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Loading ...Twitter is great. We have good discussions among a bunch of the medical bloggers about a bunch of things. Sometimes it is a little odd (imagine that), sometimes it is about “mundane” things in life,” and sometimes it hits issues in medicine. This past Tuesday we had one of the latter – a discussion on EMR, which started (on my Radar) with a statement by Kevin Pho.
- kevinmd @healthITgirl Depends if the EMR will make doctor’s lives easier. re: will doctors use EMRs. Right now, EMRs are too cumbersome to use.
- rlbates@kevinmd “EMRs are too cumbersome to use.” I agree!!!
- kevinmd: @doc_rob Big if. Seamless EMR implementation is in the minority, and requires superb organization and committment. Not everyone does so.
- gruntdoc @doc_rob Agree, EMR’s are overall good, but there are levels of utility and interface frendliness.
- doc_rob: @kevinmd There are some EMR’s that are bad – true, but I have seen many failures with good products.
- doc_rob: @kevinmd My point is that people think a good product means an easy implementation. That’s false. The task is titanic regardless of product
- kevinmd: @doc_rob That is absolutely true. Unfortunately. re: “The task [of installing an EMR] is titanic regardless of product.”
The issue of EMR is near and dear to my heart. Before I was a blogger, I was a lecturer on the EMR circuit. In fact, it was an EMR talk that introduced me to someone who suggested I start blogging. Our office runs on EMR, and I have posted on it many times. This discussion on Twitter hits at the core of something I think is not said enough about EMR. It is hard…really hard. I don’t think we would be having these discussions if it were not hard.
EMR adoption remains poor. Of those who have adopted, few would say that EMR adoption has been a financial bonanza. Most EMR users I have spoken to are ambivalent about it. Yes, there are good parts, but there are also many problems. Those who have yet to adopt do so for several reasons – many based on the complaints from EMR users. Complaints about EMR generally fall along the following lines:
- EMR slows you down. The workflow with EMR is often more complicated than without. In a system where payment is based on volume, this means that you not only have to bear the cost of the product itself (which is often high), but you have to expect a downturn in revenue. This can be the kiss of death for many small offices.
- EMR makes easy tasks harder. In paper, it is simple to update a medication or problem list – you simply cross it out and write the new one down. In EMR, you have to do a bunch of clicks. Sure you get more info with EMR, but often it is information that is of no use.
- EMR is about over-documentation. The job of many EMR products is to simply meet the E/M standards so that billing can be done better. This results in notes that are full of useless stuff that is not there at all for clinical reasons. Over-documentation is not innocent, as anything in the record is potential fodder for malpractice attorneys.
Physicians seem to be waiting for the products to improve to where this will not be the case. The general perception is that the fault lies with the EMR products – that they are poorly-made and out of touch with real life in a physician’s office. While this may be true for some products, I think it is mostly wrong. Selling EMR’s is a lot like selling hybrid cars a few years ago when the price of gas was low. You could spend more money for gas efficiency, but why? Get a smaller car for more money with difficult technology with little savings….not an easy sell except to those who were either enthusiasts or very tuned into the future.
But medical records are the basis of care. They are the foundation on which care is given. Changing this foundation will not happen by simply putting computers in the exam room. We have done this for 12 years, and the nature of our practice has changed dramatically. We do things very differently on computers than we did on paper. It does not matter how elegant a solution is, EMR affords the opportunity to completely overhaul the way care is done and the way an office visit happens. The bigger the change, the bigger the benefit. This has been our experience.
Bottom line:
- EMR is essential to healthcare reform. The mismanagement of medical information leads to a huge amount of waste of money and time. Paper kills.
- EMR adoption is difficult. Saying the words “EMR Adoption” is easy, and many confuse the ease to which the words are to say with the ease of how it is done. It is kind of like the words “World Peace”
- Those who have to adopt have the least resources to do it. PCP’s are the doctors who would have the greatest impact if EMR adoption happens, but they have the smallest margins.
- The payment system discourages EMR adoption. Until this changes, EMR adoption will be spotty at best.
- Life with a good EMR is way better than life with paper – for both doctors and patients.
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I started 3 1/2 years ago with a new PCP who is based at a hospital that uses EMR. Yes, it takes a little longer to enter info while we’re talking, although she types pretty fast. But it makes it easier to follow up on questions and problems from previous visits, or to see possible problems and questions coming up in the future. Information is not lost in a pile of papers. She also has a connection to the web on the same computer, so she can find and print out articles and drug information for me, or send information to another doctor about my condition as we speak. As a patient, I’m sold on the concept. If I ever had to move away from this doctor, I would actively look for a new PCP who used EMR.
Dr. Rob,
Funny you should describe the problem of overdocumentation as a byproduct of the EMR…a coworker and I (we are both coders for a system of PCP’s offices) were just talking about that today. The standards we use to determine a level assigned to a visit come from those in the front of the CPT code book (as I’m sure you know), and not all practitioners understand that; then they get to wondering why we changed their assigned level (it doesn’t matter the direction; some providers get just as miffed or curious about the upcode as the downcode). We’re not just pulling it out of nowhere; it comes from a documented standard suggested by none other than the AMA. Usually once they realize that, then it makes more sense and the process flows more smoothly.
EMRs are far from perfect, mind you, but they sure do help with that age-old problem of having to decipher impossible handwriting (which comes from a lot of individuals, not just the fabled “doctors have terrible penmanship” category). Sometimes they all start to look the same, but we do have a few “older” docs who write much the same way they’d have probably written in a standard record. A couple of them actually give me a laugh now and again with the things they write in their comments at the bottom of the document. I don’t think I could handle standard paper records; I’d get too lost in the boatloads of extra information that I’d have to sort through. (They are what I learned with while still in school; EMRs were not spectacularly common when I started on my educational journey back in 2000 or so.) The downside comes when the system crashes and you have limited to no access to anything. Then you’re out of luck.
Like SandyVoice, my current PCP’s office has an EMR system. I never knew how great it could be until my PCP sat down with me for my first appointment, wireless-enabled tablet PC in hand, and wrote with her stylus as we discussed the reason for my appointment. From that same PC, she can send prescriptions to the pharmacy of my choice (all the local ones are in the database) and it has significantly improved the efficiency of the appointment. I’m sure when they were adopting it, it took time and money to get past the learning curve, but from a patient’s perspective, it is a big part of the reason I continue to see her as my PCP.
I’ve seen several specialists in the past year with varying degrees of EMR implementation, and the ones who use it more fluently seem to have much more efficient offices. It cuts down even on the number of times I have to explain a problem I spoke about at a past appointment; with the computer in the exam room, it’s much easier for the doctor to look up his past notes.
Count me as a patient completely sold on this concept. Given the choice, I would go with an office that has fully implemented EMRs, rather than one still paper-based.
I’m from New Zealand (the little place next to Australia, you know – where they shot Lord of the Rings). Over here all doctors have EMR. I can’t recall ever having been to a medical/dental/physio/hairdresser/etc appointment in my life where documentation was on paper. I’m constantly amazed at what a big deal it seems to be in the US! Here, it’s just the way things are done.
Paper is still necessary for some things (eg in hospitals – charts are still charts), but ever clinic and hospital has a database and local intranet. The Auckland University Health Service is spread over four different campuses, in widely different parts of the city, and has a fully integrated network connecting all four clinics.
Changing to EMR might be difficult, but it’s inevitable.
I don’t know the specifics of “how it works” but my practice uses EMR, and it’s pretty good from where I’m sat. The doc and practice nurse can see exactly what meds I’m on, what routine tests were done when last… (always handy in a true group practice where you might need number of doctors + 2 visits to see the same person twice). Yes it might take them slightly longer to enter notes, request additional tests etc, but by the time I’ve walked the 30 feet from the consulting room to the nurse’s room they know what tests have been asked for, and have looked out the relevant kit.
As Daphne says, there are times when paper records are still necessary: for example, if a patient writes you a letter saying that they may have been exposed to, say, asbestos at work between 2 dates then you need to keep the paper copy in case they need to raise a future legal action against their then employer, but EMR enables much more “joined up medicine”, say when a patient is transferred between consultants at different hospitals.
What the heck is EMR?!
Electronic Medical Records. Basically it is patient charts on computers, but it is more than that in reality. It is a database of all the patient’s information that can help the doctor keep track of what has been done and what needs to be done. Doctors have been very reluctant to get on EMR.
I have had many physician clients tell me that they do not want to implement a traditional EMR due to cost and difficulty of use. I even know some who bought an EMR only to abandon it.
I’m interested in what you said about “The payment system discourages EMR adoption” – can you elaborate on that?
Interesting post Rob!
I really like your new intro on the side bar and I like how you vacillate between the absurd, sad, educational and funny, etc., and think you have a great blog!!
hey…what’s a girl gotta do to get a golden Llama award? Can ya make the contests any easier? I am only so humorous you know. I can do inane though. Well you don’t miss what you never had. I may covet…but don’t miss the llama… but I’m coveting. I know…time for me to get some sleep!
I’ve used quite a few EMR programs. And as a previous Finance guru, I’ve seen the complexities of billing programs. I am a MSW student (social work) and have interned at both the VA and our local big academic hospital in social work roles. The VA system was superior to any others I have seen. It wasn’t nationwide, at your finger tips, but throughout the multi-state “division.”
I am working in the acute rehab at the academic hospital right now. We have a good system, but not great. It is difficult to get PT/OT notes and assessments. From a previous manager of the IT department (I was not a techie, I just told them what was priority and gave them $$), I think a simple code could make things easier.
However, we still have paper records. At a hospital, it is almost impossible to have enough computers to people. As a discharge planner, I still have to keep paper applications to SAR and SNF, and whatnot. Most importantly, I have my little post-it notes with phone numbers and my doodles.
But the medical paper chart has the doctor’s daily round notes (that only he and his residents can read!) and healthcare proxies, and allergies and precautions. The paper chart is really limited. Meds are giving by “cows” with barcodes. It is all good.
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