physicians underwent 23.9 hours of EHR training as part of the implementation process.  Of those 24 hours of training, I suspect five minutes was spent demonstrating the basic features of reviewing the travel history of the patient.  As is too often the case in medicine these days, our greatest challenge comes from the constant bombardment of too much information, not too little.

As a PhD researcher who spent approximately six years researching physician training methodologies and software (another hat I wore that I recently put on the shelf to focus on my fast growing business and growing family), I can tell you that most EHR training is flawed.  We can’t fully blame physicians for improperly using an EHR, when they were improperly trained to use that medical tool to begin with, and when we are pressuring them to care for more patients in less time. It just doesn’t add up, and we must keep this in mind when planning to implement new initiatives with great potential to further strain the interaction between physician and patient.

As the lead author of AHIMA’s physician ICD-10 training program (yet another hat), I have found that ICD-10 introduces a new opportunity for the healthcare system and possibly physicians, although for many it may not appear that way.  In fact, just this past month the Physician Foundation released their biennial report, which among many questions asked physicians how they felt ICD-10 would impact their practice.  Seventy five percent said it would unnecessarily complicate coding, 50 percent said it would create a severe administration problem, and 38 percent reported that it would expose physicians to liability and penalties. 

Being the educator that I am, I would also note that 81 percent of physicians said they were either overextended or at full capacity, compared to 75 percent in 2012.  For a significant portion of the almost 1 million physicians in the US, the added year we get to implement ICD-10 is indeed a blessing.  That said one key stakeholder we have yet to address, whose hat I have been fortunate to avoid this year, is the patient. 

According to a 2014, Commonwealth Fund report, US patients are on the receiving end of the worst healthcare system among 11 industrialized nations.  In my opinion, it is not physicians who are failing these patients, and not even the EHRs they are struggling to use, it is the faulty healthcare system.  Without a payment model shift to better align reimbursement with the quality of care delivered, as opposed to paying for the volume of care delivered, the healthcare system would have continued on a failing and unsustainably costly track.  However, this new system will indeed operate unfairly for physicians; if it does not include a way to appropriately risk adjust patients using a more detailed code set than what was released 34 years ago.  I’m not referring to the ICD-10 code for being struck by a turtle (W59.22XA), I’m talking about the 141 new pressure ulcer codes in ICD-10 that specify location in addition to depth/stage.  Or the expansion from a single non-coronary angioplasty ICD-9 procedure code to 854 in ICD-10 that account for the specific non-coronary vessel dilated, the approach and device used. 

Physicians won’t be expected to memorize all of these codes; they would only use a very small fraction, which can be more accurately assigned to a patient when documentation is complete.  However, if we don’t learn from our EHR failures after an average of 24 hours of training, and attempt once again to overwhelm physicians with too much generic training, then the industry will fail them just as much as it would fail the patients they are ultimately responsible for.

 

My role as a physician takes precedence to my role as software vendor, and ICD-10 training expert, yet they are all important to providing me with a unique perspective to the challenges faced by both physicians and patients. I believe that we must learn from our wins and loses with the EHR, and take into consideration the fears of physicians who are continuously asked to adapt, while assuming most of the risk in regards to patient care.  Training should not be considered an item on a checklist, but a transformation process that can mal-equip physicians if it is too long, too basic, or too general. This nation stands to benefit from the impending transformations in healthcare.  We can all support this if we remain open minded accounting for all the various hats we wear in our own lives, applying our varying insights to take into consideration the perspective of, and support both physicians and patients during this process.

 

Andres Jimenez, MD

Andres Jemenez, MD, is the founder & CEO of ImplementHIT, a physician and PhD Candidate in adult education, and his company's training software is used by hundreds of hospitals to train physicians on ICD-10 and their EHR.

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