EHRs in the real world

A doctor gives us the (lack of) incentives to convert:

Start with the cost of more than $37,000, plus some $14,000 per year on maintenance. Then there are the weeks out of practice to learn the new system and the slowdown while everyone becomes familiar with using it. Then add, as Technology Editor Ken Terry mentions, that the payers will simply lower their rates to counteract the improved documentation and coding.
As at least one researcher has pointed out, EHRs in hospitals have not lowered the error rate but rather just changed the type of errors committed. Huge amounts of over-documentation have also occurred. Another downside is the tendency of providers to concentrate on the computer screen and not the patient. And do I really lose that many records or lab results to make switching worth it in my little solo practice? The answer is No.
So, there are a huge cost, no real financial benefit, and little other advantage. I am underwhelmed.

MD Net Guide also with the case against EHRs.

Comments

Anonymous
I agree. For a practice the size of the one where I am working, the costs of purchase and introduction are formidable. I would have to train all the staff, or pay contractors to do the same. There are substantial follow-on expenses each year for maintenance. The systems are proprietary with limited, usually solitary suppliers (and there has been an unfortunate record of company failures with practices being left with orphaned systems.) There is the extra hardware to buy and install.
I work relatively efficiently. My inefficiencies are not those an EHR will help much. Missing charts aren’t really a problem. I chart quickly and document effectively to the level of service I am providing.
I don’t need to work from remote locations where I need access to all my records. I don’t spend all that much time writing prescriptions. In all, I don’t believe an EHR will allow me to see more patients in a workday or bill at a higher coding level or save me time while I wait for records to be fetched. The cost savings of persons fetching records isn’t likely to be all that great unless a system is so efficient that it will allow me to eliminate my front desk check-in and checkout staff which it will not, since they are needed for other tasks the EHR will not eliminate, like scheduling and collecting copayments.
It will cost me a lot of money now and in the future. It is dubious that it will benefit me. (Do I really believe that I will have access to a web of interconnected databases of all my patients’ equally wired doctors and pharmacies so that I will be able to acquire a full list of current medications without asking the patient? No. Will communications with all my patients’ other doctors become all that much easier? No.)
The government iniitiatives to promote EHRs with a stick and no carrot are benefiting computer companies and software writers. They are the primary beneficiaries. Unless there is to be some secure yet easily accessible master library of patient data outside of a doctor’s office that everyone can access when needing information on a patient, I am not convinced that there will be any significant portability of patient records, only a lot of competing disconnected office systems each with its own discrete collections of patient data. Where will the benefit to safety in screening for medication errors come from? I don’t see any.
Anonymous
I certainly agree. I pledged to myself when opening my solo family medicine practice in Louisiana that I would have an EHR in 6 months. I thoroughly researched them, including the VA system that is essentially free through the Freedom of Information Act. Lab and radiology studies, referral letters received, etc. would each have to be individually scanned and put into any EHR that would be even semi-affordable for us. Michael Davis. thefamilymd.com thefamilymd.typepad.com
Gasman
“Huge amounts of over-documentation have also occurred.”
This is a huge problem. Reams of text can be inserted simply with a ‘insert normal exam here’ keystroke. The documentation then appears far more robust than the actual physical exam, review of systems or history of present illness. It leaves the reader with two challanges, 1) find the important bits, those that the experienced focused examiner would have sought and documented in the paper system, among the chaff on the voluminous documentation and 2) determine the veracity of all of the reams of allegedly negative information, simply and mechanically inserted into the text but which might not have been equally rigorously established as negative in the real exam process.
The burden of handwritten (or manually typewritten) notes is that the writer must be parsimonious of word. Excessive ease of documentation leads to recording negative facts more strongly than warranted.
Josh
First let me say that I enjoyed learning more about your practice Dr. Davis. It seems to be more inline with what family medicine should be than I’m used to seeing.
COST: I’m curious what you Drs think a EMR cost to purchase / set up because I think you’re fairly mistaken. e-MDS is the top ranked program by MDs on the AAFP website and cost 15K in software and hardware. Honestly, 30K is not that big of an investment if it improves the quality of care.
PAPER VS EMR: Do EMRs have their own set of problems sure, but so do paper charts. Often times, the complaints of an EMR are the result of inappropriate use by the provider, not the software. Besides, paper charts are riddled w/ problems. I’d rather have a chart I can read from anywhere in the world but w/ too much info, than a paper chart I can’t read at all.
CHANGE: Its too bad physicians are so slow to technology. If banks operated like doctor’s offices, you’d bury your money in the backyard. Speaking of which, banks went through the painful adaption period when trying to standardized the personal check. It was a bloody time w/ proprietary systems fighting each other but it ultimately led to huge benefits (same could be said for credit cards).
A time will quickly come where people won’t respect drs who don’t adequately use technology in their office. Pts will want to manage their health electronically whether in the form of PHRs, emails, etc and physicians who don’t adapt will fall by the wayside.
Anonymous
Josh, you write as one who seems to spend a lot of time with a computer and has become facile enough to belive that everyone interfacing will have the same efficiency and acceptance of it. I just wish that were true.
As to cost, much depends on what has to be networked, and whether the software in all the networked devices is as well written to afford easy interoperability and in/out flow of data to a database storage device. In my specialty, there is a lot of device-generated data that needs to be attached to patient records: charts, angiography capture, photography, and multiple other device inputs that have to be assembled into a complete chart. All the machines have to work seamlessly with a very high order of reliability, or the EMR will be a failure. Text from chart entries are the simplest components. There are a few privately developed commercial systems in the market, but they are expensive, and the follow-on costs are high too. I have been looking at them for a couple of years now, and there are still concerns. There is also a regrettable history of costly failures of earlier systems whose developing companies went under and for which there was no effective follow-on support. That has made a lot of people cautious.
Most doctors aren’t unwilling to change, and aren’t technophobes either. EMRs are as much a business decision as a technical one, and there are no examples of screaming business successes or clear advantages of these systems in places where they have been introduced. Best case is possibly a break-even, and I haven’t seen too many of those (most were beta sites who got below-market pricing for early adoption) and almost every case took at least a year to introduce the system and create a working database just for intramural use. In no cases have I seen any worthwhile extramural applications. None.
With the margins of third-party payors already trimmed, I just don’t believe there is much of a carrot to offer to those taking the risks and bearing the up-front expense of these systems. Threatening to cut reimbursement for those who don’t buy these systems has a high risk of blowing up in the faces of those making those threats–I would just as soon tell those payors to get lost, if in the end that were the cheaper alternative. I sure don’t owe Aetna or Medicare anything.
Anonymous
From my experience so far trying to adopt the pathetic AHLTA system (military/TRICARE EHR), EHRs suck. By the way the DOD has wasted $10 billion on this project (go contactors!). EHRs, in my opinion, may even be dangerous to patients, because so much jibberish surrounds the actual doctors note. I believe the important information written by the doctor may be overlooked. I think EHRs are OK for all the surrounding data (coding, meds, allergies, etc), but the doctors note must remain sacred in order to protect patients and ensure the proper diagnosis and treatments are rendered (maybe scan the note into the EHR). I have tried going back to some of my old EHR/AHLTA notes when patients come for follow-up and it takes too long and many times I can’t get the jist of what I was thinking with the prior visit. Maybe I am unusual, but I feel alot of what I write in my notes are telegraphed by the actual physical writing of the note and typing into a computer makes the notes very sterile and impersonal. Just my $0.02…
Anonymous
So much of the EHR I get formwarded to my office is rubbish. It is more legible than handwritten notes but less likely to be relevant. I will get entire sections about the prostate exams done on female patients. Sometimes I even learn the both the prostate and the cervix appear normal. Crap is crap even if it is legible crap. I dictate my charts. I do have “normal exam” templates that my real live transcriptionist uses, but I check them and the transcriptionist will call me to tell me if I say something stupid. That is 3 cross checks. It isnt cheap but it does protect my patients and provide a legible record for me, my referrals and posterity. Screw the emr
Josh
Everyone continues to blame the EMR and not the Physician User. Just b/c you may take special care to have quality paper charts doesn’t negate the fact that the vast majority of paper charts are still sub-par. User error = user error regardless of format.
The advantages to EMR be it meta-data, accessibility, coding, clinical red flags etc will continue to out-weight the potential drawbacks.
I appreciate the extra effort you docs are taking to make your paper charts right, now imagine how good EMRs could be if other docs took the same time.
I don’t mind constructive criticisms of EMRs but lets correctly place the blame.
Anonymous
Josh,
As a former IT professional, now in medical school, let me offer a suggestion: when people say that there is a problem with implementation, the problem has to be addressed. I recognize that the first instinct is to blame the users, but bear in mind that if an elegant, efficient design does not meet user expectations, or cannot be used effectively by its intended market, it’s simply garbage.
The mark of good software is one that pleases its users. Period. It is not the job of the user to adjust to fit the software, it is the job of the software to suit the user, and the task he wishes to accomplish.
I do know the frustrations of designers, and the frustration of implementors, and I do sympathize. But begin at the beginning, and listen to the problems. Those problems are real for those users, and have to be addressed before they will use the software.
my $.02
Josh
Well I can’t argue with that, you make an excellent point. However, I think the problem comes when physicians aren’t willing to learn anything new and most are techno-phobics. Case in point is the 36 y/o plastic surgeon i worked for 3 years ago who couldn’t even type. It is indeed a balancing act by the software (needs to meet the needs of the user) and the user (being willing to adjust to a diff system).
Docs can learn to use an EMR, I have and I’ve seen many others use it very well. The ones who took the type to become superusers are the ones who swear by their EMR. My favorite Preceptor told a story of how he was filling scripts and responding to pt emails while on a train b/w DC and NY. His office is in Kansas. Everyone benefited b/c he got his work done when he needed it, and the pts were still able to communicate w/ their doc even if he was out of town.
In a sales pitch, an emr salesman used a line form a doc who said “the program has to give me the info quicker than I can ask for it, or i’ll just ask someone else to get it for me.” Admittedly thats a good goal, but a bit stubborn.
My wife just finished nursing school and they basically force them to do what ever they want. All nurses take an ongoing course in the EMR whether they want to or not. Docs should be the same b/c if we’re not forced to change, we ususally don’t and it hurts the system.
Anonymous
what are EHR’s? I skimmed the article but couldnt seem to find out.
Josh
EHR = Electronic Health Record, also known as EMR = Electronic Medical Record. You may also hear the term PHR/PMR which = personal medical record. This usually belongs, is purchased and maintained by the patient and is often on a flash drive or online.
EMR is software that medical offices can use to store information about and track their patients. Basically it replaces the paper chart.

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