The Vitals - May 2015
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Despite Benefits, Switching EHRs Comes at High Cost
LEAWOOD, KS — When trying to decide whether to migrate from a current electronic health record (EHR) to a different one, some practices might be better off following the adage, “Grow where you are planted.”
The changeover rarely is an unmitigated success, according to the latest survey from the journal Family Practice Management, published by the American Academy of Family Physicians.
“Over the last several years, electronic health record (EHR) systems have become pervasive,” according to the report authored by Kenneth G. Adler, MD, the journal’s medical editor who practices in Tucson, AZ, and Robert Edsall, former editor-in-chief of the publication who now works as a freelance medical writer and editor based in Kansas City, MO. “Numerous surveys, including our prior surveys, have shown that overall physician satisfaction with EHRs is relatively low. Increasingly, physicians are changing EHRs or at least wondering if there are better EHRs out there.”
The authors said they sought to answer three questions:
- What key factors are driving practices to change EHRs?
- What main challenges are they encountering along the way?
- Does changing EHRs lead to improved EHR performance and user satisfaction?
Family physicians were invited to respond to the survey, which was published in Family Practice Management and data was collected from mid-July through September 2014.
After exclusions for failing to meet participation criteria or answering all questions, 305 respondents were left — about half in practices up to nine physicians and the other half in practices of 10 or more.
Survey responses involved 41 EHR systems in current use, and 73 in previous use.
Respondents said the primary reasons for changing EHR systems included a need for additional functionality, an effort to meet meaningful use requirements, an attempt to increase usability and improving training and support.
Most, 59%, of the respondents expressed agreement or strong agreement that switching to a new system had improved functionality and 57% indicated that, because of the change, their practice now was better able to meet meaningful use requirements.
Yet only 43% of respondents said they were pleased with the change to a different EHR system, although the physicians who were directly involved in the decision to change EHR systems expressed more satisfaction than those who did not play a part in the decision.
In addition, 81% of those answering the survey said they found changing an electronic medical record system to be challenging because of issues such as productivity loss, data loss and data migration problems.
While conceding that changing EHR systems might be necessary in some situations, authors of the report emphasize that "if you just want to change because you don't like using your current EHR or consider it a drag on your productivity, the grass may not be greener on the other side."
Congress Repeals Sustainable Growth Rate – Now What?
WASHINGTON, DC — When it was put into place in 1997, the sustainable growth rate (SGR) formula was touted as a way to control government spending on physician services.
Over the years, however, the formula, which ties physician payment updates to the relationship between overall fee schedule spending and growth in gross domestic product (GDP), has been found to be unsustainable.
Congress has enacted 17 short-term patches to prevent significant Medicare reimbursement rate cuts over the past decade at a cost of $150 billion. Without legislative intervention, physician services would have faced a 21.2% payment reduction this year.
That didn’t happen, of course, because the repeal of the formula despised by physicians has been passed by Congress and signed by President Obama.
In signing the legislation, Obama said it will help improve physicians' quality of care "because it starts encouraging payments based on quality, not the number of tests that are provided or the number of procedures that are applied but whether or not people actually start feeling better … it encourages us to continue to make the system better without denying service."
The question for many physicians is, “What’s next?”
The SGR Repeal and Medicare Provider Payment Modernization Act of 2014 provides for the following:
- Ends the use of the SGR methodology from the determination of such annual conversion factors;
- Prescribes an update to the single conversion factor for 2014-18 of 0.5%;
- Freezes the update to the single conversion factor at 0.00% for 2019-2023, and
- Establishes for 2024 and subsequent years an update of 1% for health professionals participating in alternative payment models and an update of 0.5% for all other health professionals.
While Republicans and Democrats reached some agreements on policy last year, the greatest barrier to replacing the SGR formula remained how to pay for it. This year’s bill was passed overwhelmingly despite vehement objections by fiscal conservatives because the costs were not completely offset by other budget cuts.
The new law also streamlines Medicare’s existing web of quality programs into one value-based performance program that would increase payment accuracy and encourages physicians to adopt proven practices, according to the bill’s supporters.
At the same time, incentives are included to promote the use of alternative payment models to encourage doctors and providers to focus more on coordination and prevention to improve quality and reduce costs, proponents emphasized..
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Reliable Research Available on Very Few Commercial Weight Loss Programs
BALTIMORE – Just telling patients they need eat less and move more to lose weight rarely is effective. Physicians often need to make specific recommendations on where they can get help in taking off the pounds.
The problem is that relatively little evidence exists on the effectiveness of commercial weight-loss programs, according to a new study published recently in the Annals of Internal Medicine.
To help physicians navigate the effective of the programs, Johns Hopkins University School of Medicine researchers reviewed 4,200 studies on 32 major weight loss programs. They found that only 11 of the programs have undergone rigorous study, and only two of those programs – Weight Watchers and Jenny Craig — can prove scientifically that their participants, on average, lost more weight after one year than people dieting on their own, just getting printed health information, or simply receiving other forms of education and counseling sessions.
"Primary care doctors need to know what programs have rigorous trials showing that they work, but they haven't had much evidence to rely on," said Kimberly Gudzune, MD, an assistant professor of medicine and a weight-loss specialist at Johns Hopkins. "Our review should give clinicians a better idea of what programs they might consider for their patients."
For the study, peer-reviewed articles from two major research literature databases and the weight-loss programs themselves were collected by researchers. Included were investigations that ran for 12 weeks or longer and were randomized controlled trials.
Because the majority of weight-loss programs have never been studied in randomized clinical trials, the researchers say, they ended up with 39 trials covering 11 programs. The programs fell into three categories:
- High-intensity programs, such as Weight Watchers, Jenny Craig and Nutrisystem, which incorporate goal setting, self-monitoring, nutritional information and counseling;
- Very-low-calorie meal replacement programs, such as HMR, Medifast and OPTIFAST; and
- Self-directed programs, including Atkins, SlimFast, and the Internet-based Biggest Loser Club, eDiets and Lose It!
"Clinicians could consider referring patients who are overweight or obese to Weight Watchers or Jenny Craig,” the authors suggest. “Other popular programs, such as Nutrisystem, show promising weight-loss results, but additional studies evaluating long-term outcomes are needed.”
The study found that programs based on the Atkins diet — high in fat, low in carbohydrates — also helped people lose more weight at six months and 12 months than counseling alone, adding that the approach "appears promising.”
Recommendations on Screening for Diabetes Continue to Evolve
PORTLAND, OR – To screen or not to screen for diabetes.
That is the question researchers tackled as they worked on an upcoming update of U.S. Preventive Services Task Force recommendations on whether physicians should screen asymptomatic, non-pregnant adults for type 2 diabetes. The results were published recently in Annals of Internal Medicine.
Proponents have argued that widely screening for diabetes could lead to earlier identification as well as earlier and more intensive treatment, which could improve health outcomes. Studies on the issue haven’t completely borne that out, however, finding that screening does not improve mortality rates after 10 years of follow up.
A study team from Pacific Northwest Evidence-based Practice Center and Oregon Health & Science University reviewed studies published from 2007 through October 2014 to assess the benefits and harms of screening for type 2 diabetes, impaired fasting glucose, or impaired glucose tolerance among asymptomatic adults.
Researchers found that, in two trials, screening for diabetes was associated with no 10-year mortality benefit vs. not screening. While 16 trials consistently found that treatment of impaired fasting glucose (IFG) or impaired glucose tolerance ( IGT) was associated with delayed progression to diabetes, most trials of treatment of IFG or IGT found no effects on all-cause or cardiovascular mortality.
One trial indicated that lifestyle modification was associated with decreased risk for both outcomes after 23 years, while another trial found no effect of an intensive multifactorial intervention on risk for all-cause or cardiovascular mortality for screen-detected diabetes vs. standard control.
In diabetes that was not specifically screen-detected, nine systematic reviews found that intensive glucose control did not reduce risk for all-cause or cardiovascular mortality and results for intensive blood pressure control were inconsistent.
In 2008, the USPSTF recommended that physicians screen for type 2 diabetes in adults with treated or untreated sustained blood pressure greater than 135/80 mm Hg, even if they showed no symptoms of high blood sugar. That recommendation was based both on the ability of screening to identify persons with diabetes and evidence that more-intensive blood pressure treatment was associated with reduced risk for cardiovascular events, including cardiovascular mortality, in patients with diabetes and hypertension.
Later studies suggested otherwise.
“Screening for diabetes did not improve mortality rates after 10 years of follow-up,” the authors point out. “More evidence is needed to determine the effectiveness of treatments for screen-detected diabetes. Treatment of IFG or IGT was associated with delayed progression to diabetes.”
Draft recommendations for public comment were posted last October, and the task force currently is incorporating that commentary to finalize the recommendations for future release.
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