Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, April 24, 2007

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.
"Better" is one of those nebulous terms that is very much in the eye of the beholder. Certainly an EMR has the capability to spew out voluminous notes that don't actually say very much. "More" is not "better" by a long shot. The FPM article actually discusses this, using the term "signal to noise" ratio. The vast majority of EMR-generated notes I have seen have so much noise that the signal can barely be found.

What are some objective qualities that might constitute "better" documentation?
  1. Legibility
  2. Organization
  3. Completeness
Come with me and peek into my charts for a moment; see how I'm doing now before insisting that an EMR can do it better.

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.
Giving this statement the benefit of the doubt by assuming that it does not count the initial learning curve, I still don't buy it. One EMR ad touts the time-saving advantages of its system: "Get out of the office at 5:00 every day." I already do. About half the time I've got the entire note written by the time the patient leaves the office; the rest of the time I slip it in between patients and during other miscellaneous slots of free time through the day. Even if I have an entire stack to write after hours, it rarely takes me more than one minute (by the clock) per chart to finish them. It's the phone calls to patients about lab and test results -- not to mention playing phone tag with other doctors -- that eat up the time. EMRs aren't going to do anything about that.
  • EMRs improve reimbursement.
Bullshit. That's just bullshit. How exactly does this happen? Through P4P incentives? Allow me to plagiarize myself for a moment. From the mouth of a recognized "expert" in P4P and performance enhancement who came to give a talk to a regional meeting of my state academy:
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.
Performance of what, as measured by whom? The usual example trotted out is something like, "How many of your diabetic patients have hemoglobin A1Cs under 7%?" Who cares? I do not take care of populations; I take care of patients, one at a time. Being able to say "87% of my patients are at goal for LDL" is a completely meaningless exercise for me.
  • The government is pushing EMRs hard, and are working towards providing incentives to practices that adopt them.
Yeah, right. The government thinks it's a good idea. Don't forget this is the same government that was so sure there were WMDs in Iraq and that still believes, despite the evidence, in the efficacy of abstinence-only education. Sarcasm aside, this point may be true, but I don't see them getting their act together any time soon enough to make a meaningful impact on me or my practice.
  • An EMR will add value to the practice when you go to sell it.
Once upon a time, medical practices were actually bought and sold. The assumption was that patients "belonged" to a practice, so the value of a practice was calculated as the sum of the hard assets of the practice (equipment, furniture, etc.), the accounts receivable (money owed to the practice that hadn't come in yet, such as insurance payments) and "goodwill," that indefinable thing that basically meant patients walking in the door. If this were still true today, I suppose this argument would have some merit, in the sense that a practice with nice new modern equipment would be worth more to a buyer than one with all old beaten-up stuff. Still, I'm not looking to sell in the near future, and this advice sounds kind of like selling vs. living in your house. It's not worth putting a bunch of money into home improvements you don't really want or need, but would enhance the sale price, unless/until you're ready to sell.

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.)
(Emphasis mine.)
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.


At Wed Apr 25, 07:54:00 AM, Blogger Richard A Schoor MD FACS said...

I agree with all your points, 100%. Commercial EMR's are BS. You can design your own, as I did, that will work well in your office, because YOU designed it. There is one main advantage of EMRs. They save space. I don't have an office full of charts, taking up square footage that I pay for.
Nice post.

At Wed Apr 25, 11:49:00 AM, Blogger Sam Bennett said...

I love this post. Great points all around. I shared my thoughts over on the 4point44 blog.

At Wed Apr 25, 12:09:00 PM, Anonymous Anonymous said...

Excellent post. I, too, don't envision adopting an EMR. I am a 50 year old internist in solo parctice. Just not practical given the cost and ROI.

I'm envious, though, of the time it takes you to chart. I dictate my notes using a voice to text software and it takes me about two minutes per chart.

At Wed Apr 25, 01:24:00 PM, Blogger Paige Erin Hatcher said...

I understand that in solo practice you might not take many students, but I posted from the student perspective on my blog.

At Wed Apr 25, 01:59:00 PM, Anonymous Anonymous said...

Dear Dr. Dino,

Sounds as if your charts are legible and organized. You are a dinosaur!

As a specialty consultant, notes from the referring doctors are very important to patient care.

Unfortunately 100% of the handwritten notes that I receive are not legible. (The majority of records are handwritten).

Doctors learn how to handwrite poorly! This may be in attempt to save time, but I really wonder if in many cases, it is not intentional. If I can’t read the note, I really have to wonder if the doctor even actually saw the patient. At the very least, I have to wonder if they put any thought or time into the patient care.

I don’t how this gets by from a med-legal standpoint. (If you have ever done a med-legal deposition, you know that half of the time is spent- “Doctor, could you please read us your note from ……).

I am not sure that current EMR products are the solution. Most of them do not have much capability to add narrative text. Options such as inking and speech recognition help.

I dictate all of my patient reports using speech recognition. Every patient visit gets a dictated follow-up note or consultation report.

I sure miss the old referral letters and formal consultation reports.

Frustrated Specialist

At Wed Apr 25, 05:55:00 PM, Blogger Dr. David said...

Check out Amazing Charts, and I think you may find your comments do not apply to all EMRS.

At Wed Apr 25, 06:19:00 PM, Blogger Unknown said...

You certainly make some valid points. One additional consideration you might want to give some thought to is the time savings for chart retrieval when either you or your staff answer patient phone calls. With an EMR, the data is readily available immediately when needed and so you avoid the "phone tag" issues, assuming you can handle the calls as they come in. To have access to the records at any time from almost any location frees everyone up from that necessity of finding the paper chart to review it before answering questions or taking care of refills, etc.

I have worked with numerous practices whose physicians AND staff would not want to go back to the paper chart world. It really can make your life easier.

At Thu Apr 26, 01:54:00 AM, Blogger Dreaming again said...

From a patient perspective ...the clinic that I take my kids to uses EMR's ..and they drive me nuts. I want to take the laptops and throw them away and tell the resident to look at us not the computer!

Occassionally, we'll get a resident that will look at us and the computer and even more rarely we'll get one that will only look at the computer when he first gets into the room and then at the end when he's making his plan.

I've been in the room where one resident almost forgot to examine my son (we were there for his asthma) she was so involved in reading his history I she said "well, here's what we'll do... " and my son actually asked her "aren't you going to listen to my breathing?"

"oh yea"

At Thu Apr 26, 12:02:00 PM, Anonymous Anonymous said...

Excellent post! I was recently referred for an ENT consultation. After entering my demographic data medical history, allergies etc. I was thanked, roomed and interviewed by a very nice young lady who proceeded to ask me about my medical history, allergies etc.

So......, whose time was wasted?

At Thu May 10, 11:20:00 AM, Anonymous Anonymous said...

I think that there are two views points to be considered when strongly advocating the use of EMR in practices. For a Doctor it needs to easy to use and save time so that more time can be spend on the patient. Currently we have many vendors with different types of EMR that are so hard to use that it simply puts them off. I think healthcare technology companies need to develop product after regular interaction with doctors to ensure that they provide just what is required. At binaryspectrum we have developed our healthcare solutions after spending countless number of hours with doctors to ensure that its work flow is kept simple and intuitive. This is then followed up with a period of Beta testing in real time environment before it is offered as a product in the market.

At Thu Jul 05, 08:41:00 AM, Blogger Offshore Software Development India said...

This comment has been removed by a blog administrator.

At Sat Aug 01, 09:17:00 PM, Anonymous Anonymous said...

1) as of 2009, of those practices who have installed an EMR, 30% have UNINSTALLED the EMR.

2) EMRs do NOT increase efficiency, indeed it takes 6-18 months to RECOVER the same numbers of pts seen while learning the system.

3) EMRs do NOT save ANY MONEY -- all ROI (return on investment) studies include reduction of the cost of daily dictation in the mix, many practices don't even use this method anymore.

4) Improvement of patient care -- recent study based on 2004 data did NOT confirm that the EMR using groups were better than the paper using groups.

5) use of an EMR to "help you use your office staff more effectively while rearranging their duties (workflow) has NOT been SHOWN (and in this day of "evidence based medicine" to be better.

Use technology to help you see pts, organize your life, BUT if PAPER WORKS BETTER, USE IT!

Matt in Western PA
Solo x 5 years
FP x 20 years

At Fri Sep 25, 05:33:00 PM, Anonymous Anonymous said...

I understand the frustration with implementing EMR. Our hospital is in the process of doing this. There will be a huge frustrating learning curve. I do think that something needs to be done to improve the sharing of patient information among all physicians caring for each patient.

I can't tell you how many times I have seen a patient have more than one order for the same or similar exam done within a 24 hour period because one Dr. didn't know that the other had already ordered the test.

I can't tell you how many times I have been unable to read another physician's notes or consultation because of illegible handwriting. i am aware that your handwriting is very good but yours is the exception, not the rule.

On another post you complain that a cardiolgist changed meds of one of your patients after you had just discovered that the reason for the elevated LDL was poor patient compliance. Unless you send a note along with al your referals to specialists how would the specialst know what recent changes you have made and why?

At Fri Nov 06, 12:40:00 PM, Anonymous Anonymous said...

While I am not in favor of ramming EMRs down doctor's throats, at the same time, I do have a couple of questions for #1 Dinosaur:

1) What happens if your offices burn down - how do you explain to your patients the lost of all of their records? Electronic information has the relatively easy ability to store in multiple locations.

2) This was talked about loosely above, but an electronic chart allows for access by multiple individuals from multiple locations. Isn't this an issue with paper records?

Thanks - good article with some good points.


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