Why an Electronic Medical Record is Not Right For Me
Note on terminology: Electronic Medical Records (EMRs) and Electronic Health Records (EHRs) are synonyms. I'll mainly be using the term "EMR," except when quoting from elsewhere.
Family Practice Management recently ran an article on Myths about EHRs; how they don't fix everything, why they won't eliminate errors, and so on. The problem with this article, though, is that it's from the point of view of a practice implementing one, implying that they have at least bought into the idea that there is in fact something to be gained by working their way through the "myths" they proceed to debunk in the article. As I read it, I was struck by the mythology of those underlying assumptions. I'm no Luddite. I've thought long and hard about whether an EMR is a worthwhile investment for me at this stage of my life and the life of my practice. Over and over again, I find that each pro-EMR argument is based on assumptions that do not apply to me. Here are some of them, in no particular order:
- An EMR produces better documentation.
What are some objective qualities that might constitute "better" documentation?
Legibility: I hand write my charts, but I happen to have beautiful handwriting. Something about teaching myself calligraphy in high school, it's the artist in me that finds indented, outline-style notes easier to look back at when I need to review.
Organization: I have templates in my head of what questions need to be asked for a given problem. The trick is to fill in the answers as the patient gives them, then ask only those questions that are left. In many ways I think like a computer, and I have considered "creating my own EMR" by using a database to create the same notes I currently write. It might allow better functionality for searching, but that's about it.
Completeness: Again, those templates in my head serve me well. The inside front cover of my chart serves as Problem List, Med List, Allergies and preventive care flowsheets. I review and update those lists every time I open a chart, including phone calls and prescription refills in addition to patient visits.
The bottom line is that whenever my charts have been reviewed -- as they have by countless insurance flunkies, QA nurses and the lawyers involved in my lawsuit -- they have been uniformly praised on all counts. No one has any complaint with my documentation. I can easily find what I need when I need it. What do I have to gain from an EMR?
- EMRs save time.
- EMRs improve reimbursement.
A man in the back spoke of the new EMR he had just purchased for $30,000. Once all the numbers were crunched, though, it turned out he was only going to see about $3,000 in P4P bonuses. The response, delivered somewhat more softly than the stentorian tones of the main presentation, was that his return was more likely to be in the areas of quality and lifestyle. I imagined presenting a proposal to an insurance company -- actually to any kind of business -- and saying, "Now, you'll only make back about 10% of your initial investment, but you're likely to see improvement the areas of quality and lifestyle."A related point:
- EMRs improve performance.
- The government is pushing EMRs hard, and are working towards providing incentives to practices that adopt them.
- An EMR will add value to the practice when you go to sell it.
Here's the line from the Family Practice Management article that inspired this post:
An electronic record is not a paper record on the computer, and you will maximize your efficiency only by making significant changes in your workflow. Expect to work differently to make the most of the EHR system's advantages as well as overcome its disadvantages compared to paper (yes, you will find some.)Why do I have to change my workflow? It works -- very well indeed -- for me. This is not to say that I've never changed anything in my practice. In fact, I'm continually modifiying and adapting my workflow, often in response to evidence-based practices. But so far, no one has been able to credibly show me that the benefits of adopting this new technology outweigh the considerable disadvantages, starting with the initial monetary outlay, when addressed in the specific context of my practice.