Paperwork in an EHR-enabled medical office

Robert Rowley, MD
Twitter: @RRowleyMD

Electronic Health Records (EHR) systems come with the vision of eliminating paper in a medical practice. “No more paper” is the rallying cry of many an EHR company. But is this the case? As it turns out, not really. Stacks of legible, computer-generated paper still pile up on a medical practitioner’s desk, despite having an EHR system that addresses workflows within the walls of the office.

In its current stage of development, health IT has created products that work reasonably well within their silos. Yet healthcare is more interconnected, and addressing these cross-system workflow issues has not yet been adequately served by current technology. This is especially true for primary care, where care coordination between different entities (each highly regulated and forms-driven) is a big part of daily life.

To look into this with a bit more detail, let’s look at a specific example, which can serve as an illustrative anecdote to the issues here. My own practice is a primary care small-group practice, which has been using an EHR for a number of years (Practice Fusion). It functions within a large regional Independent Practice Association (IPA) which delivers, manages, and takes risk for multiple HMO contracts (both commercial and Medicare Advantage) – this accounts for just under half the business, with the rest being a combination of standard Medicare, Medicaid and commercial PPO. The IPA makes available an account with Relay Health, which serves both as a conduit for IPA network referrals and authorizations, as well as a secure email portal for patients to the practice (the PHR exposed to patients from Practice Fusion does not yet have the ability to conduct two-way secure messaging with patients, so we use Relay Health for this).

Paperwork that has been eliminated by the EHR
Most of the in-house workflows have been rolled into the EHR. To be clear, it’s not that the work has disappeared – it’s just that this work can be done using the EHR, and therefore does not drop to paper. Given that our EHR is web-based, this work can be done in the office or outside the office (e.g. from home).

What is gone is the mountain of charts from patients seen the current day, needing notes to be completed, and bills sent. What is gone is the additional mountain of charts from refill requests, phone messages from patients, lab and other reports needing review, and forms that need filling out. The EHR allows more thorough, legible and (once one becomes facile with the interface) faster creation of chart notes for patients seen. Refills can be managed, labs can be reviewed, and messages can be handled without needing to drop anything to paper, with the documentation becoming an integral part of the patient record. Similarly, documents that come into the practice via fax or mail can be scanned, uploaded, tagged and placed into the patient’s record.

Certainly, this is a huge leap forward from the days in the 1990s, prior to our using an EHR. The common experience of staying late in the office “catching up on paperwork and completing charting” is dramatically reduced. This was work that needed to be done in-person, in the office, and often after-hours, since that was where the charts were. Now, if there is any spill-over of work around charting, lab review, message management, refill management, or scanned document review, these can now be done remotely, from home or elsewhere. Getting home in time for dinner is the rule, no longer the exception.

Paperwork that has not been eliminated by the EHR
Despite having an EHR, there is still a considerable pile of paperwork that builds daily on my desk. Looking through them, this falls into roughly 5 main categories. These will be examined in more detail below, with hopes that their description can serve as a set of use-cases for advancement of health IT tools.

Refills. Even though the EHR contains built-in e-prescribing capability, and is able to receive refill requests from pharmacies through the Surescripts hub used by the EHR, not all refill requests come in through that channel. Refill requests for a primary care practice is a significant workload – in our practice somewhere between 20 and 30 refill requests are received every day. Slightly less than one-third of these requests come through Surescripts. The remainder come either from patients calling the office and requesting a refill (or requesting it through secure messaging – in our case, Relay Health messages), or from faxes from pharmacies.

The phone message refill requests can be handled within the EHR. However, the refill requests from faxes remain a burden. For reasons unclear, pharmacies that may send a refill request via Surescripts (and therefore via the preferred channel to our system) for some patients also send fax requests on other patients. Such faxes then need to be addressed manually one-at-a-time, the record opened up, and an eRx sent (shredding the paper fax when finished).

DME supplies. Routine medical supplies, often diabetes testing supplies such as test strips and lancets, usually come as faxed requests. Rarely do they come in via Surescripts. The DME vendors require certain information beyond the usual items on a prescription – diagnosis, whether insulin dependent or not, when the patient was last seen, and justification if the usage rates exceed Medicare allowances. Therefore, DME suppliers have specific authorization forms that needs to be filled out for each prescription of supplies. In our experience, this is requested a few times every day.

Disability and similar paperwork. Patients who are temporarily disabled often need state disability paperwork filled out, or FMLA forms completed. The state disability form is a 6-page document (4 pages filled out by the patient, 2 filled out by the clinician). The state is moving to an on-line version of the form, but even with that it is a workflow outside the boundaries of the EHR. The documents require a “wet signature”, then need to be faxed out, and scanned in to the EHR record as a scanned document. These forms need completion generally a handful of times each week.

Clearance for elective surgeries, and other communications with specialists. In primary care, one is generally a referral-generating source, rather than a referral-receiving place. Referrals to others are an administrative function, which usually need a referral and/or authorization number, and the referrals (even if computerized) need to be uploaded into specific web portals. Our EHR has attempted to address this with some in-product features, but these have not been very successful in that they do not address the actual steps needed in a referral workflow.

Commonly, some surgical specialties (e.g. ophthalmology, in anticipation of elective cataract surgery) need medical clearance prior to outpatient surgeries. Such requests are often via a form faxed from the specialist’s office, and can generally be addressed by printing out sections of the patient chart (problem lists, medications, allergies, recent labs, sometimes recent imaging study reports and EKGs), and faxing it back to the specialist.

It is naïve to think that the specialists that we deal with will be on the same platform (a few are, but most are on a whole array of different EHR products). True peer-to-peer connectivity tools, which can effectively transmit information between disparate practices, is an active hotbed of innovation in health IT currently. The kinds of things that are needed are more than just summaries (problem lists, medication lists, allergies), but also include some specific documents (like labs, EKGs, other correspondence, and imaging reports).

Home health forms. By far, the largest paper volume that builds on my desk comes from home health agencies. Home health derives most of its income from Medicare, given the population that needs their services, and is highly regulated. There are home health-specific software products that gather all the needed data points, present them in the needed fashion, and report them to Medicare for payment and certification (the OSCAR data, maintained by CMS). They are not going to abandon these products. This represents a significant silo outside an in-office EHR.

In addition, there are very many different competing home health agencies. CMS data in 2011 showed that there are over 11,000 Medicare certified home health agencies in the U.S., with 1015 of them in my state of California alone. The forms presented by each agency is a little different from those presented by other such agencies (they use different software, much like different medical practices use different EHR software).

What is universal, though, is that every care summary, every update, and every single order needs to be “wet signed” by the physician and returned to the agency. Depending on the number of frail and home-bound patients being followed by home health (and in primary care it can be a few dozen at any given time), this may result in several hundred pages of paper that needs to be “wet signed”  and returned. Typically this is all trafficked through faxes, and the signed documents then scanned and entered into the EHR.

Conclusions
The use of EHRs in ambulatory medical practices has come a long way in relieving many of the paperwork burdens facing a busy clinician. However, it is naïve to believe that this alone will eliminate all paperwork. Several domains of common paperwork still clog the workflows of an office, and result in a continuous stack of paper that needs to be addressed, despite having an EHR-enabled practice.

Collaboration tools will help coordinate communication between different practices using different EHR products. It is short-sighted to think that this will emerge from current EHR vendors, unless they are forced (which Meaningful Use stage 2 and 3 will pressure). More likely, new companies will emerge that will be successful in addressing this gap.

One of the biggest burdens, however, is interfacing with systems, already computerized within their internal silos, which require “wet signatures” for authorization of services. Home health is a very big part of this. As we move towards more organized delivery systems (such as ACOs), the use of home health will undoubtedly increase, and good collaboration between platforms is needed.

There is both a policy and a technology issue here. An effective way of capturing an equivalent of a “wet signature” for all authorizations (particularly with home health), and trafficking the order sets back and forth between settings is a policy question (Medicare needs to allow some way of doing this in its OSCAR data reporting). It is also a technology question. Perhaps lessons from Computer Physician Order Entry (CPOE) systems used in hospital EHRs can be applied to outpatient cross-platform order entry. This is an area ripe for innovation, and (once solved) will result in some of the largest-volume paperwork reduction that residually still burdens an EHR-enabled medical practice.