EMR's--The Tail wagging the Head

[surgblumm]

[h=1]Explaining the epic failure of EMRs[/h] Kiran Raj Pandey, MD | Tech | December 19, 2012

It is no news a lot of doctors like to stick up a rather snotty nose to EMR. The defenders of the EMR tend to label such doctors as archetypal Luddites, sticking to their archaic ways and unbecoming of change and the new times. But as is usually the case with any two heated but opposite arguments, the truth likely lies somewhere between the two extremes.

On an objective basis, there is no denying that automatisation of medical record keeping is the new way forward. In theory, if the machine could keep records for you and give it back to you when and where you want it, thus freeing up valuable time for the patient encounter, that should be winsome for everyone. That alas, is a vision of the EMR utopia, and let alone being anywhere close to such utopia, it is difficult to ascertain if we are even set in the road leading us there.

Sometime ago, exasperated at the sheer waste of time that the clunky new discharge module was causing because it would not work the way it is supposed to (my hospital is means challenged, so they are building a patchwork of cheapskate EMR suite on top of their legacy system from the 90s, just to placate the gods of CMS), I complained to the IT guy that the thing barely works! The guy was sympathetic and said, “look I know the discharge module sucks, just bear with it until the end of the year when we should be able to weed out the bugs.”

But that’s not all, I said, even if it were working just the way it is supposed to, the discharge still takes me longer than what it used to with paper. “That’s something you will have to learn to live with,” he retorted. “Computer records do take a longer time than paper, and there is nothing I can do to change that.”

Right there, I think is where EMR loses a lot of ground against paper records. At any practice, time is the most valuable resource, and anything that doesn’t offer a straight off benefit to save time will have a hard time being adapted. Add to that the inertia people have about their old ways and you have a deal breaker right there.

That’s not all. Driven by the constant government whip to adopt EMR, and an EMR industry that is hell bent upon imposing itself on healthcare, a lot of makeshift EMR adoption has taken place. So you have hospitals where one part is using one system while the other is using a completely different one. At one clinic I recently worked at, we had to switch between 3 different EMR systems, just to get the patients records. And there still was the paper records not to mention the dictation.The constant juggling not only made the patient encounters time consuming and cumbersome, it literally made us curse at the computers and ruin an otherwise perfectly normal day at work. Patient volumes have gone down from 15-16 patients per day to a half of that after EMR adoption.

What’s wrong with the current adoption of EMR? Why are even the converted like me questioning EMR?

I think there are two reasons for such seemingly epic failure. First, how we interface with an EMR. Second how the EMR tries to impose its will on to us instead of the other way around. A keyboard and a point and click device may well have worked for many other interactions with the computer, but with an EMR it doesn’t always appear to be nifty. It is a common experience that most people find dictating their notes much faster than typing them. Accurate automated transcribers could really speed up record keeping, thereby selling EMR to the unconverted while saving costs over manual transcription.

On the same note, no EMR is going to be see a faster adoption if something like writing a prescription takes a minute when in paper it barely takes 10 seconds. Right now doing something as simple as writing a prescription feels like running through a bunch of fire breathing hoops. Someone may argue, you can at least read it better, but don’t get me started on how the EMR can come up with its own ludicrous set of errors, something that would never be possible with paper.

Trying to impose a ready made architecture on to health care will not work. “It works for retail and banking,” some people seem to offer cluelessly. But a patient encounter is no visit to your bank cashier. And human body is not your bank account, it is way more complicated and it is bound to generate way more complex information that is difficult to straight jacket into the rigid and rudimentary pipeline of set information pathways. An ideal EMR is supposed to be a seamless body-glove; today they feel like the hangman’s cloak, not only are they cumbersome, dark and dreary and suffocating, under their apparition, they force things you to do things you wouldn’t otherwise do.

Such forced behavior modification may make the administrator, the insurance company, and the government happy but I can’t understand how selecting a dozen pesky radio buttons while doing the discharge makes the patient lead a healthy life or make his doctor particularly enamored with the EMR, just because the government said so, or that it made the IT companies a few million dollars richer.

[EMEDPA]

interesting how "epic" and emr failure are in the same sentence.....:)

I can write a chart or dictate one in less than half the time of doing the same on an emr.

we are being turned into secretaries. I am fighting it every step of the way.

[burnpac]

Cerner EMR has it issues but I haven't touched a paper record since July, and I'm loving it. I can access everything on the iPad that I carry, and rapidly chart and enter orders from templates I've created, and continue to improve and modify. The only thing I still dictate are procedure notes and discharge summaries. Consults, H and Ps, and progress notes are rapidly generated from templates. I spend much less time doing the administrative work associated with managing inpatients than I used to. However, it has been very hard on the older clinicians at our facility who have never developed computer skills. I make it a point to help them whenever I can. They can still chart in writing, but CPOE is the law of the land and no written orders are allowed in our facility.

[True Anomaly]

Steve- I know we've talked about this before, but while we both have Cerner, I'm sure we're using different versions. Have to agree that the benefits outweigh the risks.

 

Look folks, there's no arguing that EMR has tons of growing pains. Plus the fact that there are so many different software packages out there, and with that variety comes incompatibility. What I mean by that is I'm sure, more often than people will admit, that the wrong EMR is matched up with the wrong practice/hospital/specialty setting. And if you're in that situation, you've made such an investment in that EMR that it's unlikely you're gonna change anytime soon- you'll cause an even greater revolt than when the EMR idea was first introduced.

 

I would never try to put someone down as a luddite or just "too old for computers"; However, the point I will always argue when it comes to EMR- it makes communication between practitioners so much clearer, and prevents unnecessary re-testing or re-admission. When we used paper T-sheets, trying to decipher someone else's medical decision making was damn near impossible, as well as fine points of their exam. The chart was hurried and sloppy, and couldn't communicate anything to anyone other than the person writing it, who may have to decipher it for a deposition years down the road. When patients would get admitted, and consultants saw them and wrote their chart, again it was damn near impossible to interpret what they said. So that chest pain patient whom cardiology has admitted and may have written "THIS IS NOT CARDIAC IN ORIGIN- STOP ADMITTING THIS PATIENT BECAUSE THERE IS NOTHING ELSE WE CAN OFFER", gets lost in translation because I can't read your handwriting- and thus I am more likely to admit the patient again because I can't find a reason not to. I can't decipher the warnings from another practitioner in the ED who saw a back pain patient who may have had a violent confrontation and documented it in their note, but since I can't read it I can't take that into consideration of my medical decision making- despite the time they took to write it. I can't decipher a particular reaction someone may have had to a drug that, while listed as "allergy" on the hospital system, actually isn't an allergy because a thoughtful practitioner took the time to ask them and write down what they said- but it's completely illegible and now they're in front of me and unconscious- can't ask them now!

 

EMR helps solve these communication problems. And yes, I am a fan of dictation because it also solves this problem. ANYTHING that's gonna make it easier to read what you're trying to communicate I am all for.

 

My dream is to have regional systems where hospitals share records. So that patient who went to hospital A for abdominal pain and had a negative CT scan and was discharged, only to show up to hospital B for the same complaint the next day and didn't tell us they were at another hospital and did the million-dollar workup- and if you ask them if they went anywhere else they just say "They didn't do anything", you can easily look it up on the shared regional computer system (and not have to call that other ER that is likely even busier than you and unfortunately can't help you out right away).

 

EMR isn't perfect- no one has said it is. But eventually, like all technology, it will improve and make itself more user-friendly.

 

Now feel free to flame away :)

[Contrarian]

Since I am historically a poor typist (never took lessons) and have poor handwriting due to the amount of writing required.

 

I trialed every version of Voice to Text (VtT) software produced since 1996 with mixed results. Early versions had me spending more time correcting errors than it would have taken me to simply type out the information, so I abandoned the VtT (Voice to text) idea until it improved. I still sampled each version of dragon and other VtT software, with an eye towards purchasing it when it was truely ready for primetime. To me... this meant a error rate less than 4%. Simply put... 96% accuracy to the spoken word after extensive training.

 

Meanwhile... I first taught myself how to use/program "Autotext" in Word 1997 and basically use it as a EMR. This worked GREAT for a while. I quickly found that the limiting factor here was that I would have to be on a specific computer with the autotext macro/templates installed for this to work and that it is IMPOSSIBLE to "template" the "Subjective" part of a note (How do you template purple elephants and green space shuttles??)... so notes were still slow until after I got past the "HPI."

 

Shortly after this... Dr. Borges put together a complete EMR (sans billing) based upon MS Word. It was called the "MS Word EMR Project." (Look it up) I was one of the "Beta Testers" for this. It took full advantage of the MS Office suite to leverage a practice management system. It used Office for Schedualing, Excel to list ICD-9/CPT codes to help with later billing submission, Word and Access databases for the actual EMR. The beauty of this was that since it was all MS... it all talked to each other well.

 

I later bought MS "Infopath" and started teaching myself MS programing (C++, etc) in an attempt to improve on the use of MS for patient notes/encounter creation. I quickly lost interest in this endeavor and started shopping for a experienced progammer to complete what I had started. I still have a handful of useful automated forms if anyone is interested and owns Infopath.

 

I bought my first actual EMR in 1999... (SoapNote for palm devices then SoapWare for my laptops and desktops)

These worked well and on various jobs I used different EMRs... but still had the efficently documenting "Subjective experiences" issues... so it became clear to me that regardlesss of the EMR cost/type... the most effective one would be a combo EMR that allowed for as much or as little of the EMR to be entered using Templates and for the "subjective" to be entered by VtT. So I tabled any further EMR investment until the VtT improved.

 

At this time..... All of the big name EMR companies were gouging practices and selling individual seats (licenses) for tens of thousands of dollars in installation fees and then additional thousands of dollars per month in maintenence fees.

 

In the interim... I discovered "phrase express" which allowed me to basically use "autotext" and templates on ANY computer with a usb port.

 

Today... at my "day job"...

I use a combination of "Dragon Medical Edition".... "PhraseExpress" and sometimes free typing for things I KNOW the VtT won't get right. I can thoroughly document a Complete H&P in about 5 mins and a Follow-up visit for a established patient in about 2.5mins using this combo.

 

The challenge was getting the "subjective" portion of the note accurate and in the chart in a efficient manner. Nothing is as efficeint as simply talking... and the newer versions of Dragon Medical Edition (versions 11.5 and 12) do this WELL.

 

These newer versions cost about $2k ($1,500 for software and $500 for the Microphone) but are WELL worth it to ME... and can simply be written off on my taxes as a business expense.

 

At my private practice, I use Medtuity. This EMR is great and "Tablet Centric."

 

Just a few thoughts based upon my personal experience...

 

YMMV

 

Contrarian

[rev ronin]

EMRs are not for clinicians. They are not for Physicians; they are not for PA's, and they are not for NP's, either.

 

They are for...

1) Billing accuracy and optimization. This (along with government incentives) is what pays for them.

2) Lawyers.

3) Public health

4) Internal cost control/containment

 

Once you understand that EMRs are not for us, we can stop fretting about it and focus on reducing any additional work burden on us to the greatest extent possible.

[burnpac]

EMRs are not for clinicians. They are not for Physicians; they are not for PA's, and they are not for NP's, either.

 

They are for...

1) Billing accuracy and optimization. This (along with government incentives) is what pays for them.

2) Lawyers.

3) Public health

4) Internal cost control/containment

 

Once you understand that EMRs are not for us, we can stop fretting about it and focus on reducing any additional work burden on us to the greatest extent possible.

 

I would disagree with you on two issues. The EHR has actually reduced my workload and increased my accuracy and efficiency.

 

Second,you forgot one very important stakeholder in this discussion: The patient.

 

CPOE has been instrumental in reducing medication errors common with hand written orders. Ours also does automatic interaction checking and forces the clinician to review each of these and comment on the interactions prior to prescribing (it doesn't stop you). This is critical in hospital medicine, when our sick surgical patients with co-morbidities are on scores of medications.

 

The EHR, while reducing errors common to hand-written records (like not being to understand one effing word that another clinician writes!) interjects others, like cloning erroneous information when you are allowed to copy forward previous progress notes to make new notes. Nothing is perfect, but the EHR has made medicine safer for the patient, and allows better sharing of information as systems learn to talk with each other.

 

Sharing of health data among and between systems is actually mandated for meeting "meaningful use" of EHRs, with a phased in implementation. The initial goal is 10%. This is also good for patients and continuity of care.

[burnpac]

On the outpatient side, nothing comes close to DrChrono EHR running on an iPad. We looked at them all. Our private plastic surgery practice has been using this for nearly one year. It includes medical grade, adaptive dictation at the higher levels of subscription, but is robust even in the free version. We pay $199 per clinician per month, and there were no upfront fees. Not needing a transcriptionist made up this difference alone. It is updated continually, and their customer service and training are the best.

 

Our level includes dictation, electronic faxing, Square integration and eprescribing. Upper levels include billing. It meets "meaningful use" criteria. Well worth the money.

 

The iPhone app is a good adjunct for accessing the record, making appointments, looking at radiographs, taking clinical photographs, etc.

 

I have access to the total practice EHR anywhere I have internet access.

[Guest Paula]

We are in the process of adopting the Indian Health Service EHR which is closely modeled after the VA EHR. So far, i have only been set up for the scheduler, and I just received my tablet. Since the government is mandating EHR I believe every practice/hospital should be using the gov't EHR, for free, provided by them. It would then give us all access to every patient's record all over the US, etc., just like the VA can get access to all veterans records. It seems too simple to institute, and makes too much sense. Honestly, I don't know if the system works, but according to articles I've read from the VA, it is a stellar system.

 

Some of my comments are to be taken tongue in cheek.