Electronic medical records and its rushed implementation

Electronic medical records are being aggressively pushed by the government.

As most know, they’re pouring billions of dollars into the initiative, hoping the spur adoption among doctors and hospitals.

But, like most government-provided financial incentives, they come with a host of regulations designed by those with little understanding of physician practice.

As reported in Politico, hospitals and doctors are taking issue with the meaningful use guidelines demanded of them:

In January, the CMS published a proposed rule on how to determine eligibility. Hospitals and eligible providers would have to meet about two dozen “meaningful use” criteria to receive grant dollars in 2011. Among the requirements for doctors is the ability to e-prescribe and provide patients with access to their own electronic medical rec­ords upon request.

But what CMS defined as “meaningful use,” major medical groups saw as an untenable and aggressive rule, one that would require meeting more than 20 benchmarks with a little more than a year to prepare.

Implementing an electronic medical record is a tremendously disruptive process, both from a financial and workflow standpoint. In most cases, physician productivity is slowed, and patient care worsened, while they adapt to these systems that are often not intuitive to use.

Last month, David Kibbe wrote a cautionary post on meaningful use:

Our national leaders should understand that unless duplicative, wasteful, and completely non-productive documentation is streamlined and significantly reduced, the nation’s small and medium size medical practices will likely sit on the sidelines … not because the money is too little, or the technical help offered insufficient, but because they simply don’t have the cycles to take on the new paperwork (even if it’s computerwork). If that happens Meaningful Use will be at risk of becoming a failed experiment that merely lined the pockets of the highest utilizing, and therefore highest profit, physician groups and hospitals, along with the legacy EHR vendors who they favor.

Unless those in charge of leading the electronic record revolution have a better grasp on how hospitals and physician practices are run, there’s a significant risk that a rushed, misguided digital push may entrench us in a system that may be worse than the status quo.

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  • Max

    And as I’ve said in other posts, at the end of the day, after all that cost, disruption, headache, extra time, etc etc etc you get the SAME payment for that patient visit as you did before. Oh some of the ‘smart’ systems tell you to ask a few more questions to get that level 4 visit. Really. I just wanted to practice medicine and see my patient. Is that so bad?

  • KP Internist

    Take from doctors who work a KP, a fully functioning EMR saves time, lives, and money. I haven’t opened a paper chart in almost 5 years and my patients expect that anyone who “touches” them to have complete access to their medical records. It is worth the effort. Once you get up and running, no one will regret it.

    • rezmed09

      Not all EHR’s are equal. Many products out there are not integrated. Many systems now being implemented do not have the trial and error experience of KP’s.

      To say that “EHR’s saves lives or time or money” is a crap shoot. There are no standards out there for implementation. Let’s be open minded. Right now there are products being sold which might loose support in five years when the company goes belly up. Right now there are systems which are better or worse for patient care. We are implementing systems about which no one has done comparative effectiveness studies on.

      No one is advertising that their EHR went down for a day, or that problems with patient care occurred. That kind of bad press will only attract tort claims. It seems to me that it is only a matter of time before we see the billboard and phone book ads popping up for “Did your doctor’s EHR lead to an error in your care?”

  • http://pagingdoctorgeek.blogspot.com Dr Geek

    While I agree that rushing the process will be detrimental, if physicians haven’t been thinking about EMR way before Noe, they’re woefully behind. I know that there are more pressing daily concerns. I know that people who haven’t been using computers for 25 years, like some of us, may have trepidation about the changes involved. This simply shouldn’t be a surprise to anyone…

  • Tom

    Call it a hunch, but I’ll bet that before long there will be a movement to have an EMR in your practice mandated for licensure. After all, you can’t be keeping up with the profession if you don’t use an EMR. This push speaks more to the continued erosion of individual and small practice docs, pushing us into greater collectives like Kaiser, which will be more “responsive” to government initiatives.

    • KP Internist

      I agree that the move is to larger group practices or even something like KP. It takes an army of IT people and administrators to keep our system going. The only other option is if the government provides the IT infrastructure and licensed providers can only provide content.
      I think that if your experience with an EMR is just as a notewriter, then you haven’t seen a EMR. The implementation that we have here has really been a game changer for patient safety and cost savings. There has been many examples of my not ordering an MRI on a patient because I can see the report from 1 year ago at another facility and read the note from the neurologist associated with that episode. The ability to interact with patient by a rich secure messaging system has also reduced office appointment requests. I addressed 10 patients this morning by e-mail and probably reduced 5 office visit for something that could have been handled electronically. Implementing an EMR for KP was not easy, but it was worth every penny.

  • http://takadakatakata.blogspot.com/ Medical Student Notes

    How the application of EMR in developing countries? I think that EMR can be used in big hospitals. However, Is EMR required in a private doctor’s office?

  • andymc

    KP,

    Most don’t debate that once an EMR is up and running it is efficient and useful. Any doc using a fiully functioning EMR can attest to that.The point was regarding the bulk of practices in the US- small to medium sized practices that don’t have near the requisite resources larger groups do to make this transition effectively. And then to monitor, trouble shoot, make sure all the “meaningful use”hurdles are cleared. Hearing Kaiser and Mayo trumpeted as the models to follow is a bit unrealistic at best in terms of implementing EMRs..

  • Terry

    As a KP doc do you get paid for you time to answer emails? Did you get paid for your time to train on an EMR?
    Did you have to put the cash up front (with little chance of reimbursement) to purchase the equipment in the first place?
    Did you notice that your CPT codes went up a notch and that’s why the big KP is so keen on using EMR’s.
    The only thing the Gov’t is interested in doing is data mining.

    In many other businesses and professions the government will mandate changes to their operations that cost them money but unlike medicine they pass on the cost to the consumer. The Gov’t just tells us to suck it up!

    This mandate and the cost of introducing ICD-10 into small primary care practices will destroy the backbone of the medical profession in this country. We’ll all be doing KP duty in the future.

    • KP Internist

      Yes, the implentation did include time for training and we did hire extra pool doctors to work while we got up and running. Yes, it did improve our coding and revenue. Small group practices should realize that times are changing and that model just won’t work anymore. When was the last time you went into a privately owned and operated pharmacy? System costs, demands on physicians to be both a doctor and bussiness owner, and struggles to keep with patient expectations will drive all small groups out of operation. EMR is just one example of why large group practices will dominate the market from here on out.

  • Terry

    And with that the loss of the heart and art of medicine and the intimacy with the patient. More’s the pity.

  • http://www.upstate.edu/biochem/faculty-rest.php?EmpID=ChAFPxPx Robert West

    Afraid I agree with KP Internist and respectfully disagree with Terry (though I support your point). Have had KP coverage before and it was great.

  • http://ehealth.johnwsharp.com John Sharp

    It may not be perfect, but meaningful use is one way to move health care from a cottage industry (as noted in a NEJM op-ed on healthcare reform), to the 21st century. If that means large group practices and integrated health systems, then so be it. Can we continue to tolerate a system in which 20% of patients show up for a postop outpatient visit without their PCP having a discharge summary? When do these kinds of ineffective, paper-based systems become unacceptable? See Chaos and Organization in Health Care by Lee and Mongan.

  • LynnB

    I work in a medium sized PHO system,in GIM . THere are 6 docs in my office -was 9, two left because their incomes DROPPED so much they had to go to hospital work. One left because life is pretty hard in clinic. Takes , even after 4 years about one hour after clinic is closed to document one hour of appt. time. I shudder to think how much patients are paying to watch me type at 20 wpm or use Dragon at 75% recognition , 4 years later. We have no army of IT workers. This is what most of us will face in the underfunded rural or less insured city world. The PHO has a couple hundred docs and is far as I can tell only 3 IT people assigned to outpatient record. All 3 are exemplary, but outpatient visits are basically a money-loser. The investments go to procedural specialties, lab and more radiology toys . That is a rational, if perhaps less than flattering business plan.

    IT frustrates me , an ex-computer programmer ( back when we used Fortran , Cobol , Basic and Pascal, and worked in DOS -there was a small company across Lake Washington that supposedly had an easier operating system) that EMR should be a tool as Kaiser doc says . Instead its a burden. The data entry is so time consuming the majority of docs don;t do it, so the population management features , even IF we had people to run them , are not helpful

    We had 2 or 3 unpaid 1 hour training sessions , (wait, they brought lunch!) and were not allowed to ask questions that might confuse the group. When I go to conferences this is lower end for a big group, typical for a medium group . Small groups of course get nothing or nothing meaningful once they have paid up.

    Meaningful use guidelines, sadly are just another scam, like P4P. Good idea, compliance impossible unless you have a well supported IT system. So the IS rich get richer and there are more and more non-functional or poor;y supported systems out there that we are forced to buy.

  • Molly Ciliberti, RN

    Was once in the EMR business for ED’s and was stunned at the crap that was out there being sold to unsuspecting hospitals as the greatest thing since sliced bread. Many of the systems both HIT and department specific are POS and are created, sold and managed by people who know nothing about medicine, nursing, etc. They just learn the buzz words. Even the large EMR vendors suck except for Epic Systems in Wisconsin. I have no connection to them just years of watching them do an excellent job and refusing to be bought out (and probably squashed as HBO and Cerner and others have done in the past.)

  • http://www.TheWriteTreatment.com Barbara Hales

    Finding the right emr system is an arduous process and a daunting task, especially if you are unfamiliar with features that are available and what qualifies for meaningful use as well as finding the one that is most economically feasible.

  • jo

    I just received notice that the Obama Administration is actually considering the FDA to have oversight of all EMR companies. If this wasn’t so frightning it would be funny.

    It seems to me that the FDA is having trouble monitoring itself and seems not to be able to keep up now with all they are to enforce.