Cash contests alone won't make EHRs work for specialists

A new contest announced by the Office of the National Coordinator for Health IT (ONC) offers cash prizes for applications that integrate ophthalmologists' examination devices with their electronic health records. If one or more parties came up with apps that met all of ONC's criteria by Nov. 9, the contest deadline, that could be a step forward for eye doctors. But it would still address only a portion of their health IT needs.

Here's what ONC requires of the winning application: it must warehouse data from many different devices; convert the data from proprietary formats to a single, vendor-neutral format; enable clinicians to manipulate data and images; and interface with existing EHR systems (presumably, just the top dozen or so).

To the uninitiated, that might seem sufficient to create an information system that would fit an ophthalmologist's workflow. But a 2011 report from the American Academy of Ophthalmology paints a different picture.

For starters, the report notes that most EHRs were designed for primary care and include features that don't meet eye doctors' needs. For example, these systems allow the documentation of vital signs that an ophthalmologist would never record, such as height and weight, while neglecting other vital signs, such as visual acuity and intraocular pressure, that are fundamental to an eye exam.

In addition, ophthalmologists often make anatomical drawings and notate them. The mouse-based drawing methods used in most EHRs just frustrate them, the report noted. Moreover, ophthalmology is both a medical and a surgical specialty, with a unique workflow that is rarely replicated in EHRs.

While there are specialized EHRs for ophthalmologists, they're produced by small firms that lack the resources to integrate their systems with the devices used in ophthalmology practices. And the major vendors have no business incentive to tailor their systems for this relatively small specialty.

Ophthalmologists are not the only ones who have a beef with EHR vendors. There are very few EHRs designed for oncologists, partly because of the complexity of administering chemotherapeutic drugs. And, although cardiologists said they were more satisfied with their EHRs than eye or cancer specialists in a recent KLAS survey, subspecialties such as electrophysiology have unusual needs that are difficult for vendors to satisfy.

On a scale of one to 10, the KLAS survey found that internists and family physicians rated their satisfaction with EHRs at 7.6 and 7.5, respectively, compared to 5.8 for oncologists and ophthalmologists.

So what can be done? Cash contests might make a dent in the problem if EHR vendors used the winning apps. But the companies would have a stronger incentive to invest in specialty versions of their EHRs if CMS gave eligible professionals a wider choice of clinical quality measures (CQMs) in Stage 2 of Meaningful Use.

In its notice of proposed rulemaking (NPRM), CMS provided two options for quality reporting: 1) EPs could choose 12 measures from a long list of potential CQMs on the proviso that they selected at least one metric from each of six specified domains; or 2) EPs would have to report on 11 "core" CQMs and one measure selected from a menu. CMS does not plan to let physicians choose between these two methods; instead, the agency will require one or the other.

For specialists, the first option is clearly preferable, because it is much more likely they'd be able to find measures that fit their specialties. And if certified EHRs had to be able to produce a wide range of quality data, vendors would be forced to expand their software to meet the needs of specialists.

Of course, this approach is not a cure-all. It wouldn't ensure, for example, that vendors integrated the devices used by ophthalmologists and other specialists with their EHRs. But it could go a long way toward increasing the differentiation of EHRs by specialty. And that, in turn, would make EHRs more usable by more physicians. - Ken

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