EHR Angst

At the American Psychiatric Association’s November Assembly meeting, Dr. Judith Kashtan (with co-author Dr. Ramaswamy Viswanathan) put forth an action paper aimed at encouraging the APA to do more to educate and assist its members in making decisions about implementing electronic health records (EHRs). The proposal was debated in its assigned Reference Committee, which made revisions to the action paper before sending it back to the floor of the Assembly for discussion, further revision, and voting.

The final paper, “Improved EHR Education for Members in Solo Private Practice,” was overwhelmingly approved by the APA Assembly. This is a very timely and relevant topic, as the Centers for Medicare and Medicaid Services (CMS) is providing a small bonus for physicians who employ an EHR in their practice, and a small fee reduction for those of us who do not. This is giving many physicians a lot of anxiety over how to change their practice.

I’ll come back to this in a minute, but first I will explain the big picture of how the Assembly works for those readers who don’t know much about it. The Assembly is the deliberative body of the APA, very much like the U.S. House of Representatives. Each district branch votes on a number of Assembly representatives (and deputy representatives) proportional to the size of the APA membership in that branch. A smaller number of “reps” represent certain defined groups of members. An Assembly rep can propose an item for the Assembly to vote on.

Such items, called Action Papers, get vetted at the local level before coming to the Assembly. (There are actually more steps, but that is more detail than necessary here.) An Action Paper starts out with numerous “Whereas” statements that explain the background and reason for the paper, followed by several “Be It Resolved” statements that advise the APA what the Assembly wants the organization to do. This is how position statements get crafted, as well as how other policies and member needs get communicated to the Board of Trustees, which has the ultimate decision-making responsibility for the organization.

The Assembly meets twice per year, in November and in May. The Action Papers get divided up into Reference Committees, somewhat analogous to the various House of Representatives committees. Each committee, which may have about 8-10 people on it, hears from the paper’s author about why the paper has merit, while other reps and APA members may speak for or against the paper. At this time, further revisions or amendments may get made to the paper. The Reference Committee then makes a decision to support the paper or not, communicating that decision along with any revisions to the Assembly.

The Assembly then discusses each paper and votes to approve it or not. While I missed the Assembly discussion for this EHR Action Paper, I was present for the Reference Committee discussion where I spoke as the chair of the Committee on EHRs. The concerns raised had to do with this coming freight train of having to select an EHR, how to go about making such a decision, how to implement it and convert from paper to electronic, and what are the costs involved. The Action Paper requests the EHR committee to supplement the materials on its website, in addition to providing an area for members to discuss and compare their experiences with their own EHR, while providing additional staff support to make this happen.

The APA currently has a section on its website devoted to EHRs. This section contains important links describing the CMS incentive program, explaining the national EHR initiatives, and addressing related privacy, security, and technical issues. There is also a members-only section where one can read member reviews of several EHRs, though presently we have only 15 reviews on the site. The committee has been working for the past several months on developing an improved method that would help members provide reviews of what they have used, while also providing a framework that helps them think through the relevant issues when deciding on an EHR.

The most important decision to make is whether you want to have an EHR or continue to use your current method of documenting care. Most of us will not need to weigh the financial carrots and sticks from CMS, since they are only relevant if you have a sizable Medicaid or Medicare population. The stick amounts to up to 3% of your Medicare fees. Given that a 27% cut in Medicare fees is now on the table (or 39% per MedPAC), 3% is not worth getting excited over. Rather, the cost of the system itself will be the main financial consideration.

Other considerations have more to do with the sort of practice one has and the need for sharing information. Thinking through the risks and benefits of adopting an EHR in one’s practice can help reduce the angst one feels about this decision:

POTENTIAL BENEFITS:

• quicker exchange of information than with faxing or mailing

• less likely for papers to get misfiled or lost (eg, think Hurricane Katrina)

• better tracking of who accessed what information

• less duplication of tests

• improved coordination of care

• fewer medical errors due to more information available

• decreased liability due to sharing of important information with other providers

• improved legibility

POTENTIAL RISKS:

• decreased privacy due to potential for data breach, identity theft

• loss of data due to technical problems (viruses, hardware failure, etc)

• failure to secure data due to inadequate authentication, authorization, encryption, etc

• more errors in health record due to automated data collection processes

• increased liability due to sharing of sensitive information with other providers

Finally, just because it is electronic doesn’t necessarily make it better or safer. The Institute of Medicine recently recommended that a separate entity investigate errors resulting from the use of electronic health records, while a report in this month’s Journal of the American Medical Informatics Association found that 10% of electronic prescriptions to a commercial outpatient pharmacy chain had errors, one-third of them potentially serious. This is similar to the error rate in handwritten prescriptions.

The APA Committee on Electronic Health Records will be coming out next spring with an improved tool to assist its members in sharing their experiences with the numerous EHR products out there. Until then, ask your colleagues, go online, and share with others. Also stay tuned here, and on my blog, HIT Shrink.

<[QM]>—Steven Roy Daviss, M.D. DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, clinical assistant professor at University of Maryland, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. Find him @HITshrink on Twitter and on the Shrink Rap blog.

At the American Psychiatric Association’s November Assembly meeting, Dr. Judith Kashtan (with co-author Dr. Ramaswamy Viswanathan) put forth an action paper aimed at encouraging the APA to do more to educate and assist its members in making decisions about implementing electronic health records (EHRs). The proposal was debated in its assigned Reference Committee, which made revisions to the action paper before sending it back to the floor of the Assembly for discussion, further revision, and voting.

The final paper, “Improved EHR Education for Members in Solo Private Practice,” was overwhelmingly approved by the APA Assembly. This is a very timely and relevant topic, as the Centers for Medicare and Medicaid Services (CMS) is providing a small bonus for physicians who employ an EHR in their practice, and a small fee reduction for those of us who do not. This is giving many physicians a lot of anxiety over how to change their practice.

I’ll come back to this in a minute, but first I will explain the big picture of how the Assembly works for those readers who don’t know much about it. The Assembly is the deliberative body of the APA, very much like the U.S. House of Representatives. Each district branch votes on a number of Assembly representatives (and deputy representatives) proportional to the size of the APA membership in that branch. A smaller number of “reps” represent certain defined groups of members. An Assembly rep can propose an item for the Assembly to vote on.

Such items, called Action Papers, get vetted at the local level before coming to the Assembly. (There are actually more steps, but that is more detail than necessary here.) An Action Paper starts out with numerous “Whereas” statements that explain the background and reason for the paper, followed by several “Be It Resolved” statements that advise the APA what the Assembly wants the organization to do. This is how position statements get crafted, as well as how other policies and member needs get communicated to the Board of Trustees, which has the ultimate decision-making responsibility for the organization.

The Assembly meets twice per year, in November and in May. The Action Papers get divided up into Reference Committees, somewhat analogous to the various House of Representatives committees. Each committee, which may have about 8-10 people on it, hears from the paper’s author about why the paper has merit, while other reps and APA members may speak for or against the paper. At this time, further revisions or amendments may get made to the paper. The Reference Committee then makes a decision to support the paper or not, communicating that decision along with any revisions to the Assembly.

The Assembly then discusses each paper and votes to approve it or not. While I missed the Assembly discussion for this EHR Action Paper, I was present for the Reference Committee discussion where I spoke as the chair of the Committee on EHRs. The concerns raised had to do with this coming freight train of having to select an EHR, how to go about making such a decision, how to implement it and convert from paper to electronic, and what are the costs involved. The Action Paper requests the EHR committee to supplement the materials on its website, in addition to providing an area for members to discuss and compare their experiences with their own EHR, while providing additional staff support to make this happen.

The APA currently has a section on its website devoted to EHRs. This section contains important links describing the CMS incentive program, explaining the national EHR initiatives, and addressing related privacy, security, and technical issues. There is also a members-only section where one can read member reviews of several EHRs, though presently we have only 15 reviews on the site. The committee has been working for the past several months on developing an improved method that would help members provide reviews of what they have used, while also providing a framework that helps them think through the relevant issues when deciding on an EHR.

The most important decision to make is whether you want to have an EHR or continue to use your current method of documenting care. Most of us will not need to weigh the financial carrots and sticks from CMS, since they are only relevant if you have a sizable Medicaid or Medicare population. The stick amounts to up to 3% of your Medicare fees. Given that a 27% cut in Medicare fees is now on the table (or 39% per MedPAC), 3% is not worth getting excited over. Rather, the cost of the system itself will be the main financial consideration.

Other considerations have more to do with the sort of practice one has and the need for sharing information. Thinking through the risks and benefits of adopting an EHR in one’s practice can help reduce the angst one feels about this decision:

POTENTIAL BENEFITS:

• quicker exchange of information than with faxing or mailing

• less likely for papers to get misfiled or lost (eg, think Hurricane Katrina)

• better tracking of who accessed what information

• less duplication of tests

• improved coordination of care

• fewer medical errors due to more information available

• decreased liability due to sharing of important information with other providers

• improved legibility

POTENTIAL RISKS:

• decreased privacy due to potential for data breach, identity theft

• loss of data due to technical problems (viruses, hardware failure, etc)

• failure to secure data due to inadequate authentication, authorization, encryption, etc

• more errors in health record due to automated data collection processes

• increased liability due to sharing of sensitive information with other providers

Finally, just because it is electronic doesn’t necessarily make it better or safer. The Institute of Medicine recently recommended that a separate entity investigate errors resulting from the use of electronic health records, while a report in this month’s Journal of the American Medical Informatics Association found that 10% of electronic prescriptions to a commercial outpatient pharmacy chain had errors, one-third of them potentially serious. This is similar to the error rate in handwritten prescriptions.

The APA Committee on Electronic Health Records will be coming out next spring with an improved tool to assist its members in sharing their experiences with the numerous EHR products out there. Until then, ask your colleagues, go online, and share with others. Also stay tuned here, and on my blog, HIT Shrink.

<[QM]>—Steven Roy Daviss, M.D. DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, clinical assistant professor at University of Maryland, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. Find him @HITshrink on Twitter and on the Shrink Rap blog.

At the American Psychiatric Association’s November Assembly meeting, Dr. Judith Kashtan (with co-author Dr. Ramaswamy Viswanathan) put forth an action paper aimed at encouraging the APA to do more to educate and assist its members in making decisions about implementing electronic health records (EHRs). The proposal was debated in its assigned Reference Committee, which made revisions to the action paper before sending it back to the floor of the Assembly for discussion, further revision, and voting.

The final paper, “Improved EHR Education for Members in Solo Private Practice,” was overwhelmingly approved by the APA Assembly. This is a very timely and relevant topic, as the Centers for Medicare and Medicaid Services (CMS) is providing a small bonus for physicians who employ an EHR in their practice, and a small fee reduction for those of us who do not. This is giving many physicians a lot of anxiety over how to change their practice.

I’ll come back to this in a minute, but first I will explain the big picture of how the Assembly works for those readers who don’t know much about it. The Assembly is the deliberative body of the APA, very much like the U.S. House of Representatives. Each district branch votes on a number of Assembly representatives (and deputy representatives) proportional to the size of the APA membership in that branch. A smaller number of “reps” represent certain defined groups of members. An Assembly rep can propose an item for the Assembly to vote on.

Such items, called Action Papers, get vetted at the local level before coming to the Assembly. (There are actually more steps, but that is more detail than necessary here.) An Action Paper starts out with numerous “Whereas” statements that explain the background and reason for the paper, followed by several “Be It Resolved” statements that advise the APA what the Assembly wants the organization to do. This is how position statements get crafted, as well as how other policies and member needs get communicated to the Board of Trustees, which has the ultimate decision-making responsibility for the organization.

The Assembly meets twice per year, in November and in May. The Action Papers get divided up into Reference Committees, somewhat analogous to the various House of Representatives committees. Each committee, which may have about 8-10 people on it, hears from the paper’s author about why the paper has merit, while other reps and APA members may speak for or against the paper. At this time, further revisions or amendments may get made to the paper. The Reference Committee then makes a decision to support the paper or not, communicating that decision along with any revisions to the Assembly.

The Assembly then discusses each paper and votes to approve it or not. While I missed the Assembly discussion for this EHR Action Paper, I was present for the Reference Committee discussion where I spoke as the chair of the Committee on EHRs. The concerns raised had to do with this coming freight train of having to select an EHR, how to go about making such a decision, how to implement it and convert from paper to electronic, and what are the costs involved. The Action Paper requests the EHR committee to supplement the materials on its website, in addition to providing an area for members to discuss and compare their experiences with their own EHR, while providing additional staff support to make this happen.

The APA currently has a section on its website devoted to EHRs. This section contains important links describing the CMS incentive program, explaining the national EHR initiatives, and addressing related privacy, security, and technical issues. There is also a members-only section where one can read member reviews of several EHRs, though presently we have only 15 reviews on the site. The committee has been working for the past several months on developing an improved method that would help members provide reviews of what they have used, while also providing a framework that helps them think through the relevant issues when deciding on an EHR.

The most important decision to make is whether you want to have an EHR or continue to use your current method of documenting care. Most of us will not need to weigh the financial carrots and sticks from CMS, since they are only relevant if you have a sizable Medicaid or Medicare population. The stick amounts to up to 3% of your Medicare fees. Given that a 27% cut in Medicare fees is now on the table (or 39% per MedPAC), 3% is not worth getting excited over. Rather, the cost of the system itself will be the main financial consideration.

Other considerations have more to do with the sort of practice one has and the need for sharing information. Thinking through the risks and benefits of adopting an EHR in one’s practice can help reduce the angst one feels about this decision:

POTENTIAL BENEFITS:

• quicker exchange of information than with faxing or mailing

• less likely for papers to get misfiled or lost (eg, think Hurricane Katrina)

• better tracking of who accessed what information

• less duplication of tests

• improved coordination of care

• fewer medical errors due to more information available

• decreased liability due to sharing of important information with other providers

• improved legibility

POTENTIAL RISKS:

• decreased privacy due to potential for data breach, identity theft

• loss of data due to technical problems (viruses, hardware failure, etc)

• failure to secure data due to inadequate authentication, authorization, encryption, etc

• more errors in health record due to automated data collection processes

• increased liability due to sharing of sensitive information with other providers

Finally, just because it is electronic doesn’t necessarily make it better or safer. The Institute of Medicine recently recommended that a separate entity investigate errors resulting from the use of electronic health records, while a report in this month’s Journal of the American Medical Informatics Association found that 10% of electronic prescriptions to a commercial outpatient pharmacy chain had errors, one-third of them potentially serious. This is similar to the error rate in handwritten prescriptions.

The APA Committee on Electronic Health Records will be coming out next spring with an improved tool to assist its members in sharing their experiences with the numerous EHR products out there. Until then, ask your colleagues, go online, and share with others. Also stay tuned here, and on my blog, HIT Shrink.

<[QM]>—Steven Roy Daviss, M.D. DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, clinical assistant professor at University of Maryland, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. Find him @HITshrink on Twitter and on the Shrink Rap blog.