EHRs -- Is It Just Me, or Are They Worthless

[jmj11]

As we know, the ACA is going to change in one or two years. Probably meaningful use and PQRS etc.  However, as I have watched this 5-year experiment, I am starting to think the EMR have not contributed to better medicine.

 

I have experimented with several.  I created one that was the Lamborghini of EHRs (and cost like one) and it almost ruined us. Now I use the very basic and simple template that I can.

 

So here's my question. I work in a specialty practice and all of my patients are by referral. They come in with big packet of chart notes from their PCP. I find them worthless. They are filled to the brim with data for Meaningful use, but the word "headache" is rarely mentioned. It is not a big deal to me, but I just think their purpose it to appease lawyers, insurance companies (who want to look at the documented time spent and points clicked) and meeting meaningful use, but do not contribute to the patient's better care at all. I usually can't even find a current medication list.

[Reality Check 2]

I would agree that EMRs have not improved the art of medicine. I have used many and hate several.

 

I currently muddle through Greenway. My list of grievances is long and anything that slows me down or makes it difficult to provide a patient timely care is a complete waste of my time.

 

Our EHR can't escribe a medication that is manually entered - such as formulated Diltiazem Cream for hemorrhoids - have to print and manually fax the Rx to the pharmacy.

 

I do not take the computer into the room with me on the patient visit and still take handwritten notes.

 

One of my biggest goals has been to produce a note that is actually useful to the specialist. My plan section is usually verbose including my differential diagnosis - list of exclusionary data and desires for the specialist to help and specifically why.

 

I still dictate and HPI using Dragon so it isn't a staccato disaster. The EHR version - pain is new. pain is not at rest. pain is right sided. pain is in the head..... See Jane beat the EHR to death...............

 

My best mentors and teachers taught me to write a chart to paint a picture so someone else could read it and has an idea of what the hell is going on. 

 

Not a huge proponent of govt overlord stuff - but a universal EHR might not have been a bad idea. And not using it to mine data - how about using it to actually provide good patient care and continuity so folks can find stuff.

 

So, yeah EHRs had grand plans but have failed to meet the mark, in my opinion.

[Katera]

Depends on the EMR.  Docutap = heaven   NextGen = hell.

[Reality Check 2]

We nicknamed Allscripts - AllCRAP all the time. I vote it as the single WORST EHR ever made - ever.

 

Epic is meh, ok, not great.

 

I actually really like Centricity.

 

Meditech is an ancient system that accesses the hospitals and I believe is still DOS based - dear heaven - might as well be a bird with a stone tablet on the Flintstones.

 

I can still type faster than any of them

[EMEDPA]

I like to dictate. cerner is ok. epic bites. any emr detracts from pt care by taking you away from the bedside. we shouldn't spend more time typing than seeing pts.

[Reality Check 2]

Unfortunately, I envision body cams and constant recording in the future - read too many sci fi books......

 

I MIGHT take on a virtual touchscreen in the room that takes my voice and puts it where I want it in a chart - yeah, dream on.

 

I want to be a size 4 too.....................................

[Guest Paula]

Unfortunately, I envision body cams and constant recording in the future - read too many sci fi books......

 

I MIGHT take on a virtual touchscreen in the room that takes my voice and puts it where I want it in a chart - yeah, dream on.

 

I want to be a size 4 too.....................................

 

 

Now there's an idea for an entrepreneur to develop that technology and I can assure you someone will do exactly that.  How about you?

 

Click the mouse on the HPI and ask the questions and they automatically get loaded in the chart.

Exam: speak exam findings out loud and VOILA they are recorded in the chart or in the cloud

Speak the A & P and it is in the chart instantly.  Voice the prescription outloud and the pharmacy gets it without a fax or electronic script.

Sign and done.

 

Or put an Alexa in each room!

[SedRate]

^That sounds amazing... Jmj11, any interest in getting this started? Lol

[Evolute]

Depends on the EMR.  Docutap = heaven   NextGen = hell.

 

Never used Docutap, but I agree NextGen is very painful to use. But to say it is hell is a gross understatement, its much worse.

[Reality Check 2]

I envision a bit of Ironman's Jarvis and the up in the air display where I wave my hands and change stuff. Could pull up a chest xray and show the patient everything.

 

The ultimate would be the Jarvis voice with a touch of smartass.....

[DogLovingPA]

Jmj11..... completely agree. I feel like important medical info is missed because of EHR (nursing notes, triage info, vitals, etc) because we don't have time (or make time) to log in, open a patient chart and read everything before seeing the patient. They are all cumbersome, I can never find the information I want when I do try to find it. And yes, the notes, the notes are worse than hell. I could care less that their paternal uncle had a stroke - what the heck is the assessment? The automated HPI's are worthless. When I was in specialty I could never figure out why the PCP had sent them to us in the first place and half the time the patient didn't know either. Extremely frustrating. All the important info is buried in mounds of crap and meaningful use.

[GetMeOuttaThisMess]

I just wish the daily schedule would auto-refresh every 2-3 minutes (Cerner).

[sk732]

I used to use ACCURO in family med - was reasonable and almost intuitive.  The monstrosity that is CFHSI - Canadian Forces Health Information System - is mentally challenged at best.  It's not laid out well, you have to go back and forth through a pile of different screens and logins for schedule and patient. 

 

In Manitoba, the government is trying to have it so that there is one EMR throughout the province so that eventually all health regions will be able to talk to each other - watch and shoot.

 

SK

[jmj11]

When I had my clinic, I must have met with 10 EHR vendors. All their salespeople could say (like parrots) over and over was how their system could help you meet meaningful use. I wanted a system that was clear, that had the essential data for the patient care and would communicate clearly with the referring provider. That, they couldn't do.

 

I do envision a system some day that simply records everything that happened in the room. Then the system is smart enough to pull out the important parts of the conversation and exam, and highlights that. But stores the entire visit by video in case there is ever a suit. For example, the patient has an allergic rash to a new medication and said it was your fault because you should have know they had an allergy to sulfa. The the video recording, in court, shows you asking the patient, "Do you have any drug allergies, such as to sulfa?"  and they, glancing down at their cell phone looks up and says, "Uh . . . no. No, I have no drug allergies."

[True Anomaly]

I would posit that there is a not insignificant portion of the difficulty of reading another provider's note relate to the provider themselves resorting to using the "clickbox" method of charting an HPI rather than typing out a succinct but thorough story relating to the patient's issue.  I get it- it's easier to click through whatever EMR's version of the HPI related to the complaint, but it looks like garbage and isn't easily readable by other providers.  I don't care about the ROS, the physical exam is somewhat more necessary...but give me a decent story and some quick but succinct "medical decision making" section and I'm good- and I bet others would be as well.

 

I've long been a proponent of EHR for two main reasons, both of which have yet to come to full fruition but will eventually get there- The ability to read other's notes because it's typed instead of scribbled, and the eventual future where many different hospitals and clinics share the same EHR thus decreasing testing and treatment recidivism

[EMEDPA]

regardless of which emr I use(currently use cerner and epic), I always type a single paragraph at the end of each encounter summarizing the visit.

for example: Athletic 42 yr old male with chest pain at rest after doing pushups 6 hrs ago. no cardiac risk factors. reproducible chest wall pain on exam. cxr, ekg, and trop ordered by triage protocol all neg. rx nsaids and muscle relaxants, pcp f/u or return to ED prn.

if you get nothing else out of the emr encounter that paragraph tells the whole story.

[Reality Check 2]

regardless of which emr I use(currently use cerner and epic), I always type a single paragraph at the end of each encounter summarizing the visit.

for example: Athletic 42 yr old male with chest pain at rest after doing pushups 6 hrs ago. no cardiac risk factors. reproducible chest wall pain on exam. cxr, ekg, and trop ordered by triage protocol all neg. rx nsaids and muscle relaxants, pcp f/u or return to ED prn.

if you get nothing else out of the emr encounter that paragraph tells the whole story.

I just wish you could BOLD that part in all EMRs and make the font about a 20 and title it WHAT REALLY HAPPENED  or LOOK HERE.

 

There is so much BS in so many EMRs - seatbelt use, domestic violence risk, bike helmet use, counseled on smoking, - all when the patient came in for a cold. Those topics hold their own importance but need to be somewhere NOT in the middle of my note and take up so much room. 

[Guest Paula]

I'll be starting  new EMR training next week.  Athena.  Wish me well.  The joke in my clinic is that we are going to have bowls of alprazolam on all the nurses stations so we can partake when the stress gets too high, production suffers, administration punishes us for not seeing enough patients and paychecks go down. 

[RuralER/Ortho]

I'll be starting new EMR training next week. Athena. Wish me well. The joke in my clinic is that we are going to have bowls of alprazolam on all the nurses stations so we can partake when the stress gets too high, production suffers, administration punishes us for not seeing enough patients and paychecks go down.

If it's any consolation.... Athena is pretty solid. Probably the most user friendly EMR I've used.

[Febrifuge]

Anomaly is right; the biggest single issue with every EMR I've ever seen is clinicians who can't manage to string together a few lines to tell a story. In a world where people on Facebook use a paragraph break correctly and then feel obligated to say "sorry this was so long," it's harder and harder to advocate for clarity over brevity. But guys, brevity doesn't matter if you're not saying anything.

 

I have templates and macros for all my various exam components, and I can drop them in as needed. Nobody cares about that stuff, nor should they unless it's unusual. What matters, six weeks later when things aren't improving or three years later when the patient can't remember if their new symptoms are like their previous ones, is the story.

 

Three or four lines of HPI, click a bunch of buttons, then three or four lines of MDM, then let the system populate the diagnoses and orders. Boom, your note is 10x better than anybody else's.

[south]

Former scribe trainer (EPIC formal school, even!) with a legal background:  

 

This: 

regardless of which emr I use(currently use cerner and epic), I always type a single paragraph at the end of each encounter summarizing the visit.

for example: Athletic 42 yr old male with chest pain at rest after doing pushups 6 hrs ago. no cardiac risk factors. reproducible chest wall pain on exam. cxr, ekg, and trop ordered by triage protocol all neg. rx nsaids and muscle relaxants, pcp f/u or return to ED prn.

if you get nothing else out of the emr encounter that paragraph tells the whole story.

 

Plus this :

 

 

Three or four lines of HPI, click a bunch of buttons, then three or four lines of MDM, then let the system populate the diagnoses and orders. Boom, your note is 10x better than anybody else's.

 

Equals fast, easy, and win.  I'll do the absolute minimum of stupid redundant crap (to not get in trouble) and these two things.  BAM.  

 

I would add Ddx though.  Too easy to claim you didn't consider it otherwise.

 

The best and fastest system I have seen so far has been EPIC with Dragon - the facility paid a couple hours' time for each provider to sit with a trainer and set up their templates and dot phrases (chest pain, ab pain, laceration, etc) and how to tweak later.  You can do a really solid note on a complicated case in literally about 45 seconds. 

 

These docs are all football nuts so all their dragon keywords are football related - all you hear is "hike", "touchdown", "fumble", "bam", "boom", and stuff like "kidney stone" all shift.  4 or 5 keywords and a little but of typing at the end, and your stroke workup note is done and you are off to the next.   

 

But most other systems?  Yeah - cringe.

[greenmood]

We're transitioning to EPIC next year and I'm excited. My hospital currently uses a horrifying mish-mash of proprietary EMR systems that requires clicking through (sometimes) three separate programs to do what you want.

 

The transition is going to be agonizing (I've been through it before) but I think it will make things better when we come out on the other side.

[jmj11]

The expense of these big systems are incredible. My wife is in the process of buying one for their hospital and I think it will come in around 8-10 million for the software for a small community hospital.

 

I worked for a year creating, reviewing and purchasing a software for my practice. The up-front cost for me (personally) was "only" $10,000, but then the nickel and diming started. It would work unless you had the premier equipment, not just one great internet services, but two. The monthly expense became about $2,000 for all the needs of the system. Anyway, while it worked well (the notes were MS Word documents that you could either use Dragon or in my case, templates and macros). It generated a clear and concise letter back to the referring provider and it did all of this while I was still with the patient. The down side was 1) the monthly cost as I mentioned and 2) they eventually required us to use their software for our billing. It made sense at first because with one click you could submit the bill to the insurance. HOWEVER, the software failed miserably in the billing (most claims were not accepted by the insurers). It became a real mess and eventually was the last straw that caused us to close our practice. Then they demanded a $18K payment to end the contract. We almost went to court over that.

 

Now, I use Kareo. IT is cheap (was free) and simple and I hand type and use macros to generate simple notes.

[Febrifuge]

south's point is well-taken. I should clarify that I include DDx in that "Medical Decisionmaking/ Discussion" section.

 

I allow the 'Assessment/ Plan' section to be populated by a macro that restates chief complaints, then pulls in visit diagnoses and tests/ orders from today's visit and organizes them by how they're linked up. It's pretty ugly but it's accurate and great for billing purposes.  

[EMEDPA]

in cerner's ER platform there is a ddx field where you circle possible ddx or can free text in others. I do this on every pt. you can also backslash them then free text next to it so slash pulmonary embolism then write "no risk factors, nl ekg, nl pulse and resp rate. nl sao2, PERC score zero".