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Independent medical practices facing squeeze of electronic records requirements

When Patricia Edwards sees her young patients for their annual checkups, she asks how the school play went the previous spring, or how soccer camp was last summer.

She’s not endowed with a super-human memory for detail. Just an old-fashioned paper chart, with a regular habit of making notes in the margins about things that are important to her patients but that don’t fit neatly into the forms of their medical records.

Edwards is hearing from some younger doctors that they’re finding it harder and harder to connect with patients, and she wonders if their lack of margin notes couldn’t be one reason.

Why no notes in the margins for those other doctors? Their offices have switched to electronic records, so there’s no paper margin to make notes in.

“Patients pick up on this, and for doctors, you’re losing the narrative of medicine. There’s no nuance. It’s, ‘Are you doing well in school? Click. Are you playing sports? Click,’ ” said Edwards, president of Concord Pediatrics.

Whether or not to go digital is a “constant conversation” for her and her partners, Edwards said, but for now the decision is still no.

They have the ability to stay offline because the office doesn’t rely on Medicare for funding.

Other providers are finding they are stuck between adapting or losing significant portions of their revenue in the near future.

The federal stimulus bill passed in 2008 contained billions of dollars in funding for medical providers to adopt electronic health records. Hospitals jumped at the chance to use the incentives to pay for expensive electronic programs they were planning anyway.

The incentive payments are disbursed based on how many of a practice’s patients are covered by Medicaid and Medicare.

To hold providers accountable for how they used the incentive funds, the government outlined a list of standards called “meaningful use” for electronic records. All providers will have to meet meaningful use eventually, or they’ll face deductions from their Medicare payments.

Hospitals in particular faced steep penalties if they didn’t eventually comply with the standards, which are designed to increase patient safety and engagement in their medical care.

For some smaller providers, such as independent doctors’ offices like Edwards’s, the incentives haven’t been big enough to justify the costs of meeting the high standards; after all, the threat of Medicare penalties isn’t very ominous to a pediatrician.

However, for New Hampshire Oncology-Hematology, which has offices in Concord, Hooksett, Laconia and Londonderry, the looming penalties were compelling, said Peter Crow, a physician partner at the practice.

The practice has paid close to $1 million over the past five years for an initial electronic records installation, plus hardware, training, monthly software updates and maintenance, he said.

The move to electronic records was controversial, and was decided after much debate among the physician partners.

“For those who were against it, and I understand where they were coming from, they said, basically, it’s stupid and it has nothing to do with quality,” Crow said.

“I argued, if we want to keep doing the things in our practice that are important and are related to quality, we have to get money where we can. . . . There have been incentives, and it’s been good to recoup some of that money, but certainly not all of it,” he said.

Concord Women’s Care, a two-physician obstetrics and gynecological practice, adopted a cloud-based record system four years ago, partner Ashish Chaudhari said.

“Ultimately, the reason to switch was we could see the writing on the wall that technology was changing at a rapid pace and the government was going to require us to change eventually,” he said.

Like Edwards, his practice likely won’t face much threat from the Medicare penalties awaiting providers that don’t comply. But his practice wanted to take advantage of the incentive dollars.

Even with the funding, “the cost is substantial,” he said.

“There were three to six months of learning the system. . . . So there was a loss of income from seeing fewer patients, and staying later to learn the system, and paying out for the hardware and software. For at least a year, it was a solid hit,” he said.

Meaningful use was designed to achieve several goals. By having electronic records, patients could access their own health information and make more informed choices, and doctors could coordinate care across multiple health settings. Electronic records, like bar codes on prescriptions that have to match codes for the patient receiving the drug, for example, are also less open to human error.

Even while they agree electronic records can provide benefits, some doctors still say the standards can be cumbersome, time-consuming and annoying.

If a woman came to Chaudhari’s office with a minor gynecological complaint and then returned a week later for a follow-up visit, he wouldn’t have taken her blood pressure and pulse again for the paper system.

Now, the record of every visit has to contain up-to-date vital signs.

Physicians also have to mark in the record if a patient smokes, and then ask at every subsequent visit if the patient has quit or considered quitting.

“When we’re treating patients with terminal lung cancer, it really doesn’t matter if they quit smoking,” Crow said.

His practice has set up the system so the basic health questions and evaluations are handled by assistants, not the oncologists, he said.

“If it’s not part of their job and it’s not something they value, the doctor isn’t actually going to be that good at doing it,” he said. “Ideally, you’d want us to be focused on the patient with lung cancer, not on a screen.”

(Sarah Palermo can be reached at 369-3322 or or on Twitter @SPalermoNews.)

Legacy Comments23

I am always surprised by upset right wingers are about the thought of the government knowing too much about you and not even caring how private corporations and businesses are using the information they ask everyone for every time you go on line or shop The government has everyone's social security number and have had them for 70 yrs. With this number they can track you from birth to death. Maybe itsa's drone was China watching us all. Beware..

When Bush pushed and had the USA Patriot Act passed, progressives had a hissy fit and hammered him for nearly 8 years. Now that Bush is gone, the NSA is out of control, the IRS is targeting people and drones are spying on us and progressives are either silent or saying that is "no big deal". Oh I forgot the fact that Homeland Security ordered armored vehicles, one is coming to Concord, the BEARCAT and once again, progressives supported it.

Having worked over 12 years in a hospital environment I can safely say that electronic medical records are probably the best thing to come along since penicillin. Having to rely on handwritten notes in a paper file is just dangerous. Almost universally, Dr's are unable to write legibly. It is much faster to pull the patient information at a workstation than wrestle with "charts". As for the ability to have margin notes, I don't know of an installed system that doesn't have a notes or comment field available. Can this be a burden on a small practice, sure I see that, but to dismiss this because you see a veiled attempt by sinister forces to track you, is frankly crazy. If you were that worried then you are too late. This information already exists in the databases of private insurance companies, they get the bills, pharmacies to make sure of drug interactions, medicare/caid, IRS and a million different databases. You have picked the wrong battle and way too late at that. You've already been watched.

And how does a patient correct the many errors that show up on digital records? As anyone who's tried to get the light company or bank to correct a computer error knows, it's nearly impossible. As for doctor's handwriting, I worked in hospitals. It doesn't take long to figure out their handwriting. You quickly learn each doctor's handwriting patterns. You do realize the purpose of digital records is data mining, don't you? That's why doctors hate them. They're not designed for good patient care or staff use. They're designed for market research. Also, what was once private between doctor and patient is no longer. My medical records are now being shared with a hospital 35 miles away. It was done in an opt-out sleight of hand. I lost the papers I would need to fill in and send somewhere to protect my privacy. Should I have to do that to protect my medical privacy? No. I no longer confide anything in my doctor and no longer view him as a resource in my medical care. He's so busy appeasing the computer gods all I see is the top of his head. And our discussions are no longer private. I define "private," by the way, as being between two people. I do not define it as being between one person and anyone else hired in a network.

BIG BROTHER IS WATCHING YOU FROM EVERY ANGLE. This is the change NObama promised you - this is small beans compared to where the democrats plan to take you.

That is so true. A woman I know purchased a new camera and she was taking pictures of the moon. When she loaded them down on her computer she noticed something crossing over the moon, enlarging it she discovered that it was a "drone". To think that they are not watching us is naive. If Bush was still in office and all of the things that the NSA, IRS and administration were going on, progressives would be rioting in the streets. The reason why they don't care now is in their minds, the ends justify the means.

I know of someone that was related to someone else who once heard a story about a guy that was able to capture pictures of a yeti, lockness monster a rational conservative poster, and last but not least proof of UFO's. Really??? What about the off chance that you need medical care while away from your 20th century doctor. Do you wait for your records to me mailed to the new doctor? Or do you receive treatment instead of waiting for the mail because your records were available to the new doctor electronically. Perhaps I am not paranoid enough but data mining when there are hundreds of ways to get information especially if you ever use a credit card. BTW, you should google "itsarepublic", NH quite an interesting history of posts, not all from the cm. Quotes are necessary for the search.

Hey, I googled "itsarepublic" and guess what, none of the non CM posts belong to me. Are you stalking to find out who I am, well, think again, I ONLY go by ItsARepublic, it is original and I don't go by "itsarepublic". But basically, it is no one's business what illnesses I may or may not have and what I take for medications, etc. You folks started with a woman's choice is between her and her doctor, well practice what you preach. Stalk if you wish, good luck....Brad.

Brad, Stalking - you are paranoid plain and simple. I was merely pointing out how much information can be found without big brother and his data mining schemes. BTW, searches are not case sensitive. In our efforts to make life easier we have sacrificed so much privacy. You still don't get with electronic medical records, they do exist to better insure a persons care whether you believe it or not. On stalking, don't flatter yourself, geesh...

You can data mine all that you want. I have no issue with electronic medical records so long as a politician, government official, etc. don't have them, only my doctor and I should have access.

Itsa, finally something we both agree on.

Well, when that happened in our family the patient received immediate excellent treatment. Without any records from the "family doctor" now owned by a large corporation. The patient rarely gets to see the doctor, the doctor is too rushed to do a good job. But we get regular calls and letters from the medical corporation that own him trying to sell us lucrative services *they've* decided we "need." We get these calls whenever our insurance company covers something new. Suddenly we need it. And our data is right there, available for mining. This has nothing to do with medical care.

Hilarious! - this article is about the strong arm of Big Govt mandating a business to do something or the big bad Govt punishes them ...Some how an elite liberal turns that issue around to smack the for-profit sector that has made America great. That kind of political thought has 2 feet well over the line into a philosophy that has "ISM" after it and it isnt capitalism.

What are you talking about, do you know? I suppose that if your Dr's office doesn't care about providing vital patient info to another Dr. office that would be one thing. But just how many family doctors actually don't refer people to outside specialists?? As for forcing rules down medical practices throats, READ carefully - only if they participate or plan to participate with Medicare. Selective reading at it's finest.

Go to the Obamacare website. On about the third or fourth click it tells you that your private information may be used by the IRS, etc. and you have to expect no right to privacy. Privacy is protected under the US Constitution. Do you know how dangerous it is for politicians to have that kind of information?

silly girl...didn't you know that a democrat has already proposed that all doctors MUST take Medicare and Medicaid patients. That is not the democrat party of your parents that is a party so far left they have escaped the gravitational pull of the earth

sail, Who on earth do you think OWNS these politicians you hate so much? None other than your precious corporations. Do you seriously think they're operating in some sort of rarified vacuum???

I was a relative, I have the picture, it was a drone. Disgusting that Big Brother is watching......and unConstitutional.

Data mining is sooo much easier when the specific type of data is all in one tidy place. Can you not see this? Are you saying doctors were unable to treat people before digital records? Really? It takes months to get an appointment with some specialists, plenty of time to send records, you know. We also have FAX machines. We also have patients who can hand carry records.

You made that up, right, Itsa? You droll fellow you, playing with sail like that!

mr. sail, once again I agree with your sentiment but not your facts. I am vehemently opposed to digital medical records. But surely you can manage to see beyond your cloud of hate to have noticed digital records preceded Obama's election. It really would not matter who is president. These digital records are being pushed by hospitals (CH markets to me relentlessly, using info mined from my medical records) and pharmaceutical companies. These corporations own all the politicians. We're nothing but pawns in the game and you really short yourself by focusing your hatefulness on one person. What are you going to do when he leaves office? Who will you replace him with as your Objet d' Hate?

These electronic records are part of the corporatization of medicine. They exist for the purpose of data mining and will make a bundle for pharmaceutical companies, insurance companies and the hospitals that now own your doctor.

that is an incorrect supposition.

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