5/31/07njm

**Electronic Health Record (EHR) Implementation: Worth the effort?**

Moderator: David Johnson

<David.Johnson3@ihs.gov>

**Case**

A 64 year old man presents to a typical busy IHS clinic for a routine
follow-up visit.  He has diabetes, hypercholesterolemia and chronic
kidney disease.  The provider enters the room, greets the patient and
sits down at the desk next to him.  While talking with the patient, she
logs onto the computer and opens the EHR.  After reading through her
last note, she review the chief complaint and vital signs already
entered by the nurse and opens a new note for today's visit.  While the
patient describes his symptoms, the provider begins to type a note.  She
then examines the patient and returns to the computer to enter her
findings.  She turns the computer screen toward the patient and reviews
his recent labs.  She is concerned about his worsening renal function
and poorly controlled diabetes.  She orders a nutrition consult and a
repeat set of labs for next month.  She proceeds to reorder the
patient's medications and receives a warning that his creatinine now
exceeds the level recommended for using metformin.  She discontinues the
metformin and initiates pioglitazone.  The patient is scheduled to
return in one month and is sent to pharmacy for his medications.  The
provider spends several minutes reviewing and completing her note before
signing it and leaving the room to see the next patient.

**Questions**

1\. How has the use of the EHR changed the typical clinical encounter? 
What are the benefits?  What are the negative impacts?

2\. How do you think the use of an EHR affects the provider -- patient
relationship?

3\. Most IHS sites have significantly limited resources (both personnel
and financial).  How have sites balanced the costs of EHR implementation
with other competing demands?

4\. This provider has a computer in the exam room.  Can an EHR be
successfully implemented without computers in the exam rooms?

**More resources**

Background material and links to other resources

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/EHRIntroduction.doc>

Implementation and Use of an Electronic Health Record within the Indian
Health Service.

[Sequist
TD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Sequist+TD"%5BAuthor%5D),
[Cullen
T](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Cullen+T"%5BAuthor%5D),
[Hays
H](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Hays+H"%5BAuthor%5D),
[Taualii
MM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Taualii+MM"%5BAuthor%5D),
[Simon
SR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Simon+SR"%5BAuthor%5D),
[Bates
DW](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Bates+DW"%5BAuthor%5D).

[J Am Med Inform
Assoc.](javascript:AL_get(this, 'jour', 'J Am Med Inform Assoc.');) 2007
March-April;14(2):191-197

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Sequist4207.doc>

**Bizahaloni, Betty (IHS/NAV) \[Betty.Bizahaloni@IHS.GOV\]**

**Wed 5/2/2007 6:40 AM**

Over a year and half ago, my father was recently hospitalized at
Flagstaff Medical Center, the facility had computer in each rooms. I
have seen nursing and medical and other professional using or
documenting after they have talk with my dad. I believe that one can
save more time; rather that seeing the patient and then going out of the
room to document. Showing patient x-ray or lab results would be
beneficial, since most Navajo's have a greater understanding of things
when you show them visual materials. It may cost to implement the
computers in the long run it should benefit the patients.  

**Wed 5/2/2007 7:06 AM**

**Mckittrick, Katherine km (IHS/NAS) \[Katherine.Mckittrick@IHS.GOV\]**

Good Morning,

I began using an EHR in my work as a physician assistant in an
outpatient clinic of a small hospital about two years ago. We are beta
testers of the IHS system. In spite of the fact that my physician
assistant training program mandated laptop computer use, the learning
curve with the EHR has been a steep one. Initially, I tried taking my
tablet into the exam room with me and found that it consistently failed
shortly after it was removed from our main charting room. So I
experimented with taking notes by hand and then typing them into the EHR
after each visit. Predictably, this double work was time-consuming and
resulted in many extra hours. Now I have a laptop which I take into the
exam room with me. I usually ask patients whether they mind if I type
while they tell me what has brought them to the clinic. No one has ever
objected (hard to imagine that many of our patients would suggest that
they feel uncomfortable; this is probably not the most effective
strategy for assessing comfort levels). Sometimes I explain that I want
to make sure that I get a good description of their concerns. Patients
do not seem annoyed by my attention to the computer while they are
talking. I hope that this means they feel that I am listening and
translating their stories into their medical records.

Negative impacts

I believe the most significant negative impacts of electronic health
records have to do with the systems themselves. They are imperfect and
often require enormous amounts of time and energy to accomplish simple
tasks. Sometimes the EHR actually complicates important jobs such as
analyzing medication history. I anticipate that this will improve as our
experience grows.

Provider-patient relationship

I would be interested in knowing how patients feel about the changes
that have come with EHR implementation. I think we would have to do an
anonymous survey to get a true picture of patient\'s feelings. I know my
perspective on the presence of the computer in the exam room is greatly
colored by my awareness that, if I don\'t bring it into the room with
me, then I end up working a lot of extra hours. I am highly motivated to
find ways to make it an acceptable part of clinic visits.

Benefits

1\. My notes are now longer and more detailed because I can type much
faster than I can write. My subjective impression is that a history
taken as it is given is probably more complete than one recalled even a
few minutes later.

2\. Immediate access to historical records, especially in graphic form,
is useful from both a clinical and educational perspective. For example,
flipping through pages of exam notes to get a sense of blood pressure
history pales in comparison to our ability to generate a graph of blood
pressure readings over the last two years that can be discussed with and
printed out for patients.

3\. When patients watch me work on the computer, I wonder if this gives
them a more complete picture of my role. For example, I used to say,
\"I\'ll order that medication for you and you may pick it up at the
pharmacy.\" If there was any delay, patients had no idea of what might
be happening. Now they are able to watch me as I order the medication,
perhaps learn of a reason (as in your example) why that might not be the
best choice, consider alternatives, and finally order the medication.
Even though this may be time-consuming, it is obvious to them that I am
working on their behalf and most patients seem to appreciate this.

4\. The EHR has the capacity to teach (and remind) providers about
relevant clinical information (as noted in your example). We also have
immediate access to UpToDate, a resource that I am happy to have at my
fingertips.

5\. The most significant advantage of an EHR seems to me to be access to
more complete information regarding patients. In spite of the
difficulties in implementation, I would not choose to go back to paper
records. Even when I work in our emergency room (which has not yet made
the transition to the EHR) I log on to the EHR to get background
information. We use health summaries in the emergency room but there is
nothing quite as helpful as recent clinic notes which are now only
available through the EHR.

I look forward to hearing about other experiences with EHR
implementation. We have a lot to learn about this new tool.

Sincerely,

Kate McKittrick, PA-C

Cherokee Indian Hospital

**Johnson, David E (IHS/ALB) \[David.Johnson3@IHS.GOV\]**

**Sun 5/6/2007 7:22 PM**

Thank you Kate for starting off our discussion about EHR. Your comments
highlight some of the frustrations with adjusting to a new \"system\"
when implementing an EHR, most notably the loss of efficiency with
previously routine tasks. What frustrations have other providers and
sites encountered when trying to implement an EHR? Have you learned any
tricks to get past these? Have any providers or sites simply \"thrown in
the towel\" because of these early frustrations?

Interestingly, you noted that your ability to type well has resulted in
more complete notes. I have found that many providers feel their typing
skills are more of an impediment to using the EHR successfully. What
have other sites found?

David Johnson, MD

Albuquerque Indian Health Center

**Heath, Stephen W. (IHS/ALB) \[Stephen.Heath@IHS.GOV\]**

**Mon 5/7/2007 6:31 AM**

As a former IHS clinician, I would like to add some comments regarding
the patient-provider relationship with respect to the EHR. My recent
experience as a Tri-Care Prime patient was at the 377th Medical Group at
Kirkland AFB here in Albuquerque. Although this was not an IHS
experience, I think my comments as a consumer of healthcare would apply
to any system using an EHR.

I was seeing a provider I had not seen before, and apparently Kirkland
had either advanced to a more comprehensive use of their EHR or my
previous providers had chosen not to use the monitor in the room for
record keeping. Anyway, this was a very negative experience, because my
provider-of-the-day chose to sit at the screen with his back to me,
showing more interest in the computer than with me! He asked me a number
of standard questions, checking off lots of boxes, seemingly to comply
with various requirements. The screening nurse had already asked me many
of the same questions, and I had filled in a paper questionnaire with
some of the same information as well.

The provider spent several short spans of time in silence, typing his
note, again with his back turned to me. His time facing me, talking
directly to me, and time spent \"at the bedside\" were minimized. I
found all this quite rude and somewhat dehumanizing. The impression left
was that my provider was more interested (or mandated) to ensure that he
was performing his record keeping correctly rather than having a
positive and more personal interaction with is patient. I left the
encounter feeling cheated. He did not ask and I did not tell him that I
was a physician.

I guess my point is that technology should not interfere or detract from
the time honored hands-on approach to patient care. Simple measures such
as how the monitor is placed in the room with respect to your view of
the patient can make a big difference to the encounter. I am all in
favor of improved, accurate and readable charts - they make for great
defensible medical records, and that is the cornerstone of my job. But I
agree with Kate McKittrick that we also need the patient\'s perspective
as to what impact the switch to full EHR will have on our encounters.

Thanks for listening

Steve Heath

IHS Risk Management Program

Hamstra, Scott (IHS/TUC) \[Scott.Hamstra@IHS.GOV\]

Mon 5/7/2007 7:47 AM

Excellent points \-- and I do agree that we should do all in our power
during encounters to present the \"EHR\" to the patient as the
patient\'s health record and how it directly benefits the patient.

I do agree that inside and outside the IHS - providers are still having
to adapt to some degree to the technology, that the technology is still
not quite advanced enough to adapt to the way we currently practice.

That said, EHR is an advance, and I find it very helpful during the
encounter to \...

1\) show graphically many measures over the past 1-2 years \-- BP,
Weight, Labs (HgbA1c,

Cr) \-- that many patients who are very visual seem to greatly
appreciate - maybe for the

first time

2\) instantly update the problem list - and enter the plan including
next steps that the patient

is willing and able to do

By being excited about and \"showing off\" the EHR to the patient \-\--
how this advance is helpful and useful to them and to their health (not
primarily for my benefit or for administrative benefits), seems to go
over well most of the time. Whining about what the EHR doesn\'t do or
doesn\'t do right, especially during a patient visit, does nothing to
enhance the patient\'s relationship with us or with our agency.

I do think that meshing EHR (timely, accurate information) with the
Patient Wellness Handout (this could be greatly improved - if
interested, call Chris Lamer), i.e. getting pertinent health information
into a readable, usable format that helps a patient better understand
their own health issues and what they, with our information, guidance
and support, can do to attain their goals is a pretty laudable goal and
may be closer than we think - in fact, you can do this today. Admittedly
it\'s a bit crude at this point, and input from the front lines all
across the IHS is not only welcome but desired.

Thanks for a great listserv discussion.

Scott Hamstra, Pediatrician, ER physician, Sells, Tucson Area

**Saltclah, Rose (IHS/NAV) \[Rose.Saltclah@IHS.GOV\]**

**Mon 5/7/2007 2:16 PM**

Excellent feedback by Scott Hamstra..

I have been using EHR at my hospital for \~ two years.

Main benefits are the comparative graphs I show to my patients. The
Navajo patients I serve appreciate the graphs; weight, vital signs,
cholesterol levels, tsh, and Blood pressure trend esp. to the
hypertensive patients. Medications is another benefit; I let them see
the meds they are taking, review the instructions\-\--you just read off
the EHR for them, and dosages\-\--I let them see the dosage they are
taking and what the increase dosage is. Some may ask for types of
diabetic pills available at the hospital\--and showing them types of
meds via EHR is interesting to them and reassures them of medication
compliance.

Navajo patients, likewise, with other patients, seem to like see
numbers, graphs and thus enhance their compliance level. My patients
usually ask for their weight comparison and a1c.

Yes, intermittently, we have EHR technology issues and we have excellent
IRM staff that provides service in efficient manner.

I focus on the benefits of EHR for patient\'s benefits.

It also helps medical records with the billing process and timely
reimbursement is important. It makes a positive impact to the
pharmacist; legible notes and med. Doages, etc. and if any questions RPH
immediately will send a message that pops up on the screen.

Overall, I find it beneficial to me as a provider, to patients, and
interdepartmental staff that use the system (ie. Referrals to dental,
eye, diabetic clinic, physical therapist, orthopedic, and others).

Typing speed can be a set back to some, for me, my speed has increased
over time.

We have the EHR system now \-- and is worth the effort and future
dictation would be more efficient and timely.

CDR Saltclah, FNP, NAIHS

**Stuart, Peter (IHS/NAV) \[Peter.Stuart@IHS.GOV\]**

**Mon 5/7/2007 2:33 PM**

Technology obviously brings with it both great promise and the potential
for ever more catastrophic failure. I am reminded of some of the
philosophical attempts to categorize human societies and technological
advances - there is the temptation to idealize ever higher levels of
functioning and interdependence (i.e. tribal societies are \"less\"
advanced than \"more\" developed civilizations). A better angle on this
is that while higher levels of organization may provide some new
functions and advantages, they also can contribute to correspondingly
greater failures and consequences (aka nuclear energy).

Dr. Heath\'s experience is the darker side - and our patients\'
experience of our systems as dehumanizing is unfortunately common. My
father fairly recently required extended treatment for a non-Hodgkins
lymphoma - and reported feeling like a widget that was being processed
through the system - he spent much more time with the machines than with
other human beings. He will acknowledge that his lymphoma is gone - but
that the experience was less than healing. EHR\'s have been part of a
larger press for more efficiency (how else can physicians, particularly
in the US, justify their payment levels?) with a reduction in the amount
of time available to individual. At the same time, time with patients is
correlated positively to reduced exposure to liability suits, if not
improved clinical outcomes. At its best, the EHR potentially allows the
provider to focus their attention on the patient, while still being able
to cover the many data points that make up a patient\'s health status.
It is easy, however, to convert this improved efficiency into seeing
more patients in less time - with resultant predictable consequences.

My experience suggests that during the actual face-to-face encounter
with the patient the attention should be focused squarely on the
patient. That does not mean that the EHR cannot be used during an
encounter - in fact, demonstrating lab values, getting patient
assistance in filling out parts of the record, looking at radiological
studies, searching for, reviewing and downloading information pertinent
to the patient\'s condition - patients appreciate and find these types
of activities valuable - as long as they are done WITH the patient.
Multi-tasking in my view is not appropriate when with patients.

I would not go back - but going forward requires sensitivity to having
another human being in the room with us - who in the end is worth far
more than any EHR.

Peter

**Graziano, Kristin (TCRHCC) \[kristin.graziano@TCIMC.IHS.GOV\]**

**Tue 5/8/2007 7:42 AM**

Greetings from Tuba City,

Thanks for all the useful comments thus far.

We are in the process of evaluating various EHR systems with the hope to
begin implementation over the next several months (we are a 638 site
looking at a number of different systems). Our administration and
financial experts tell me that the financial/billing package of the IHS
EHR system is inadequate when compared to other software from private
companies.

Admittedly, finances and business matters are not my strong suit; I
don\'t know if this is indeed the case. But as an IHS clinician, I have
concerns about what we may lose if we don\'t use a system compatible
with RPMS. And, from my initial exploration, I\'ve been pretty impressed
with what the IHS system can do in the realm of patient care.

However, I need a better understanding of the money matters. Can anyone
give me specifics about the IHS EHR\'s capability regarding billing,
accounting, payroll, accounts payable, and purchasing? If someone has a
knowledgeable finance person at their site with experience using the IHS
EHR that I could contact, that would be quite helpful as well.

Thanks much, Kristin

**Applegate, Roger (IHS/POR) \[Roger.Applegate@IHS.GOV\]**

**Tue 5/8/2007 8:32 AM**

I\'ve been using EHR for 2 yrs now, and although I feel like a data
entry clerk at times (I think provider productivity should be measured
in clicks per hour), I\'d never go back to paper given the choice.

As far as interacting with the patient, we have computers in the exam
rooms but I don\'t use them for data entry. Just seems like bad manners.

I usually begin the encounter by just sitting and talking with the
patient and just letting them say what they have to say (having to cut
people short on occasion, of course). The human aspect of medicine will
always come first in my book. That being said, when it comes time to
turn on the computer, I involve the patient directly, looking at graphs
of weight, blood pressure, A1c, reviewing problem and medication lists,
etc. Patients invariably are impressed with viewing their records on
screen. I then do my data entry elsewhere.

Re: billing I\'m not aware that the EHR program itself has anything to
do with billing as it\'s just a GUI for the RPMS.

Roger Applegate, M.D.

**Manning, Thomas (IHS/POR) \[Thomas.Manning@IHS.GOV\]**

**Tue 5/8/2007 9:12 PM**

I have been using EHR now for about 3 years. It definitely has changed
the patient encounter, for both good and bad.

It took some time to get used to making myself look at the computer
first to familiarize me with the patient before going in the room. I no
longer had the chart to scan just before going in the door. One benefit
of not having the paper chart is that the Nurse Aid will give me a brief
verbal update as well when letting me know the patient is ready. This
used to be a paper transaction only. Another upside is immediate access
to information, ability to more easily cover important issues from the
problem list, medications, clinical reminders, etc with the patient
while not having to flip through the chart looking for where the various
items are covered. The graphics are extremely helpful in showing
patients where they are and where they have been in BP, weight, A1c,
etc.

As for negative, it was interesting to me to see someone say that they
appreciated the ability to make much more descriptive notes, putting in
more information. I feel like I have gone through that phase and am now
working on how to make my notes as concise as possible with still being
able to convey the important information. The EHR does have the ability
to seduce us into trying to become medical Shakespeares. The critical
issue is that EHR takes more time and I have to fight the urge to take
too much time in going into more than sufficient detail in notes.

2\. How do you think the use of an EHR affects the provider - patient
relationship?

My usual pattern is to greet the patient, then make sure the computer is
on and their record is pulled up before beginning the encounter. That
way if we do need to look at something, or I need to look something up,

I don\'t have to interrupt the encounter. I do not do any note taking

on the computer during the patient encounter. I do use the computer
often if I am going over medications with patients to remind both of us
of all the medications, and I will enter refills, renewals, new orders

at that time. Another time I use the computer while engaged with the

patient is in reviewing clinical reminders. I think that reduces some of
the anxiety for patients sometimes to discuss alcohol, smoking, domestic
violence, depression etc. to see that it is something we survey all
patients for.

3\. Most IHS sites have significantly limited resources (both personnel
and financial). How have sites balanced the costs of EHR implementation
with other competing demands?

Our medical records department staff is half of what it used to be. Our
coding and billing processes are nearly real time. Granted, that didn\'t
happen overnight, but that\'s where we are now. I don\'t exactly how the
beans stack up on each side of the ledger here, but moving to EHR is not
just an increased expense. There is a savings side to it as well.

4\. This provider has a computer in the exam room. Can an EHR be
successfully implemented without computers in the exam rooms?

Having EHR but not having it available in the rooms would provide some
benefit in documentation. But you would lose the benefit of having
information available to review with the patient. You would not even
have a paper chart to review. I really don\'t see that working very well
at all.

**Petrakis, Steve (IHS/ALB) \[Steve.Petrakis@IHS.GOV\]**

**Tue 5/8/2007 1:54 PM**

I have a much less favorable view of the EHR, or at least of the
seemingly urgent need to start it up ASAP with whatever warts and faults
that may accompany it. I\'ll start by allowing that it\'s been clear
ever since the apeman picked up the rock at the beginning of
\"2001-Space Oddysey\" that an eventual EHR was inevitable and
unstoppable. That doesn\'t mean that we should be ignoring significant
negatives. What negatives, you ask?

1\. No matter what you say, this system is impersonal. Dr. Murphy\'s
original case scenario for this thread, where the IHS provider is typing
merrily away during introductions and during the patient\'s history, and
Dr. Heath\'s eyewitness account, echoed by many others who have been
there, reflect accurately how the visits will usually go. Unless you are
Mavis Beacon there won\'t be many empathetic glances being exchanged and
the worse the typist, the less the eye contact. The supposed tradeoff,
the turning of the computer screen to show graphs, doesn\'t impress me
much. It smacks of a computer version of the white coat, which impresses
the patient, without differing in substance from writing the last 3
weights or A1C\'s on a piece of paper.

2\. It is inefficient. Where the system is introduced productivity
falls.

Providers busy jumping from screen to screen, making appointments,
ordering labs, showing graphs(!), fall behind. The provider described by
Dr. Murphy stayed after the patient left \"for several minutes\"
bringing the record up to date. She probably got more behind. I\'ve
heard it stated that when you fall behind with EHR you switch right over
to paper again until you catch up. (Think John Henry and the Steam
Drill). We work for a vastly underserved patient population. Why
knowingly adopt a whole set of behaviors that will slow us down and
potentially reduce access?

3\. The system we are using is not ready for primetime. You can\'t scan
in outside documents like consults, EKG\'s, discharge summaries, etc so
you still need the paper record. So parts of the information will be in
various places, just like it is now. I have questions about basing our
conversion on an operating system like RPMS, which has always seemed
clunky and \"last year\", compared to others.

These are some of my concerns, tossed out there to stir up a bit of
debate. This is a very serious issue, it affects the type of care that
all of us will be giving in the future and it probably will have deep
impact on the way we see ourselves in our jobs. I think it should be
treated in the best skeptical fashion and not just given over to the IT
teams to ram it through.

Steve

**Lewis, James A (IHS/OKC) \[James.Lewis@IHS.GOV\]**

**Tue 5/8/2007 2:18 PM**

It is interesting to read Steve Heath\'s comments about his experience
with electronic health records. I have been in the Indian Health Service
for 32 years and have seen several changes in the paper record, and we
now are into a nonproprietary electronic health record system that had
its start with the VA system is now with the IHS and is here to stay.
When the electronic health record keeping was started here at HIMC we
were told by non-clinicians that after several months of being
clinician/clerk-typist we would be back up to seeing the same number of
patients that we had been seeing in the past. That is so much fiction.

At our hospital we are so crowded that each clinician has but a single
exam room/office/computer terminal. It is impossible to arrange our
computer position to negate the fact that we are spending significant
time with our eyes on the monitor/hands on the keyboard rather than on
the patient. At our hospital you cannot have the patient obtain lab,
obtain drugs, go to x-ray etc. without the clinician typing in the
request for all of the above. I agree with the previous comment that our
productivity now seems to be based upon keystrokes/words per minute that
we can type. Yet being able to read a fellow physician\'s note, or mine
for that matter, retrieving lab, and having the chart instantly
available when needed is a great plus compared with the scribble on the
old PCC. One thing that could help is a very sophisticated voice
recognition system, NOT Dragon Speak, that could speed up text entry,
because template/check boxes can only go so far in describing a child\'s
condition with anything more complicated that an otitis media.

Jim Lewis M.D.

Hastings Indian Medical Center

Tahlequah,OK

**Domer, Tim (IHS/NAV) \[Tim.Domer@ihs.gov\]**

**Wed 5/9/2007 9:14 AM**

Replying to Peter:

I have a much less favorable view of the EHR, or at least of the
seemingly urgent need to start it up ASAP with whatever warts and faults
that may accompany it. What negatives, you ask?

1.No matter what you say, this system is impersonal\...\...

It is not clear from the writer if he has actually used the EHR, but my
impression is that it is not part of his routine.

I have used the EHR for the past two-three years and would not go back.

I have not seen any negative change in my relationship with my patients.

In fact, I have found that they like to look over my shoulder and see
what I am writing about them. I have been corrected more than once.

Any system can be as impersonal as one cares to make it. Looking down at
a paper PCC can be just as impersonal. Patients have complained of
impersonal care since long before any EHR was invented. It is up to the
individual to make the patient feel you care for them and their
concerns. I do not see the EHR changing that one way or another.

My concern with the EHR is that we reconcile the need to enter more
data, with the need to spend adequate time with the patient in front of
us. As it is, each encounter requires at least 50 clicks - plus typing.

The powers that be in HQ must communicate well with those of us who use
the system on a daily basis, to avoid adding more clicks that may or may
not result in improved patient care. HQ\'s need for more data must be
balanced with our need to see patients.

2\. It is inefficient\...

The system is not inherently inefficient - especially when one looks at
all of the functions that one can access in one place. The
\"productivity\" - if measured in patients seen per provider - at Fort
Defiance took a very small dip for a month or two but is now back up to
pre-EHR numbers.

If one looks at the productivity of the organization as a whole, I do
not see an argument that it is inefficient at all. More than one person
can be using the \"chart\" at one time. Charts don\'t get lost. Notes
are legible and in one place, labs are easily accessed and used more
productively, coding and billing is coming along and should improve even
more over time. Our collections are up significantly.

3\. The system we are using is not ready for primetime.

Neither were the \"Not Ready for Prime time Players\" - but they were
pretty good. The system will never be \"there\", just as medicine will
never be \"there\". The system is ready enough that it is being used
very effectively in many locations.

The EHR is very adaptable - perhaps too adaptable in some aspects. It
will evolve as medicine and the IHS evolves.

One point I would make, though - there MUST be terminals in each exam
room. This IS the chart. The provider MUST have ready access to the
chart of the person he/she is seeing.

Tim Domer MD

**Reber, Garth (IHS/BIL) \[Garth.Reber@IHS.GOV\]**

**Wed 5/9/2007 8:59 AM**

Hi

I have been using ehr now for about 3 1/2 years (I believe Wind River
was one of the first places to start using it). I think it is fantastic.

Yes it slowed productivity at its implementation stage. Yes there are
occasional technical glitches in its use and execution and yes it
creates a new set of obstacles that need to be dealt with in the exam
room. But I have found all of those initial problems have worked
themselves out fairly well.

After the first year of use my productivity, and that of all 10 of my
partners (measured not only in number of walk-ins but also in improved
billing, better notes(auditing), more complex patient interactions) has
improved.

As IHS needs to start standing on its own for income to help pay for all
those expensive contract health and direct care needs the whole clinical
experience is evolving. At our service unit we have improved our billing
(3rd party) significantly EACH year since implementing ehr which
ultimately comes back to the pt in some form or another.

We have a fairly aggressive IT dept that addresses problems as they
arrive and try to proactively forecast problems. (no electronic item in
the universe is without glitches) I can now read my partners notes!

My partners can now read mine!

We have wireless laptops that I set on my lap (like a patients paper

chart) and face the patient. I am able to type a few things while in the
room and address needs immediately in the room. Per my own survey and
our clinics patient feedback surveys it has not been seen as an
obtrusion or obstacle to good old fashion concern and caring. (really,
it is just another tool that needs to be used in the right way,
obviously turning your back on the patient to type notes is kind of

silly)

Drawbacks with the IHS EHR

1\. Pharmacy package can get a little overwhelming (but what doesn\'t
when you have a patient with 10 meds) 2. Having to type does initially
slow down. Some people will adopt some will not (not unlike life) 3.
When you go paperless it really is hamstrung when the system goes down
since we started this (4 years this fall) I can only recall 2 times
where we didn\'t have record access for more than 1-2 hours. That being
said time is the ultimate judge.

Cheers

Garth Reber D.O.

Wind River

**Placide, Frances (IHS/NAS) \[Frances.Placide@IHS.GOV\]**

**Wed 5/9/2007 7:40 PM**

As a 3 year user of EHR I have a love-hate relationship with it.

 

I love my quick access to labs, x-ray reports, medications list (albeit
cumbersome), ability to review past and pending appts, access past POV
and problem list etc.

 

I dislike the amount of time it takes me to complete the visit
documentation, but I like it when I have to re-visit that encounter at a
later date because  everything that occur at the encounter is clearly
visible to me and any other provider that my click on that record.  EHR
is an effective documentation tool though it does not feel like an
efficient use of my time during the encounter.

 

I sometimes type the patient history during the interview
process because quiet frankly it saves  time later (I am a very fast
typist).  And I actually think patients appreciate it because they feel
like I am listening to them and recording their words.

 

I too share graphs and labs with patients.  I believe it fosters a trust
that we (the system) really are attending to their individual health and
this helps break-down the \"impersonal\" aspect of this technology.

 

I find that with EHR most providers actually take the time to record
detailed patient history much more than when it was all handwritten. 
And lets not forget the time I use to spend trying to decipher
illegible hand written notes, mine included.  EHR allow for improved
communication between providers.

 

I sometimes am relieved when I cannot use EHR and have to resort to hand
written notes and check-marks. But without the EHR as a reference for
gleaming information about the patient\'s previous visits and tests, I
have to admit the encounter documentation feels less complete.

 

Yup, Love-hate.  That\'s my relationship with EHR.  EHR has improved my
documentation but I find myself apologizing a whole lot more for being
late.

 

Thanks for allowing me to share

Frances

Frances P. Placide, MMS, PA-C, OTR

Physician Assistant Chief Clinical Consultant, IHS

**Tobe Propst \[TobePropst@SEMTRIBE.COM\]**

**Thu 5/10/2007 12:27 PM**

I think the typing issue needs to be taken out of the equation.  I took
a typing course in high school...best thing I ever did.  I believe it
was 3 hrs / wk, and within about 2-3 months I was typing without
looking.  You can actually learn to type pretty well within 2-4 weeks of
spending a couple hours a day.  There are even web-based courses where
the keys light up and you learn to use the right finger to hit that key
without looking until eventually -- viola -- you can type without
looking!  Try [www.learn2type.com](http://www.learn2type.com/) or just
Google "learn to type" or "learn typing" for others.  Once you can type
without looking (even if it's slow typing), then you just get faster &
faster with the practice.

 

I guess part of the argument is that one can hand-write without looking,
but can't type without looking.  Horse-hockey!  It doesn't have to take
long to learn to type without having to look at the screen at all except
click the mouse.  We (unfortunately) have paper charts where I work now
and I have to look to write more for handwriting.

 

Perhaps free typing courses and/or dedicated time to learn typing could
be offered to any providers interested with EHR implementation
impending.  If I couldn't already type, I would consider it my
professional obligation to learn to type -- and a priority -- as a
doctor in today's world.  If I had to, I'd use my CME time/\$\$ to make
sure that I did learn to type.

 

EHRs also have the benefit of potentially allowing the set-up of
reminders or "pop-up" guidelines.  Just as an example, has anyone seen a
liver profile long overdue for someone on a statin with several other
problems?  The EHR could be set up to remind the provider anytime that
patient's chart is accessed.  It could also help avoid redundant tests
on patients because one didn't see that a test has already been done. 
Ideally, the system would be optimized as much as possible prior to
rolling it out for real-life use by providers.  Also, it would be a huge
advantage if health care systems nationwide could share the same health
information electronically...but that will be years from now.

**Johnson, David E (IHS/ALB) \[David.Johnson3@ihs.gov\]**

**Sun 5/13/2007 7:29 PM**

The patient returns to clinic 3 weeks later. He states that 2 days ago
he had an episode of chest pain while he was visiting family in a nearby
town. He states he went to the local IHS facility there and had a work
up which included labs, an x-ray and an ECG. He states the ER doctor
told him he had some lab abnormalities and should follow up with his
doctor as soon as possible. The provider calls the other IHS facility
and is told they are very busy but will fax the notes as soon as they
get a chance. She repeats his lab tests and finds his renal function has
worsened. She is able to quickly review his notes in EHR and graph his
creatinine levels to show the patient his worsening kidney disease. She
writes out a referral for to a nephrologist and hands it to the patient
to take to Contract Health. The patient is scheduled to return in 1
week.

Questions:

1\. All EHR\'s have advantages and disadvantages. What are some of those
advantages or disadvantages that HIS providers have found, either in
relation to their experience with other EHR\'s or their own expectations
of an EHR? What has been providers experience with trying to make
recommendations for IHS EHR enhancements?

2\. As previously discussed, typing is a serious limitation for many
providers using EHR. How have sites dealt with this common problem? Are
any sites using DragonSpeak or other dictation system to help with this
problem?

3\. The sharing of health information between health care facilities is
one of the long-term goals of the EHR that could truly reduce costs and
improve care. I would be interested if anyone from the EHR Leadership
Group might be able to comment on the status of this goal.

David Johnson, MD

Albuquerque Indian Health Center

**Hays, Howard (IHS/PHX) \[Howard.Hays@IHS.GOV\]**

**Wed 5/16/2007 3:25 PM**

I haven\'t seen much traffic in response to Dr. Johnson\'s posting
below, so I\'ll take the opportunity to respond, particularly to his
third question.  But first I want to thank those who have participated
in this thread.  I\'ll admit to some concern about how the discussion
would go, since EHR is a highly visible initiative and in a sense has
been my \"baby\" for the past four years - you always want your projects
to be seen in a good light.  On the other hand, there\'s nothing more
important than feedback from actual users, which is why we RPMS types
have pretty much stayed out of the discussion until now so that we could
hear what you think.  Overall it has been really gratifying, and the
message seems to be that people understand and appreciate the value of
electronic records, while at the same time identifying things that could
be improved and new features that would be desirable.  Overwhelmingly
when we hear from providers across the country, the unifying theme is
\"you need to fix this and that, but we wouldn\'t go back to paper.\"

 

Believe me, we are working on fixing \"this and that\", and do want your
continued feedback - not just for EHR but for all of RPMS.  If you
haven\'t seen it yet, the RPMS web page has a Feedback feature where you
can register your input:

<http://www.ihs.gov/Cio/RPMS/index.cfm?module=feedback&option=add&newquery=1>

 

I\'ll skip question #1 below because I think there has been good
discussion on this.

 

Question #2:  There are some sites using dictation with EHR (Dragon
Naturally Speaking Medical, version 9). The experience with dictation is
mixed - it works well from a technical standpoint but it\'s not always
easy to incorporate dictation into the flow.  I\'d appreciate any
comments from users on this list.

 

Question #3:  Clearly the ability to share appropriate information among
authorized individuals at different facilities is one of the most
important promises of electronic record systems.  The IHS is required,
as with all Federal agencies, to comply with evolving standards for
interoperability of electronic health information, so that critical data
can be shared and retrieved when it is needed.  We are working on
adapting RPMS to meet the standards as they are developed.  Dr. Cullen
may wish to comment further on this. 

 

One might ask whether, since IHS and most tribal facilities use a common
system (RPMS), we couldn\'t share information among our own facilities. 
The main barrier to this at present is that we have no means of uniquely
identifying patients who go to different sites.  The RPMS Health Record
Number is only unique within one facility, and the same number at a
different location will identify a different patient.   The VA has
historically used the social security number for this purpose, but IHS
has no plans to do this.  We are looking at Master Person Index (MPI)
technologies to address this issue.  We won\'t have an answer in the
short term (months) but we will definitely get there.

 

Thanks again to everybody for your enthusiastic participation in this
discussion.

 Howard Hays, MD, MSPH

**Allee, Lisa (IHS/NAV) \[Lisa.Allee@IHS.GOV\]**

**Wed 5/16/2007 8:27 PM**

Why isn\'t IHS going to using social security numbers as unique
identifiers??? Seems like that would be an easy solution and a way to
speed us toward being able to access information from other IHS
sites\--both for RPMS and EHR.

**Cullen, Theresa (IHS/HQE) \[Theresa.Cullen@IHS.GOV\]**

**Thu 5/17/2007 2:59 AM**

IHS has historically and intentionally not relied on SSN for unique
identifiers; while we collect that information and use it as
appropriate, we can not rely on SSN for unique identification. As you
know, many of our older patients may not have an SSN; we also know that
there are situations where an SSN has been shared between people. While
SSN is an important component of determining a patient's unique
identity, it is not the only data field that we need to use.

The Office of Information Technology has written a strategic proposal to
move our Agency towards the development and integration of an MPI
(master person index) into our data structure. We are hopeful that we
can move this initiative forward in 2008.

We are also working closely with the Office of General Council to
resolve the legal and security/ privacy issues around non federal data
sharing and regional health information exchanges. OGC is developing a
template for a data sharing agreement that will hopefully be a model
draft agreement for sites interested in regional data sharing.

**Traeger, Marc (IHS/PHX) \[Marc.Traeger@IHS.GOV\]**

**Thu 5/17/2007 9:08 AM**

We have Dragon voice recognition but it just isn\'t very good. One
spends at least as much time correcting mistakes from voice
non-recognition to make up for any time spent clicking, texting or
handwriting notes. Only about 5 of our \~25 providers are using it in
any capacity. The greatest advantage is when completing an H&P and there
may be a detailed history that will ultimately be faster with Dragon,
and since our radiology or other reports do not merge with EHR, one can
dictate the summary a radiologist (or consultant, transfer summary, etc)
made into the history or results more efficiently than through other
methods. But overall it provides little advantage.

**Alan Waxman \[AWaxman@SALUD.UNM.EDU\]**

**Thu 5/17/2007 2:00 PM**

This has been a very interesting and important discussion. As a former
IHS provider, I\'ve followed it with much interest.

I wholeheartedly agree with those lobbying for the ability to get
patient information from other facilities within the \"system.\" Good
patient care depends on good clinical information. As long as patients
use multiple facilities, access to information from throughout the
\"system\" will be vital.

Regarding Dr. Johnson\'s #2, I have worked for the past 4 years with a
dictation-based EMR. It allows for efficient clinic flow in that you can
jot a few notes on paper while seeing the patient and dictate your
encounters after clinic ends. The after-hours dictation is, on the other
hand, the major drawback. It can tie up your evening, and then you have
to review the dictation before signing it. Efficient patient flow at the
cost of a lot of extra after-hours time and redundant effort. I also
worked briefly with the VA system of typing notes. I\'m a poor typist
and found the extra time involved with typing each note (which I did
after finishing the patient visit) slowed down my patient flow. (Then
there were the rare days when the computers crashed and the clinic
ground to a complete halt. No patient records, no appointment system, no
pharmacy, no lab.)

Electronic records are better than paper. Unfortunately, they come with
a cost that we\'re all going to have to accommodate to.

IHS has been working on an electronic record since at least 1978 (Think
PCIS in Alaska) Hopefully with over 25 years of development, they\'ll
get it right.

Best of luck.

Alan Waxman, MD

University of New Mexico

**David Johnson <David.Johnson3@ihs.gov>**

**Mon 5/21/2007 2:08 PM**

Thanks for the comments to date regarding this topic that has a large
impact on how we practice medicine, both now and certainly in the
future. I wanted to specifically invite comments from Dr. Thomas Sequist
who has studied and written specifically about the implementation of EHR
in the IHS.

A link to his recent article is listed under \"more resources\" at the
beginning of this discussion (link below also\*). This article surveyed
many clinicians who were at sites where the EHR was implemented earliest
and found a mixture of opinions similar to this listserv discussion. One
of the findings in the study I found interesting was that while only
about one third of clinicians surveyed felt that the EHR improved the
quality of care for their patients, 87% felt that information technology
could potentially improve the quality of health care in underserved and
rural communities. Is this a comment on the steep learning curve of the
EHR, our specific EHR or something else? I would invite Dr. Sequist's
comments on this and his ongoing studies in this arena. Perhaps some of
those involved in the survey might have comments as well.

David Johnson, MD

Albuquerque Indian Health Center

\*  <http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#ehr>

**Sequist, Thomas Dean,M.D. \[TSEQUIST@PARTNERS.ORG\]**

**Wed 5/23/2007 1:02 PM**

Implementing electronic health records is a challenge, regardless of the
environment.  However I suspect that in more resource-constrained
environments it is even more challenging, and a successful
implementation requires the support of clinicians, staff, and central
leadership.  I think, though, that these settings may potentially gain
the most benefits from information technology in the long run through
increased access to information, more efficient workflow processes, and
many other benefits.

In thinking about the new IHS EHR, it is important to distinguish
between whether the "implementation" was successful; and whether
clinicians feel it is "worth it".  The former question really relies
more on getting local buy-in, getting in place the correct
infrastructure, ensuring technical capacity, good training, etc.  The
latter is more a question of ongoing usability, perceptions of clinical
impact, and other more clinical features of care.  The implementation of
the EHR seemed to go very well in the IHS thus far, with 2/3 of
clinicians reporting it was successful.  However, as David points out,
only 1/3 of clinicians think it improves quality and safety.

Part of this is timing \-\-- we asked these questions early on in
implementation (within 1 to 2 years), and we know from some work here in
Massachusetts that it takes longer to realize the full benefits of an
outpatient EHR.  Potentially a bigger part of it is that EHR transitions
are often frustrating, causing changes in workflow, loss of efficiency,
and other issues.  The final thing I thought was interesting was that
only a minority of clinicians were using the powerful tools of the EHR
\-\-- such as clinical reminders.  These are the things that will really
drive improved care via an EHR, and so is important to increase their
use.  Otherwise, you are stuck doing a lot of the "busy work" associated
with an EHR, and not cashing in on its real benefits.

One important issue that has come up on this discussion, and we saw in
our survey, is that using an EHR creates a complex dynamic with patients
in the room.  I am guilty myself of staring into a computer screen
trying to find something, while the patient sits and waits.  At least a
third of providers felt that the EHR made their clinical interactions
with patients worse, which is probably not surprising.  We need to
develop better training seminars as a whole (not just within the IHS,
but in all health settings using EHRs) that provide guidance on the
effective and appropriate use of an EHR within a clinical encounter.
 Otherwise, we risk sacrificing our "patient-centered" mission of
delivering care.  Unfortunately, there are not a lot options out there
right now in terms of training clinicians in this complicated area.

The idea that most clinicians really support information technology in
rural and underserved settings I think reflects the need for increased
access to clinical consultation, services, and information.  I think
that EHR fits into this category, but the benefits are not as easily
realized as, say, Up To Date \-\-- which is more immediate in its
perceived benefits, and requires less up front work on the part of
clinicians.

Of course, the biggest challenge is now to show that the EHR is having
an impact on clinical quality for chronic disease (diabetes, heart
disease) and preventive services such as cancer screening and
immunizations.  This will part of ongoing studies looking at the IHS
EHR.

Tom Sequist

**Johnson, David E (IHS/ALB) \[David.Johnson3@IHS.GOV\]**

**Thu 5/24/2007 11:02 AM**

Thank you Dr. Sequist.  In reference to your last paragraph, improving
the quality of care is ultimately what we as clinicians want to see,
especially as it relates to prevention and treatment of chronic
diseases.  It is also a focus of Dr. Grim\'s Chronic Care
Initiative.  Are sites and/or providers that have now been using EHR for
a longer time finding, at least anecdotely, that they are able to
provide a higher quality of care to their patients?  In what ways? 
These examples may help us all as we all move forward with
implementation and use of the IHS EHR? 

 

Additionally, Dr. Sequist or others, are there studies (outside of the
IHS) that have clearly demonstrated enhanced quality of care through use
of an EHR?

David Johnson, MD

**Sequist, Thomas Dean,M.D. \[TSEQUIST@PARTNERS.ORG\]**

**Fri 5/25/2007 6:58 AM**

I do not currently have data on whether the sites that have been using
the EHR for a longer time are providing higher quality care.   We hope
to have these data by the end of the year.  When we consider the impact
of quality, we should look at the domains defined by the Institute of
Medicine, so that we are all measuring the same thing \-\-\--
effectiveness, safety, efficiency, patient-centered, equity, and
timeliness.  I think that the EHR will have different magnitudes of
impact in these different areas.

 

There are many studies that document enhanced quality of care through
using EHRs.  Specifically, studies of electronic reminders have
repeatedly shown in randomized settings that use of preventive services
(such as mammograms) and also chronic disease care (for diabetes and
heart disease) can be improved.  I am happy to provide references for
those interested.  Also, EHRs can cut down on adverse drug events based
on observational studies in the outpatient setting, and we are currently
conducting a randomized trial here in Boston to see whether this finding
of improved patient safety holds up.  It is definitely true in the
inpatient setting that EHRs improve patient safety, just hasn\'t been
shown yet in the outpatient setting (but likely will be effective).  The
field is still wide open in terms of measures of efficiency and
patient-centeredness; however

**Reidhead, Charles (IHS/PHX) \[Charles.Reidhead@IHS.GOV\]**

**Fri 5/25/2007 5:56 AM**

Dear All,

Thank you for the great discussion. 

Sorry Dr. Johnson, I haven\'t looked for articles on EHR improving the
quality of care.  I will give my perspective which is coming from two
sources\... I have been fortunate to work on the Chronic Care Initiative
over the last year spending time on how to improve our care of chronic
conditions, and I have used our EHR for almost two years.

 

Sometimes we forget that the electronic health record is just a tool. 
It doesn\'t feel like it, because when it is implemented we don\'t have
an option of whether to use it or not.  The IHS version of EHR, is
really a great tool that gets better every day, and the more that I use
it the better I get.  Interestingly, when the tool is implemented, it
shines a huge spotlight on systems of care that might not have been a
problem before.  It tends to slow us down in the clinic, but I am
hopeful that as we improve our Systems, we will regain many efficiencies
not yet realized in most of our clinics.

 

A good source to look at if you are interested in improving the care of
patients in general is the Care Model developed by Ed Wagner
([http://www.improvingchroniccare.org](http://www.improvingchroniccare.org/)) with
the MacColl Institute.  In the Chronic Care Initiative, we are adapting
this model to the Indian Health System
(<http://www.ihs.gov/NonMedicalPrograms/DirInitiatives/Documents/CCIUpdate031507x.doc>). 
The bottom line of this model is that if we want to improve care, i.e.
improve the achievement of patient and community goals, we need to
facilitate productive interactions through effective asset based
partnering between an informed, empowered patient and family, and a
prepared, proactive practice team.  In order to improve this
interaction, we can make changes in self-management support, the
delivery system design, decision support, clinical information systems,
or the Community.

 

The EHR really impacts all of the components of the Care Model, maybe
with the exception of Community and culture.  It can help us to provide
patient-centered, planned care in a fashion that empowers patients and
helps us as practice teams to be more proactive.  There is still much to
be learned in how to improve the interactions over time, and I would
argue that if the EHR is getting in the way of the interaction, then
adjustments should be made.  Change the room configuration.  Change and
objectively assess whether the change is an improvement.  If it isn\'t,
then try something else.  The EHR for the most part, improves my
interaction with patients and families.  I can provide patients with
personalized information that was not available before, I can quickly
pull up patient education handouts, and I can encourage them to begin to
become an active participant in their care. 

 

Implementing EHR is not for the weak of heart, but if we can improve the
systems of care to make them support a patient centered model, we will
find that EHR will support us in that effort.  If it doesn\'t, then this
is the advantage of the Indian Health System\... primary care providers
can have a voice.

 Thank you,

Ty