If you don’t know by now, I am an EMR evangelist.  A poorly implemented EMR is a nightmare – slowing people down and increasing frustration.  A well-implemented product, however, will give a huge improvement to workflow in the office, benefitting both doctor and patient.

Here is our EMR in action (with HIPAA censorship present).  I am checking labs on a patient and evaluate their lipids using a Framingham risk calculator that takes the variables from the patient data.  I then generate an email and send it to the patient.  The whole process takes me about a minute (under 30 seconds if I am not recording).  The patients get an email stating that there are results waiting on our server and have to log on securely to view them.  We are notified when they view them and if they haven’t viewed them after 30 days (or whatever interval we determine).

The quick jumps between screens are macros we put on our computers using free software.

Enjoy.

My product is Centricity by GE, but the point is not to push their product, it is simply to show what is possible (and what I do every day with my EMR).

If you want more good information on choosing and EMR or making your current one work better, visit my EMR page.

OK, I am an EMR fan-boy, I will admit it.  I seem real “rah rah” in my approach to computers in the exam room, and to many I seem to have my head in the clouds; I seem to be out of touch with reality.  In response to posts I have written on the subject, comments have been thus:

“I couldn’t see as many patients if I had an EMR.  It would slow me down too much.”

“Using an EMR makes doctors ignore their patients and focus too much on the computer screen.”

“EMR is too expensive for the small practice or primary-care physician.  It will reduce their income in a time when it’s hard enough to function as a PCP.”

Yeah, yeah, yeah.  This is very familiar to me.  It’s also wrong.

True, there is a start-up period of getting used to the EMR in which you can’t see as many patients, but that goes away.  True, there is a time when you are uncomfortable with the computer in the exam room, but once you get used to it, it becomes as natural as having a paper chart.  True, EMR start-up expense is high enough to make doctors, especially PCP’s, wonder if they can afford the cost in this time of austerity.

I understand these things better than most people give me credit for, because I have lived through each of these troublesome sides of EMR personally.  Here is my EMR story:

I started thinking about using an EMR in 1995, when I saw how difficult it was for me to keep track of information in the record.  This came to a head in 1996 when the result of a test was missed, causing harm to a patient.  The problem wasn’t in the thought-process or in the intelligence of the doctor; the problem was from flaws inherent in a paper medical record.

I was practicing with another PCP at that time.  We were employed by a hospital, but were growing increasingly frustrated with their lack of interest in running our practice efficiently.  So we left them in 1996, bucking the trend at that time of hospital ownership of practices for the sake of personal control.  It put us under far more financial pressure, but the control made it worthwhile for both of us.

Feeling the sting of the missed test result, and feeling the empowerment that self-employment brought, my partner and I set about to look at EMR products.  My brother-in-law worked in a nearby practice that had already been on EMR for a few years and was functioning far more efficiently than we could ever hope with our paper record.  We both visited his practice and saw just how much we could gain from a computerized record.  Once we saw this, the question was not whether we were going up on an EMR, it was which EMR product we’d choose.

We narrowed our choice down to two products: one that was well-known and well respected, but more expensive; and one that was cheap, slick, but had a very small user-base.  We were sorely tempted by the slick sales presentation, but listened to our better judgement and went with the more established product.  After buying the product, the cost would end up being $1000 extra per month per physician (given the terms of the loan we could secure for an $80,000 installation).  We both winced at this, given our short time of independence, but then my partner boiled it down very simply:

• How much do we earn on average per patient visit? We shot low, and said $50 per visit.
• How many days do we work each month? Both of us worked 20 days per month at that time.
• How many extra patients would we each have to see to pay the $1000 monthly loan payment? One extra patient per day would easily cover our expense.

One patient per day?  That’s all??  It made the decision quite easy, and it made the ROI quite easy to grasp.  Our goal was to use the EMR in such a way that it would improve efficiency (something we had seen in my brother-in-law’s practice) and focus on other benefits of EMR once we had it paying for itself.  We reached that goal easily within the first 6 months of using our EMR, and exceeded it soon thereafter. Neither of us saw ourselves as slaves to the EMR, we saw the EMR as a tool.  Consequently, we found our own means of accomplishing our goals, using the EMR in ways that other users hadn’t considered.

• We didn’t care about being paperless, the goal was efficiency and quality of care, not saving trees.
• We didn’t like the standard templates supplied by the EMR vendor, so we made our own.
• Whenever I became frustrated with a process, I talked to my partner and then changed the template to fix the process.  I soon became an expert at template development, gaining prominence among users of our product.
• When the process inefficiency was not template-driven, such as the use of nurses, the process of answering phone calls, or other common situations encountered in our office, we talked with our office manager and staff and came up with a solution.  Our EMR gave us a bunch of options for solutions we would have not had without computers.
• We quickly realized that fixing too many things at once created trouble.  I adopted the philosophy: “a good idea at the wrong time is a bad idea.”  So we worked to prioritize problems in terms of their seriousness and how easy the solution was.
• Once we had an efficient workflow, we realized there were incredible gains to be had from a care-quality standpoint.  We were not paid more for good quality, but our efficient workflow afforded us the opportunity to focus on it nonetheless.  That may seem backwards for non-clinicians, but it is the reality of private practice.  In truth, our quality had already gotten significantly better simply from the improved organization of our records and instant accessibility anywhere, any time.

Forward to 2010, and here is where we stand:

• I see on average 25 patients per day, working 4 days per week.
• We have 5 Physicians and 2 PA’s.  The efficiency of our office has increased with each additional provider, as we haven’t had to increase overhead much at all with each addition.
• We no longer see patients in the hospital (except pediatrics, which is a small number), and we don’t do many in-office labs or other procedures.
• Despite this, our income has been very good – well above the national average for PCP’s.
• On quality measures, our practice has excelled every time we’ve been measured.  We easily qualified for NCQA diabetes certification, and our measures for prevention are impressive – with colon cancer screening, childhood immunizations, adult immunizations, and cholesterol screening far above national averages.
• Most importantly, I give my patients the time they need.  I make a point to not rush my visits.  Each visit is given 15 minutes, no matter of the type, but visits that require 30 minutes are given that time (which is usually offset by the 5 minute sinus or ear infection visit).

That is why the arguments against EMR ring hollow to me.  I see it like the arguments people give against exercise:

“I don’t have enough time to devote to exercise.”

“I hurt after I exercise, and basically feel lousy.  I can’t afford to feel that bad.”

“I need my sleep in the mornings and am too tired at night to exercise.  I’m doing OK without it for now.”

Yes, I sympathize with these arguments.  I have made them all myself, and still struggle to exercise regularly.  But anyone who says people are better off not exercising are just plain wrong.

Quiz:  What does the term “meaningful use” mean?

a.  Using something in a way that gives life purpose and leads to carefree days of glee.
b.  It depends on your definition of the word “term.”
c.  It is not mean.  It is really nice.
d.  A large number of rules created by the government to assess a practice’s use of electronic medical records so that they can spur adoption, give criteria for incentive rewards, and have physicians in a place where care can be measured.
e.  Job security for those making money off of health IT.

The answer, of course is d and e.

Meaningful Use, in the eyes of many is seen as curse words, especially doctors. Here are the rules:

(Click on image to see enlarged version)

Under the plan, physicians will be paid cash dollars for meeting these criteria.  Here’s the payment:

• 2011 – $18,000 per physician, one-time payment
• 2012 – $12,000
• 2013 – $8,000
• 2014 – $4,000
• 2015 – $2,000
• 2016 – $0
• 2017 – 1% penalty in Medicare payments if you do not qualify.
• 2018 and beyond  – 2% penalty.  More criteria to qualify?  More quality measures?  More penalties for not meeting criteria?  Stricter criteria for A1cs?  Other insurance companies using the same criteria or different criteria?  More government control is a definite.

So what’s the big deal?  Why would doctors be against getting extra money?  Here are some of the main reasons:

1. They don’t want to use EMR and feel like the government is forcing them
2. They think the rules are so onerous that it’s hopeless to even try
3. They only like yellow charts, and the blue ones make them feel depressed
4. They see that eventually non-adoption of EMR will be penalized.  This makes many conclude that Meaningful Use is just a ploy for the government to cut reimbursement.

I too wish the chart was yellow, but overall I am not upset about all of this.  The reason I am not upset is entirely selfish: I have been on EMR for 14 years and use a high-end product, so I will very likely be awarded the full $$ and avoid penalties.  I also see this as an opportunity for physicians practicing good care to be seen as good doctors, and the bad ones to actually be penalized instead of rewarded.

You see, I have always seen EMR as much more than a computerized version of the paper chart.  The true value in EMR is not that you get to type, it is that all of the information is stored in a single place, organized, and easily retrieved when needed.  Using an EMR for documentation alone is like using a car to travel only as fast as you can walk.  If payment is not so much based on the quality of my coding and my note-taking, but instead based on the quality of the care I give, isn’t that a good thing?  Isn’t that what we should want?

No Patient Left Behind

The devil is in the details.  Or, to be more accurate, the devil is in DC.  The real problem with meaningful use is the fact that it is a mandate.  Mandates like this – the use of testing/criteria by the government to get people to act in a certain way – have a huge flaw.  This is best understood with another mandate of the government that has caused it’s own trouble: the No Child Left Behind law of 2001.

The intent of the NCLB law was to improve the quality of education in the US.  It established standardized testing to:

1. Set a minimum requirement for education – students cannot be passed-on to higher grades unless they pass the test.
2. Held schools accountable for quality.  Schools performing in the lowest range on the standardized testing would be publicly identified and penalized.
3. Teachers with low student scores would be penalized as well.

But the law of unintended consequences has caught up with NCLB, with schools/teachers “gaming” the system, undo focus on test-passage over comprehensive education, and squashing of teacher creativity with fear of low test-scores.  Talking to teachers and parents (as a pediatrician), there is very little love for the NCLB law.

And children pay the price of this legislation as well.  I saw a child recently who is a very hard worker, a very conscientious child, and who has been able to get mainly B’s in his classes.  The problem for him is that he does not take standardized tests well.  Despite medication and even allowances made in the testing setting, he fails the test which covers information he has shown in the classroom that he knows.  The government calls his school and teacher as the cause of his failure, but he is the one who has to be held back until he’s able to pass the test.

In the same way, making a bunch of criteria for EMR use is sure to have a slew of unintended consequences.  Doctors will select EMR systems based on meaningful use criteria, not on how well they work.  Doctors will select patients who can get the scores higher and discharge those who probably need the most help.

Sounds familiar.

Meaningful Meaningful Use

What should be done?  The real question should be: what can an EMR do to impact patient care that would be truly meaningful?  If an EMR improves the ability of the doctor to take care of the patient, that is meaningful.  But if the EMR makes the doctor pay more attention to qualifying for the cash payment than to the real care of the patient, it is more meaningless use.

I use an EMR every day.  I use it because it helps me give better care and makes our office run more efficiently.  If we have a new process that works better by using paper, we use paper.  We are not wed to the idea of using computers, we are committed to good process and excellent care.  The good news for us is that doing so has made us efficient enough to increase our revenue significantly at the same time that we improve our care quality.  That’s what everyone wants.

It really worries me that the imposition of these criteria on EMR will dilute my focus on patients with a focus on achieving meaningful use.  This is similar to the experience of many good teachers who had to abandon more creative teaching methods to ensure better test performance.  If the criteria are not right, they will do this; there is no question.

So before imposing a set of criteria to be evaluated on doctors, we need to be sure that the criteria themselves are scrutinized.  For them to truly improve care and not add more burdens to medical offices, they should:

• Improve doctor/patient communication
• Make information more accessible to doctors and patients
• Capture data automatically, not necessitating extra steps that could distract from care
• Capture data so it can be used for reminders and clinical decision-making at the point of care
• Improve doctor/doctor communication (primary care to specialists and hospitals)
• Capture interventions, not just outcomes.  For example, the prescription of a blood pressure medication should be rewarded, not only if the patient takes it.  The ordering of a mammogram should be rewarded, not just if the patient gets it done.
• Systems should be required to “close the loop” for interventions, meaning that ordering providers should be alerted to any test, procedure, or consult results that do not come back.  This is an enormous problem that frustrates many doctors and patients, increases medical liability, and causes harm.  Computers are good at this kind of thing.

I am sure there are more, but my word count is getting high.  The bottom line:  meaningful use has to be truly meaningful.

I was talking to a fellow physician about a mutual patient.  I had information  that would help him in their care and he was taking the unusual step of asking me for my information.  I was impressed.

“Could you fax me those documents?” he asked.  ”Here’s my fax number.”

I scrambled to get a pen to write down his number.  Then I had a thought: “I could email you those documents much easier.  Do you have an email address?”

Silence.

After a long pause, he hesitantly responded, “I would rather you just fax it.”  He said no more.

This is a typical reaction I get from my colleagues when suggest using the new-fangled communication tool called email.  The palms sweat, the speech stumbles, and the awkwardness is thick in the air.  It’s as if I am suggesting they join me in an evil conspiracy, or as if I am asking them to join my technology nerd cult.  There is a culture of fear in our healthcare system; it’s a wall against change, a current of stubbornness, a root of suspicion that looks at anything from the outside as a danger.  Instead of embracing technology, doctors see it as a tool in the hands of others intent on controlling them.  They see it as a collar on their neck that they only wear because others are stronger than them.

It’s the only reason I can see for the resistance of a transforming technology.  It’s the only way to explain how they would favor a non-system that hurts their patients over a system that can improve their care immensely.  After all, what good is it to embrace a technology – no matter how good – if it will take away their ability to practice medicine?  ”It’s good for you!” they hear from politicians and academics, but they see it as a poison pill.

What gives me cause to use such strong words?  Surely it’s not that bad! It is, and what makes me so sure of it is the very high cost of their resistance.  The cost of this fear is huge, and so the fear itself must be bigger for a healer to accept that cost.  What is the cost?

Frustration

We see our patients without information.  The call from the specialist I described at the start of this post was a truly rare event.  Most of my consultants don’t expect to get information from me, and I expect to work without their input.  All of this has happened despite my repeated attempts to improve our system.

• I have offered to send our referrals with attached appropriate documents.  I can do this very efficiently using email.
• I have tried to send labs, x-rays, and other information to specialists when I felt they couldn’t do their job well without them.
• I have requested that they stop mailing their information to me, instead faxing them to our server.
• I have offered our hospitalist physicians after-hours access to our records for our patients.

Ironically, the only physician who has embraced my offer is an ENT at our local teaching hospital who specializes in parathyroid surgery.  I shoot him an informal email when I have a suspect calcium level and within the day I get a response.  In exchange, he gets consults with a full set of labs and can practice with greater efficiency.  He also sends me quick notes on my patients when he sees them, asking me questions to fill any gaps.

Cost

The total lack of communication results in huge cost to our system.  It’s not that the communication tools are not there, it’s that they just are not used anywhere near where they should.  Examples?

• A woman came to my office recently after being hospitalized.  I never was notified of her hospitalization, only finding out when she came for a “hospital follow-up” visit.  While in the hospital, she was found to be anemic and so had a workup for this condition.  This workup included a full consult by a hematologist and a gastroenterologist.  If my records had been looked at, they would have noticed that I did a workup 6 months earlier for her anemia.
• Specialists not accepting email copies of the labs I run usually end up repeating the tests.  For specialists like rheumatology – where the diagnosis is largely made on the basis of those labs – this elevates the cost by several thousands of dollars.
• I have had patients rebuffed by consultants who “didn’t know why I sent them.”  Nobody calls, and nobody accepts email.  I could send them whatever information they need in a matter of minutes if they would accept email.  Heck, they could even text me if they wanted.

The real cost, of course, is to the patient.  The Hippocratic oath says we should “first do no harm” as physicians.  Yet our non-system of communication does just that, and even kills people.

So why would presumably smart people reject a technology that could improve care, reduce cost, and reduce frustration?  Did any of them order gifts from Amazon?  Do any of them bank online?  I am sure they do, and they do so because it makes things easier and more convenient.   So why does that ease and convenience not apply in medicine, which is far more broken than shopping or banking ever was?  It’s not fear of technology.

To be honest, I don’t really know.  My best guess is that it is the overwhelming sense of pessimism most doctors feel about their profession.  Docs are second-guessed by lawyers, patients, TV shows, insurance companies, and the government.  The fate of medicine is not in the hands of doctors, it is in the hands of politicians, corporate executives, and malpractice attorneys.  It seems to me that the only way to avoid more scrutiny and to hang on to some control is to hold tightly to what we’ve got: our information.  Once that information is on computers it is far more accessible by others, and this is a bad thing if the goal is to retain full control.

So are docs just power hungry, wanting total control because of their inflated egos?  Some are, but most are not.  Even the most technologically-minded of us, however, have an increasing unease about the intrusion of others on our ability to do our job.  I don’t want to be thinking about attorneys when I am prescribing medications.  I don’t want to withhold information important from the chart because I know patients will be reading it.  I don’t want to be forced to include a lengthy justification of a procedure in my notes to make the insurance company happy.  As it stands, it sometimes feels like anything we include in our records “can and will be used against us.”

If someone like me, a physician who embraces technology, feels increasingly penned in by the increasing number of people peering at what I do, it is very understandable that other physicians reject technology outright.  They’ll quit before they give up their independence.

Is it stupid?  In some ways it is.  It certainly is a rejection of the centrality of what’s good for the patient.  But our system can’t afford to alienate physicians at this time.  If technology is going to be pushed, there needs to be a reassurance that this won’t be used against them.  I am frustrated at the lack of  acceptance of technology, but even more frustrated at a system that is hostile that forces docs into this foxhole.

Yesterday’s post generated a heated discussion on Twitter (and in the comment section here) about what exactly the patient should have access to see.  Some readers have had bad enough experiences with physicians that they want to be able to see things themselves to assure what they are being told is accurate.  I can’t say that I blame them.

I took exception to the idea that anything I wrote should be available on the internet for the patient to see.  I went over this ad nauseam yesterday, so I won’t belabor the point.  The bottom line for me is this:  if I am required to publish everything I write online, the notes will not contain as much information.  I will self-edit and limit the usefulness of the chart if I think the published information will compromise confidentiality or the care itself.

But there is another issue to consider.  Here are two x-ray reports I have recently received:

So here is my question: do my patients really want to read this stuff?  Do they really want to have the word “Pseudospoldylolisthesis” thrown at them?  I’d have to look it up to know exactly what it means!  X-Ray reports are often written in a way that is complex and hard to understand even for me.  I would suspect that instead of answering questions this would raise a bunch of them.  Patients would be scared that there is something terrible, when in fact it may just look that way on the x-ray reading.

I suspect that my patients would vote for a list of the procedures that were done and my interpretation.  If they want to see the actual copy, then they can ask for it.

One of the folks on twitter said that patient fear was bad, but ignorance could kill.  While I agree with the thought behind the statement (that’s why I proposed opening up our records), I have to say that fear can be deadly as well.  People can be paralyzed by too much information.  We in the medical profession have seen patients do this by fixating on their problems and looking up everything they can on the Internet.  The problem is not that they shouldn’t know these things, it is that they don’t know how to filter the information.  I encourage patients to be involved in their care, but I do think there is such a thing as too much information.  There is information that is important to have, but then there is information overload. Knowing where to draw the line is critical.

The top one is fine (granulomas like this are no big deal), the bottom one is arthritis in the spine that is impinging on nerves, but hasn’t gotten worse.  There is also atherosclerosis.

Thoughts?

I have heard a lot of talk about ownership of medical information.  Bloggers like e-Patient Dave, and Robin are strong advocates for patient ownership of their information.  To be truthful, I get nervous when I hear people saying they own something I have in my possession (and I’ve blogged about this).  The charts in my office are mine, right?  How can I create something and have it not be mine?

I carried this unease with me into the exam room recently.  Thinking about the ownership of medical information, I opened a patient chart.  The vital signs were already in, and I started in on the HPI (the patient’s story as to why they are there).  I do this by asking questions: When did it start?  How long did it last?  What did it feel like?  What did you take?  Did you have other symptoms with this?  How bad was it?  Have you ever had this before?

Hmmm…. Whose information is this?

Then I went on to the review of systems.  We have the patients circle symptoms on a laminated sheet and I discuss what they circled.

“You have some chest pain?”

“Well, it was a sharp pain that happened when I coughed.  Is that bad?  Could it be my heart?”

We then go into a discussion about chest pain and what to look for.

I put down the information the patient has given me and think a little more.  The patient’s information?

Then I get frustrated.  The past medical history hasn’t been updated recently, she’s been in the hospital and most of the information about this is not in the chart.  The medication list is not accurate.  The information about her family, lifestyle, and habits are incomplete and I don’t know when they were last updated.  I sigh, then try to fill in the gaps as best as I can by asking her questions without betraying my lack of confidence in our record.

We have a meeting of our IT team after this, and I am thinking about this encounter.  We are about to roll out a patient portal where patients will be able to log onto our website securely and fill out patient demographics, request refills, and get appointments.

“What information in the record would the patient be best to be in charge of?” I ask.  By being “in charge” I mean that the patients would have actual control of this information and we would read it.  I tell them about my experience and frustrations and we make the following list:

• Marital Status
• # Children
• Job/School info
• Home DM monitoring, weight, BP
• Address, phone, e-mail address
• Family history

Then I ask, “What information in the record could the patient contribute directly to?”  By this I mean that they would see the information as it is in there and be able to suggest changes or additions, but would not be able to actually change themselves.  Here’s what we came up with:

• Smoking, alcohol
• Medication List
• History of visits to other medical providers, consultant names, etc.
• Review of systems prior to visit
• Surgical history

We want to be able to assemble this information so that it is in a format that is readable to us and fits our needs, but the patient would have the ability to take this data information and perhaps download it to organize as they wish.

“So what information should they have access to?” I ask, referring to information they can see, download, and organize as they wish, but not add or subtract to.  Here is that list:

• Upcoming tests needed (Colonoscopy, etc)
• Immunizations
• Lab results
• Visit schedule – past and present
• Previous vital signs
• Recommended schedule based on their diseases
• Problem list?

Finally, we discuss what is our own information that the patient only has access to if they request it.  This is information that either will give them too much information (our thought process and remote concerns) or even things that we don’t want them to see (suspicions about truthfulness or worse).  Here is this list:

• Perhaps the problem list – if it contains things like anxiety, suspected abuse, or private things the patient has told us.
• The HPI often has information that is potentially sensitive.  People have to feel free to tell us things, and having that information be back in the face of the patient on the Internet (albeit a secure site) goes a bit too far.  Who knows if a family member can access it?  What about teens?  It’s just too complicated.
• Part of the assessment and plan is often conjecture and reminders to ourselves to pay attention to things in the future.  If a person has weight loss, we may keep cancer in the back of our minds.  If a person is asking repeatedly for narcotics, we may write down suspicions that  bear watching in the future.  We have to have a place where we can put things down and know they are for our own eyes only.

The last list is the shortest.  Yet the current state of things is that the entire chart falls into the last category.  This not only leaves the patient in the dark, it makes it so we have to do a whole lot of unnecessary work that the patient would do much better at (and without costing us a dime).

I think this is the sweet spot.  This is the way the medical record should be in the future.  It should be a shared venture – not just between PCP and patient, but also including other providers.  For care to truly move forward we have to dream about what it could be.  Our office now has this as the vision for where we want to head.  I know my patients will be thrilled, and I am pretty sure I’ll have a lot less frustration in the exam room.

Really.  No joke.

I am going to be answering questions about EMR Live on Kevin, MD at 10:30 PM EST tonight.  I will put the Java thingy on this blog, but his invitation to me to guest-host his question/answer session gives me cause to compel you to go to his blog to do the damage…I mean, ask the questions, although I will put a widget at the bottom of this post as well.

Have I mentioned that I like the word “widget”?

There are the reasons I was asked to answer questions regarding EMR, as opposed to llamas, shampoo, or Wankel rotary engines.  Here are my qualifications:

• We have been on an EMR since 1996
• I was president of the MedicaLogic (now GE) EMR user group in 1999, and served on the board for 4 years.
• Our practice won the Davies Award for Primary Care given out by HIMSS for the best use of EMR in an ambulatory setting.
• I served for two years on the HIMSS ambulatory EMR steering committee.
• I was keynote speaker for the PACT (physicians adopting computer technology) conferences put on by HIMSS in 2003-2005.  A side note is that it was at a NYC PACT conference that I met Dmitriy Kruglyac who got me into blogging.
• I have also given EMR talks for AHQA and worked with them for the DOQIT program implementation by the QIO’s.
• I have regularly written for Physicians’ Practice Pearls on the subject of EMR adoption.
• I have recently done interviews with the AMA regarding e-prescribing and Reach MD about EMR adoption.
• We have used our EMR to become NCQA certified in diabetes and have received a significant amount of P4P bonuses because of this.
• Using our EMR, our office has allowed us to not only survive the currently hostile climate toward primary care, but actually thrive.  Our profits have increased over the past 5 years, and we have not done anything but outpatient visits (we do very few office procedures).
• I use the word “widget” without blushing.

My main focus is the adoption of health IT in the small private practice – particularly in primary care.  I am very frustrated when I hear people say things like “EMR is not possible in a small office” or “EMR isn’t worth it.”  We did it, and we did it without the help of others.  Our office is disproof of the word “impossible.”

Has it been easy?  Not at all.  But we have implemented without much help – we learned things the hard way.  Hopefully our experience will give others a template on how to not only adopt EMR, but to use it as a tool to improve quality of both care and service.

See you tonight!

Do patients own their medical records?  Do doctors?  Hospitals?  Insurance companies?  Area 51?  Sanjay Gupta?

You hear this question put out there often, although not necessarily as plainly as that.  People want to “keep my medical records online.”  Google and Microsoft are trying to become a big player in the “Personal Health Record” industry with products that will allow individuals to keep their own records.

But are those really the patients’ medical records?

My office is about to make certain parts of people’s records available to them online in a secure setting.  That way they can view their medication lists, make changes to it, and request refills.  They can look at their last cholesterol or mammogram and know when the next one is due.  This would be great for us and our patients, giving them information they haven’t had in the past.  But we have no intent on making the entire record readilly available to our patients.  There is still some information that I don’t want my  patients reading.  What if someone comes into the office with a child and I have some suspicions about the family situation.  I certainly want to make note of that for the simple fact that I will need a reminder when the patient returns (or if one of the other providers in my practice sees them).  But I certainly don’t want the patients having access to this.

This is also complicated by other facts.  For instance, we started recently putting immunizations directly into the Georgia immunization registry (called “GRITS” by the way), and the question came up as to whether we still needed to put everything into our charts.  Yes, we will document we gave a certain immunization, but do we have to say which leg it was given in, which lot number, which nurse did it?  This information is already being put into the registry, so then is this registry partly ours to use as records?

It’s a really complex subject because there is medical information on a patient in a huge number of places.  Not only do I (as a PCP) have a record on the patient, but so does the hospital, pharmacy, insurance company, specialist, lab, and radiology group.  Who owns that information?  Is there such a thing as information “ownership?”  Lawyers could probably answer this better than me (with words like “heretofore,” “forbearance,” and “adjudicate” – all of which make it off-limits to anyone with ADD), but here are some of my thoughts on the issue:

1. The term “the patient’s medical record” is meaningless.  There are a large number of records, just like a person has accounts in many banks.  The idea that somewhere there is an over-arching comprehensive record is false.
2. Medical records are tools.  I use a patient’s medical record to know what I am doing on them.  Since I see people intermittently, sometimes with six months, a year, or more between appointments, I have to have some way to remember what is going on when they come in.  One of the main reasons we started using electronic records is so we could have rapid access to that information.  I am way too disorganized to do it with paper.
3. The idea of “owning data” is probably wrong.  A better way to think of it is “have the right to access data.”  When we first implemented EMR, one hospital was afraid to interface with our system because we would “take their information from their system.”  A high-up executive in a very large hospital system actually told me this.  But when I am the ordering physician, aren’t I part “owner” of the data?  Does the patient “own” it?  You see how the idea of ownership falls flat.
4. Much of the medical record is there for financial reasons.  If I could, I would reduce the size of my notes by 75-90% by getting rid of useless stuff.  That stuff is not there for me.  It is not there for the patient.  It is there so I can show I did enough work to charge what I did.  Doctors are paid by documentation, not by work.  EMR has made the ability to put more useless information much more accessible.  Does that mean EMR causes me to over-document?  No, it is the rules set by the government which make me over-document.  I just want to get paid for what I did and EMR lets me easily over-document so I can.
5. Another bunch of information is there to protect against lawsuit.  This cuts both ways; increased information is put there to cover your tail, but it also sets you up for more scrutiny.  If I put mammograms into the record that the GYN ordered and they are abnormal, I am at risk of lawsuit if I don’t follow-up on that information.  The easier it is to put information in the record, the easier it is to miss stuff and pay for it later.
6. Most of the record is now irrelevant.  I don’t care if someone had stitches when they were eight.  I don’t care what someone’s serum chloride level was in 2004.  In general, I rarely refer to information that is over 1 year old, and almost never look at information that is over 5 years old.  It is important to keep past histories up to date – the generalities may be important, but the details are meaningless.
7. Different parties will have interest in different information.  I don’t care what brand of stent the patient got in his coronaries, but the cardiologist does.  I don’t care which generic they got, but the pharmacy will.  The same goes for patients; there is only limited information that is relevant to them.
8. Persuant to the claimant forthwith that heretofore is called “client X,” the adjudicated compliance is groovy.

Do patients need to have access to their medical records?  Not all of them.  Somehow there needs to be a way to parse out what is important and what is not.  The Internet has proven to me that more information is not always better.  We don’t need more information, we need the right information when it is needed.

Be prepared to have to adjudicate a lot more information on this subject.  You’ll be hearing a lot more.

Our office has been on Electronic Medical Records (EMR) for nearly thirteen years.  We see a high volume of patients, keep our overhead down, and are able to be quite successful financially.  All of the “EMR is impossible” and “EMR makes things worse” stuff you read around the web are disproved quickly with a step into our office.  We implemented EMR successfully in a private practice setting without help from an economic stimulus, a hospital system, or a magic wand.

Not that it was easy; we went through many years of struggle to get to where we are today.  We struggled mainly because we were exploring unknown territory.  We had very few other successful EMR implementations to learn from.  We used slow computers and programming developed in the pre-Internet era.  We made huge mistakes and struggled at times to make our monthly budget.

But we did it, and practices implementing now can learn from my and others’ success.  Probably the main lesson we learned is to put office function ahead of implementation.  Since we are a business, we must stay profitable while implementing.  Since we are practicing medicine, we must never compromise quality in the process.  This meant that we implemented over time, focusing on parts that would either improve our process or at least not bring us down.

Now we are at the position I thought might never come: survival is no longer in question, so we can dream.  We don’t have to act defensively, we can push the envelope.  We can afford to ask the question: “How can we build the best medical experience for our patients?”  We can imagine a destination and actually attempt to get there.

The ideal destination is one in which our patients’ care is improved by maximizing efficiency on our end.  Obviously I don’t want to make things harder for our practice, I want to make things easier.  But the goal of care is ultimately centered on the patient, not us.  So is there a way to accomplish both goals?  I think there is, and I think that our EMR is the tool that makes it possible.

Here are our goals in the process:

• Simplify how things are done
• Always have the right information available
• Make communication clear and easy
• Achieve the highest quality possible

I’m sure some think this is just idealism and can’t happen in reality.  I agree and disagree.  No system can be perfect, but the current healthcare system is so inefficient and ineffective that huge gains can be made.  The best way to show that is to get down to specifics.  Here is where our practice is heading:

Simplify

The thing that takes the most time away from actual patient care is documentation.  Doctors are paid by the volume of documentation, not its quality.  Still, the main purpose of a record is to accurately know what is going on with the person facing you in the exam room.  Unfortunately, the patient is continually changing, so some information is only accurate for a short time.  Has the patient seen a specialist or been in the hospital?  Have the medications been changed, or just not taken?  Have they changed jobs, quit smoking, or gotten married?  Did their sister just get diagnosed with cancer?  The task of keeping this information up to date is extremely difficult.

Patients are the ones who know these things best, but they are only passive participants in the process.  To keep the record accurate, I must ask them all the right questions on a regular basis.  This cuts into time that should be devoted to care.  So why can’t the patients be allowed to maintain this part of the record?  Why shouldn’t they have access to parts of their record and the ability to correct errors?  Here is how we see this happening:

• Certain parts of the record should be available for patients to review online.  Basic demographics, medications and allergies, family history, and lifestyle information is a good start.  If something new has happened, the patient can either update this information directly (like marital or smoking status) or notify the office of changes (like medication lists).
• If the patient doesn’t update it online, then they can do so when they come into the office (while sitting in the waiting room).  Some people will undoubtedly not want to do this, but a significant percent will, decreasing the workload on the office while maximizing the quality of information.
• Patients should be able to communicate important information to the office online.  If they go to the ER or see a specialist, if their blood pressure or sugars are high, they should be able to send that information directly to the physician.

Another area of potential gain is the gathering of information for a visit.  When a person comes to the office, they have to answer a series of questions related to the visit:

• what are the symptoms the are having?
• Are there any other symptoms?
• How have they been since the last visit?

Gathering this information is essential, but it is one of the main causes of delays.  Here is how we want to employ technology to improve this process:

• Put kiosks in our waiting room where patients can provide information, such as:
  • History of their present illness.  If they are sick, then what are the symptoms and how long have they gone on?
  • Review of systems.  What other things are going on in their health?
  • Medication and demographic review (if not done already online).
• If patients fill out information online before coming to the office, the staff will bring them to see the doctor immediately (or at least as soon as possible).

Even 50% participation by patients in this process will have a huge impact on our office workflow.  The end result is a win-win: the patient is seen sooner, the information is more accurate, and the workload of the staff is reduced.  Will there be problems?  There always are; but the advent of ATM machines, airport kiosks, and online shopping are a few examples of process automation that have greatly improved the customer experience.  Why should medicine be different?

I am going to stop here, as I don’t want to lose you (if you haven’t already whacked the keyboard with your forehead).  Hopefully you can see that the use of technology applied smartly can help patients and medical offices at the same time.

And this is just the start.

Electronic Medical Records are coming.  The economic stimulus bill (furious spinning kittens notwithstanding) assured this.

Under the terms of the bill, CMS will offer incentives to medical practices that adopt and use electronic medical records technology. Beginning in 2011, physicians will get $44,000 to $64,000 over five years for implementing and using a certified EMR. The Congressional Budget Office projects that such incentives will push up to 90 percent of U.S. physicians to use EMRs over the next 10 years.

Practices that don’t adopt CCHIT-certified EMR systems by 2014 will have their Medicare reimbursement rates cut by up to 3 percent beginning in 2015.

(From Fierce Health IT)

There will be even more money for implementation.  We look forward to our checks (and are not counting on them yet).

Now it is time for the flies to start gathering.  Wherever there is lots of money, “experts” pop up and new products become available that hope to cash in.  Doctors, who are never lauded for their business acumen, will be especially susceptible to hucksters pushing their wares.  It seems from the outside to be an simple thing: put medical records on computers and watch the cash fly in.

Anyone who has implemented EMR, however, can attest that the use of the word “simple” is a dead giveaway that the person uttering the word in relation to EMR is either totally clueless or running a scam.  It’s like saying “easy solution to the Mideast unrest,”  “obvious way to bring world peace,” or “makes exercise easy and fun.”

Run away quickly when you hear this type of thing.

Just like becoming a doctor is a long-term arduous process, EMR implementation happens with time, planning, and effort.  It’s not impossible to become a doctor, but it isn’t easy.  With EMR adoption, the most important factor in success is the implementation process.  A poorly implemented EMR isn’t simply non-functional, it makes medical practice harder.  A well implemented EMR doesn’t just function, it improves quality and profitability.

How do I know?  Our practice ranks very high for quality (NCQA certified for diabetes, physicians are consistently ranked high for quality by insurers), and we out-earn 95% of other primary care physicians.  EMR allows us to practice good medicine in a manner that is much more efficient.

So how’s a doc to know who to trust?  What product should he/she buy and whose advice about implementation should they follow?  There are many resources out there.  Here are a few I think are especially worthwhile:

1. Buy a product that is certified by Certification Commission for Health Information Technology. CCHIT is a government task force established to set standards for EMR products. Its goal is to allow systems to communicate with each other and enable more interfaces in the future.  The bonuses for docs on EMR are contingent on the system being CCHIT certified (think of it as something like the WiFi standard).
2. The American Academy of Family Physicians’ Center for Health Information Technology and the American College of Physicians both have tools to help member physicians decide on an EMR. Your own specialty society may, too.
3. Several professional IT organizations have programs to improve EMR adoption, including HIMSS and TEPR.
4. Austin Merritt has written a good article of advice on his website Software Advice that underlines the importance of implementation.

The best advice I can give, however, is to visit a doctor’s office who is using an EMR successfully.  This office should be as close in make-up to your office as is possible.  You should be able to look at how they do it and see yourself in that situation.  Never buy a product before visiting at least one office like this (no matter how good the sales pitch).  When you visit, make sure you ask them about the implementation process.  How did they do it and how hard was it?

Which EMR do I recommend?  Remember, I have been on EMR for over 12 years, so haven’t had much of a chance to shop around.  You hear raves and horror stories with every product.  Here is some basic advice:

• Get a solid CCHIT-approved brand that has been around for a while
• Don’t pay as much attention to price as you do function.  Since the EMR will be absolutely central to the function of your office, it is a dumb mistake to overly-emphasize cost.
• Realize you are paying for a company, not just a product.  It is not like buying a car, it is more like having a child or getting married.  REALLY research that side of things.  A good EMR with a bad company behind it should be avoided like the plague.
• See how connected the user-base is as well.  A solid user group will do much to make up any deficiencies in the product and/or company.

So much time is spent shopping over EMR products, but buying an EMR is like being accepted into Medical School; your work is just beginning.  That’s OK, because like medical school, the effort put in gives a very worthwhile product.