Published: September 1, 2016

By Terri D’Arrigo

Electronic health records (EHR) systems are constantly evolving to meet the Centers for Medicare and Medicaid Services’ (CMS) requirements for meaningful use and transition medicine into digitization. Amid the ebb and flow of change, one thing remains certain: EHRs are here to stay.

Not that all dermatologists are happy about it. Far from it, as a 2016 survey of 1,424 members of the American Academy of Dermatology (AAD) reveals that 61 percent of the 1,022 respondents who have adopted an EHR feel that working with EHRs takes time away from their patients, and only 29 percent feel that EHRs improve their practice’s quality of care. Overall, survey respondents tended to feel that EHRs decreased efficiency.

The news isn’t all bad. Satisfaction with EHR has increased since the last AAD survey in 2011. Now 46 percent report being satisfied with their EHRs, compared to 33 percent in 2011. Still, with 25 percent currently unsatisfied with their EHR systems, challenges remain.

“Office managers like EHR, but dermatologists see fewer patients per day at much higher operational cost. Add that to stagnant reimbursement, and profit margins grow thinner every year,” said Marc Darst, MD, of Darst Dermatology in Charlotte, North Carolina, who is chair of the AAD’s EHR Implementation Task Force. “Many are hiring more staff or using EHRs with templates, which are a necessity to see a regular volume of patients [in dermatology], although the official recommendation is not to use templates because of the potential [risk] for cloning of charts.”

Indeed, only 17 percent of respondents in the 2016 survey agreed with the statement that EHR has or will save their practices money, compared to 24 percent in 2011, and only 20 percent agreed that office productivity improved after EHR, compared to 25 percent in 2011. Among the 335 who responded to a 2016 question about the role EHR played in their practice, 41 percent said it increased staff, 15 percent said they were using medical assistants as scribes, and 15 percent said EHR compelled them to increase the number of medical assistants on their staffs, while 9 percent said it increased clerical staff.

For the expense, Dr. Darst notes the catch-22 of CMS reimbursement. “At this point, the penalties become so onerous, I don’t think anyone can afford to stay with paper.”

Yet some dermatologists have opted out of reporting for meaningful use. Of the 101 survey respondents who did so, 67 percent said the Stage 2 measures were too difficult to implement, 35 percent said it was too costly to continue the program and they would rather take the penalty, and 22 percent said they couldn’t perform measures for a full-year reporting period. (Dermatologists who do not report in 2016 face a 4 percent penalty from Medicare in 2018, after which meaningful use will transition into the Advancing Care Information component of MIPS. See p. 52 for more.)

Dermatology is different

If the whole point of EHR is to streamline information-gathering and make it easier for clinicians to access records, yet many dermatologists are less than enthused about using EHRs, what gives?

Part of it is the nature of the specialty in relation to reporting requirements, said Erin Gardner, MD, of Dermatology Specialists of St. Louis, who is deputy chair of the AAD’s EHR Implementation Task Force. “The few quality measures that do apply to dermatologists are only tangentially related to typical dermatology practice, like the requirement for inquiring about smoking status and counseling patients on smoking cessation.”

In other words, dermatologists are being asked to account for measures that aren’t intrinsic to their practice, while simultaneously not being rewarded for providing high-quality care in the specialty they studied and trained for.

The sheer volume of notes to manage in an EHR system adds to the burden, Dr. Gardner said. “Burnout is on the rise among physicians, and dermatologists are among those with the highest rates of increase.” Indeed, a recent Mayo Clinic Proceedings study found reports of burnout in dermatology rising from 31 percent to 56 percent between 2011 and 2014 (90(12):1600-1613). “The problem is all the clerical documenting physicians are required to perform — so many clicks, so many swipes, it leads to fatigue. Dermatologists see a lot more patients compared to physicians in family practice, with that many more notes to complete.”

The elements of dermatologic evaluation and diagnosis also play a role, Dr. Darst said. “We derive diagnosis from visual observation. We use graphical documentation, like a body diagram on which to note where the [pathology] is.”

Dr. Darst noted that dermatology is not only a medical field, but a surgical one. “The average dermatologist does 1,000 biopsies a year. That requires a robust biopsy log. We use traditional paper in addition to EHR because it’s hard to trust the computer with [that much information].”

To that end, dermatologists cannot just buy an EHR system designed for internists. They need systems designed specifically to meet their needs.

“With such a visual specialty, it’s important to be able to include photographs and images, not only to help track lesions, but for patient safety, specifically ensuring the correct biopsy site. We need realistic and anatomically correct body images that can be marked,” Dr. Gardner said.

Furthermore, as noted in an editorial in the September 2012 Seminars in Cutaneous Medicine and Surgery, many private dermatologists outsource their biopsy results to private dermatopathology labs for reading (2012 Sep;31(3):160-2). Situations like that, and cases involving patients who must be treated in hospitals, bring to light the issue of interoperability.

“When a patient is referred to me for treatment of skin cancer and I can’t get a photograph easily through electronic means, it makes delivering patient care more challenging. So few systems have interoperability right now that it slows down care and can impede the treatment regimens of patients,” Dr. Gardner said.

Once again, meaningful use rears its head. “There is a major challenge with other providers that use EHR, especially hospitals. Meaningful use requires a certain amount of referrals, but hospitals are not ready for us to interface with them, and smaller EHR vendors don’t communicate between themselves well, if at all,” Dr. Darst said.

Dr. Gardner is hopeful. “Fortunately, interoperability is one area where the government is on target in focusing its efforts. Once interoperability exists, I believe we’ll be a lot closer to realizing the potential of EHR.”

Vendor challenges

The vendors of the three most-used dermatology EHR systems — Modernizing Medicine and Nextech on the practice side and Epic on the hospital and academic side — are aware of the challenges they face in meeting dermatologists’ needs.

Avoiding redundancy is key, said Michael Sherling, MD, MBA, co-founder and chief medical officer of Modernizing Medicine, in Boca Raton, Florida. “Dermatologists need systems that capture structured data and don’t ask them to put in information and documentation they already put in.”

Dr. Sherling pointed to inquiring about smoking status as an example. “Once the dermatologist asks if the patient is a smoker, the system should collect that information and generate it for the measures that ask for it. It should automatically do the bean-counting in the background, and the amount of clicking needs to be kept to a minimum.”

Christina Majeed, MS, chief product officer at Nextech in Tampa, Florida, agreed. “It’s important to have an EHR that can make compliance with meaningful use and the Physician Quality Reporting System seamless, one that aligns the measures they need to report on to be efficient, and not make them report on [each program’s] quality measures, which is duplicate work.”

On the clinical side, at the time of the 2016 survey, all the major dermatology systems allowed for photo upload and archiving, viewing integrated lab results, and anatomic graphics or lesion mapping. Yet users did not report that their systems offered the ability to view integrated pathology slide images, receive or respond to physician’s live telederm consults, or receive or respond to patients’ live telederm consults. (Nextech has since added live interactive teledermatology consult capabilities through its partner, DermatologistOnCall.)

Interoperability continues to challenge vendors. The legalities of information-sharing contribute to the problem, said Eric Helsher, vice president of client success at Epic in Madison, Wisconsin.

“The primary barrier to ubiquitous interoperability has been the need for health systems to create one-off legal agreements with each other prior to exchanging patient information,” Helsher said. “This typically involves aligning legal and compliance teams and is often time consuming. The technical standards for meaningful exchange exist and are in use today, but there is not a universally adopted set of operational policies, or rules of the road,’ for managing patient consent and other legal aspects of sharing patient information.”

The Office of the National Coordinator for Health Information Technology’s (ONC) Draft 2016 Interoperability Standards Advisory provides a model by which the ONC coordinates the identification, assessment, and determination of the “best available” interoperability standards and implementation specifications for industry to fulfill interoperability needs, but it’s non-binding. Public-private collaborations like the Sequoia Project’s Carequality Interoperability Framework use consensus among stakeholders to enable seamless connectivity across all participating networks, but entities need to belong to a participating network. Non-profit trade association CommonWell developed CommonWell Health Alliance, a vendor-led interoperability initiative in which providers contract directly with health IT suppliers for EHRs and other health technology services. Again, members need to pay a subscription fee, including vendors. Another non-profit, Health Level Seven International (HL7), offers standards accepted by the U.S. Department of Health and Human Services as well as a standards framework, Fast Health Interoperable Resources.

Yet the question of interoperability remains, particularly when providers must join networks that may or may not “talk” to each other. For example, Epic has adopted Carequality, but is not a member of CommonWell Health Alliance.

Dr. Sherling, whose company joined CommonWell Health Alliance earlier this year, believes there is still much work to be done. “Vendors have a long way to go to talk to one another. [We need] a Rosetta Stone of what EHR systems need to talk to one another.”

The onus should be on the vendors themselves, Majeed said. “It behooves any company to have an open policy when it comes to linking, whether they are linking hospitals, labs, or dermatology practices.”

The future

As the government requirements for quality reporting and meaningful use evolve, and as vendors and networks confront interoperability, dermatologists are left with finding ways to get the most out of their EHR systems without incurring expenses that eat away at their bottom lines or inviting audits for meaningful use.

“Scribes are going to become more important in documenting electronically. In order for physicians to turn their focus back toward patients and give patients the kind of attention that is best for diagnosis and treatment, a scribe is almost necessary,” Dr. Gardner said.

Majeed said that dermatologists seek systems that can be tailored to their needs. “They’re looking for an EHR that is in tune to the needs of the specialty. They want systems that are intuitive and easy to tweak to their workflow without having to rely on third parties to help them. For example, if there are items they never use in the pick list, they should be able to hide them as options, and conversely add items on the fly that they use every day.”

Majeed noted the expansion of telemedicine in dermatology. “It will become more and more important, with patients wanting answers at their fingertips and physicians wanting to extend care through different channels, like online visits. [There is a place for] systems where patients can upload photos, or sync up with the doctor via video, and the dermatologist or PA can decide if the patient needs an appointment, or a diagnosis and prescription right there.”

Dr. Sherling agrees. “Telemedicine is not a replacement for in-person visits, especially when establishing patient relationships. But it can be a useful tool for follow-up care and between patients and dermatologists who already have a relationship and have full access to the medical record.”

Beyond that, Dr. Sherling sees a larger role for analytics. “Physicians should have the ability to mine their own data. They should be able to see how they are doing financially, operationally, and clinically, and they should be able to get to all of that data in a way that helps them visualize where they stand. Do they spend more money per Medicare beneficiary or perform better from a quality perspective than their peers?”

Such information should be actionable, Dr. Sherling added. “They need the information presented so they can make necessary changes to get their incentives and avoid penalties.”

Majeed agrees. “Overall practice analytics across the clinical side, to the billing side, as well as to the front office operations is vital for a practice to ensure they are managing and providing the best patient care possible.”

But perhaps most of all, dermatologists seek simplicity.

“My hope is that we can streamline the evaluation and documentation requirements so we can focus on what is important to our practice, and leave optional some of the things that may not be so pertinent to our patients’ care,” Dr. Gardner said. “Most physicians didn’t go to medical school or choose their careers to spend so much time on clerical tasks and data entry.”