cians recognize many EHRs aren’t well-designed and need to be redesigned for maximum efficiency. It’s to vendors’ advan- tage to make EHRs user friendly,” he said. The AMA-sponsored study suggests better EHR usability should be an industry-wide priority and a precondition for EHR certification. A big part of the problem with EHRs, Dr. Fleeger says, is lack of workflow standardization. “I compare it to the auto industry 100 years ago. Every au- tomobile was different. Now, each car has the same basic fea- tures that allow everyone to feel comfortable driving it. It took 100 years for that to happen, but the EHR industry doesn’t have that kind of time,” Dr. Fleeger said. He calls on the federal Office of the National Coordinator for Health Information Technology (ONC) to create workflow and usability standards for EHR vendors as a requirement for certification.
“I think we will get more standardization as the EHR indus-
try matures. I hope that will make it easier for physicians to document and to glean important clinical information from EHRs,” he said.
Migrating patient records from one EHR product to another
isn’t easy either, according to physicians. To help remedy the problem, Dr. Williams would like to see the industry establish data portability standards that make it simple for all physi- cians to move patient records from one EHR system to another, regardless of vendor. “If a vendor goes out of business or a physician decides to use a different company, it should be easy for physicians to take their electronic records with them,” he said. To foster improved usability and remote accessibility, Dr.
Williams says the government should require a third-party en- tity to certify that EHRs meet certain minimum standards. “These are practical solutions. Right now, physicians must
navigate a maze of pitfalls and constantly changing criteria,” Dr. Williams said.
TMA submitted an 11-page comment letter to ONC on its
proposed EHR technology standards and certification rules in May 2012. In the letter, signed by Joseph Schneider, MD, chair of the TMA ad hoc HIT committee, TMA cited an example of the hefty expenses one Texas physician faced when forced to transition to another EHR system. An EHR vendor discontin- ued a product the physician had purchased nine months earlier. “The new product that the vendor recommended cost twice as much as the product initially purchased. Because of the price difference, the physician shopped around and decided to switch to another company. The cost for the physician to migrate only nine months of patient data was $12, 000,” Dr. Schneider wrote. To solve the problem and reduce the price associated with transferring data, TMA recommended the Centers for Medi- care & Medicaid Services (CMS) and ONC require vendors to tag key data elements that would typically be moved in an EHR transition. At this time, such a requirement isn’t part of the rules.
The letter also recommended requiring EHR vendors to fol- low established procedures and guidelines for user-centered
20 TEXAS MEDICINE January 2014
design (UCD), a process that takes into account EHR users’ needs, desires, and restraints at each stage of product design. “TMA believes that lack of adherence to established guide-
lines, principles, and best practices for the safe development of health IT software is a significant avoidable risk to safe patient care. It would be more valuable to ensure vendors embed es- tablished UCD processes into their product development life cycle through ONC requirements as proposed. Third-party UCD evaluations might be a better fit if done through the already established EHR certification process,” Dr. Schneider wrote. Though not mandated by the government, this type of work is being done in Texas. ONC awarded a four-year, $15 million Strategic Healthcare IT Advanced Research Projects-Cognitive (SHARP-C) grant to The University of Texas School of Biomed- ical Informatics in Houston to assess and test usability of EHRs. The school’s National Center for Cognitive Informatics and Decision Making in Healthcare (NCCD) is working to over- come physicians’ immediate and long-term cognitive challeng- es in HIT adoption and meaningful use achievement. NCCD researchers are focusing on EHR usability by test- ing how well EHRs handle realistic health care scenarios and then providing feedback on challenges to vendors. Their work can help vendors develop EHRs that are usable, useful, and optimized to fit physicians’ workflow. For more information on the SHARP-C program, visit
https://www.uthouston.edu/ nccd/projects/sharpc.
Playing it smart
On top of identifying problems that currently plague physi- cians, the survey sheds light on matters that are likely to hin- der physicians in providing quality care in the future. “We can’t just focus on current problems. In the words of
Wayne Gretzky, ‘A good hockey player plays where the puck is. A great hockey player plays where the puck is going to be.’ We need to follow his principle and look at issues that will be problems five to 10 years from now,” Dr. Crosson said. He says the survey makes it clear that evolving payment models need to be examined. While some physicians in the study are happy with the traditional fee-for-service payment setup, many expressed dissatisfaction with its emphasis on vol- ume of care rather than quality.
Alternative payment models mentioned in the study include
concierge medicine, bundled payments with hospitals, and a continuum of risk-bearing models designed to reward physi- cians for managing the care their patients receive. While many physicians seem willing to embrace new pay- ment models, they worry the transition period may disrupt their cash flow. Dr. Crosson says widespread acceptance of new payment methods among physicians is an opportunity for them to have a direct role in managing the cost of health care. n
Crystal Zuzek is an associate editor of Texas Medicine. You can reach her by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email at
crystal.zuzek@texmed.org.
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