Physician resistance to EMR and why CPT should be replaced

After 5 successful years with electronic medical records (EMR), I am convinced that the promise of EMR to improve physician practices and to improve the health care system is real.

If that is true, why is adoption of EMR currently limited to only 5-10% of medical practices?  Why is there so much resistance?  As folks who work in heath care IT so often ask, why don’t doctors “get it?”  I don’t mind the question but I do object to some of the sinister explanations that are offered.  Physician resistance to EMR is legitimate.

This post will explore one of the reasons for doctor resistance to EMR.

A few years ago one of our best referring physicians came to see me as a patient.  After we took care of his medical issues, I asked him how he liked our new EMR and the notes we were sending him through it.  His answer floored me: “I hate it.”  That is not what you want to hear from one of your best referring physicians.  After a moment of drop-dead silence he added, “nothing personal.  I hate all the EMRs out there, including the one our practice just bought.”

He went on:  “Notes that come from an EMR have so much extra stuffing in them that it takes me forever to figure out what you guys really had to say about the patient I referred to you.  I have to wade through lines and lines of empty verbiage to finally find a meaningful sentence or two that tells me what I need to know.  Our own EMR notes are no better.  But there’s nothing we can do about it, we just have to accept it.”

Except for that last part, he is absolutely right.  Why did things get so bad?

Doctors used to document their work with concise handwritten notes.  Then came CPT codes, which brought elaborate documentation requirements that medical records must fulfill in order to receive payment from the insurance provider.  These requirements measure the documentation, not the care itself.   Fear of documentation errors often force providers to code and bill at a lower level than their work truly deserves.  Physician revenues are thus limited not by the amount of real work performed, but by the sheer number of words one must write to properly document that work.  As long as chart notes had to be handwritten or manually dictated and transcribed, CPT effectively limited physician billing.  Providers became as much servants to documentation as they were caregivers.

This situation inspired the first marketing efforts by EMR vendors to physicians.  Recognizing the need, vendors promised improved, automated documentation and monitoring of charts for CPT compliance.  Doctors could finally bill safely at the appropriate CPT level.  With just a few mouse clicks the chart note can fulfill all the requirements to be CPT-compliant.  Now the physician can concentrate on the patient again.  In my experience this has worked well.

But sometimes it’s the side effects that kill.

EMR shows us what fully CPT-compliant documentation looks like. And it’s awful. The folly of carrying CPT documentation requirements into the information age has been exposed. The relevant data are buried in a sea of white noise — patient demographics, irrelevant historical data, normal physical findings, and diagnosis / billing codes.  Each mouse click generates a bland, repetitive phrase in order to hit a CPT-mandated “bullet point.”  The result is a multipage, single-spaced, small font monster of a chart note with very little substance relative to its size.   This obsession with documentation is distracting both EMR vendors and users from pursuing the real benefits of EMR — automation of workflow, rapid data exchange, reduced costs and improved efficiency.

Want a real incentive for docs to get EMR?  Forget HITECH.  Few doctors I know believe those incentive payments will ever happen.  All but the largest practices and major institutions will be defeated by “meaningful use” criteria.  Instead offer EMR users freedom from CPT documentation requirements.  Replace CPT with a system that is appropriate for the information age.  Leverage the power of EMR and create a system that rewards quality of care rather than volume of documentation.

Easier said than done.  But recognizing the problem is the first step.

Mike Koriwchak is an otolaryngologist who blogs at The Wired Practice.

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  • Matthew Mintz, MD

    This post is very much on target. In addition, many of the EMR’s which are designed around CPT codes can worsen the doctor-patient (check box questions) and often the extra “white noise” actually contains misinformation. In addition, with “copy forward” functionality, misinformation is perpetuated over and over agin. Difficult to find information and inncorrect information is harmful to patient care.

  • stargirl65

    These notes also make is easy for the EMR to simply regurgitate the PMHx, Social Hx, Surgical Hx, etc ad infinitum whether or not it was actually reviewed at each visit. I see notes from doctors that are follow ups. Basically they say “The patient is better. I am done and sending them back to you.” But it takes 4 pages to say that. Plus their ENTIRE history is included. Did they really review the entire hx for a person who is well?

    My system allows bolding of abnormal findings or relevant normal findings to help someone sift through the chatter for important information.

  • r watkins

    This passage from Scot Silverstein’s “Health Care Renewal” blog is relevant to this post and the one on e-prescribing. Dr. Silverstein, a widely recognized expert on clinical IT design, is on the faculty at Drexel; he quotes Ross Koppel, an expert on human-computer interaction at University of Pennsylvania:

    ‘ “Everyone focuses on why physicians are resistant to computers, but I would rather focus on how difficult the systems are to use,” Koppel says. “Most physicians are the smartest guys in the room. Their resistance to technology as such is zero, but they resist software that has a clunky structure.”

    Dr. Koppel, a sociologist, is a well recognized name in health IT critical thinking circles. He will not win any favors from the health IT vendors and CIO’s for that comment about physicians and smartness, but he is quite correct. Physicians are not Luddites. They readily adapt new technology proven as good for patients.

    In fact, in my observations IT personnel are the true Luddites, clinging to inappropriate, rigid business-IT views on the healthcare IT development and implementation process (vs. more appropriate and modern agile methodologies), holding unshakable, stereotypical views about physicians, and remaining unreasonably obstinate on clinician complaints about “clunky” health IT user experiences.’

  • J Bollen

    The fundamental problem is that doctors are focused on making as much $ as possible vs providing the best care possible. That is why places like Mayo where the docs on salary already have robust EHR’s in place with full adoption, better outcomes and are able to demand higher reimbursement rates.. In other practices like Group Health over 30% of all patient encounters are now done via email or telephone encounters (which patients prefer) but once again the docs don’t care about cpt billing codes and don’t worry about if changing their workflow changes their income. Its not the EHR that is the problem – that is nothing more then an electric penicl when implemented poorly but it is a powerful tool for transforming your practice when done well.

    • r watkins

      “The fundamental problem is that doctors are focused on making as much $ as possible vs providing the best care possible.”

      And that’s why Mayo clinics in Arizona are requiring Medicare patients to pay a $1000 retainer yearly, or be dumped.

      Let me add that Dr. Koriwchak’s point is excellent: trying to build health IT around the CPT morass is a fool’s mission.

      • Margalit Gur-Arie

        “Let me add that Dr. Koriwchak’s point is excellent: trying to build health IT around the CPT morass is a fool’s mission.”

        Very true. But why were EMRs built that way? IT types did not invent and/or enforced the insane CPT system. It came from somewhere else. Before the current HIT bonanza, IT companies built whatever they could sell, and what was selling was EMRs that did a good job at billing.
        Now, the trend is Disease Management, Population Management, so called quality measures, etc. If you look at the latest EMR versions, they all come with registries and “quality” bells and whistles.
        The CPTs are still there and will remain there until CMS does the right thing, because the customers demand that they be there.
        Would anybody here buy an EMR who did a lousy job at billing costing you, say, 20% of possible revenue?

  • jsmith

    There is zero evidence that EHRs do any good at all for pt care or that they save money. Docs resist EHRs because we know this. IT types push EHRs to make money and because of their incorrect notion that EHRs do some good. Pt care is our business, our bailiwick. What IT types think about how we should practice medicine is not important.

  • Dr. J

    Physicians will all remember the early days of medical school and being sent to see a patient in the hospital and write up the case. The result was pages and pages of information detailing everything about the patient. We all looked with envy at the attending physician as they would then write a succinct paragraph or 2 that encapsulated the reason the patient was here, how they were doing and what the prognosis was.
    What we strived to learn was information synthesis, and our notes reflected that.
    Think about an elderly patient who comes to emerg with abdo pain and not doing well at home, they have diabetes, copd and heart disease, and recently they changed doctors. She has been to emerg with her copd off and on for the past year. Her meds have been changed many times in the past few months. She is seen, evaluated and many tests and scans are ordered. Her hemoglobin is a little low, her potassium a little high, her sodium and sugar a little low, her renal function is impaired, her chest x-ray is off as is her ECG, though in a non-specific sort of way, and her CT abdomen is unremarkable.
    Now if you are the doctor who will take over her care, or her PCP do you want to see pages and pages of review of systems, pages and pages of labs and values, a litany of every medical problem she has ever had, a write up about her social situation and review of her family history? Or, would you like to read a single paragraph that sums up the case; ‘This patient has Addisonian crisis likely due to stopping her prednisone abruptly. She has received IV steroids and will be admitted to the hospital. She is expected to recover”.
    Information synthesis is what doctors are paid for, yet what is rewarded, and what EMRs seem to strive for, is the exact opposite. EMR notes look just like those notes we all took in our early medical school days, full of information both useful and non-useful, and devoid of synthesis.

  • Anon

    Many good replies, but I like Dr J’s the best. It seems I am just young enough an MD that I never got to enjoy that time when my notes could simply synthesize my thoughts. Instead, I am transported back to high school when I was constantly exhorted to “show my work”.

    Some of the criticisms as noted above can more appropriately be targeted at CPT than at EMR. CPT requires documentation of minutia to ensure fair payment and avoid being accused of billing fraud.

    Frankly, a very simple software modification, which just occurred to me today, would be to keep the “complete” note for the performing MD in the base chart, but cull out only the relevant conclusion for all correspondence, so the “coders’ can parse the full note to their hearts content, but the doctors are only sent the info that doctors all know really matters.

    The real criticism of EMR though is in other comments above. It adds little of value to medical care. There are powerful entities who clearly have an agenda, but it is not to save money or reduce errors. Those are the lies that enable others to justify the false mandate.

    If EMRs really made docs lives easier and more cost effective, they’d have to pay us not to use it. The real shame though, is that when a new technology comes out, say for some new scanner or device, it always carries a premium which insurers often pay.

    So why are they not paying a premium to offices who are “new and improved”? Why not???
    (and I don’t want to hear about the so called “meaningful use” bonus)

  • Louis Cornacchia

    Transferring from paper to digital has two immediate benefits:
    1. Codification and enhancement of office business processes
    2. Increased ease of access, exchange and “backup-ability” of data.

    However, the first does not require EHR to happen, its just that EHR requires that it happens.
    And, the second is very limited when the system is system is siloed, client-server even when VPN is implemented.

    All of this changes when the system is Internet-native.
    The Internet was designed to solve problems on communication, exchange and Interoperability.

    And Internet-native web-service based applications are “forever extensible” and mindlessly easy to upgrade.

  • Michael F. Mirochna, MD

    I like seeing that other people don’t understand why we use CPT and E&M codes. As a resident, it stupefies me every day. We aren’t the supermarket, everything doesn’t have a SKU on it.

    I don’t think there is synthesis with EMR’s because of all the time it takes to build the rest of the “note,” the amount of times the computer loses the note, the amount of time it takes for me to reconcile meds, by the end, I just want to type the briefiest A/P. I very rarely expand my thoughts… which sometimes is needed as we all know, some cases are complex. This may have more to do with us being our own transcriptionists, which is the trend, make the doctor do more and more of the things we didn’t spend all our time and money learning to do (we are not above them).

  • ErnieG

    I agree that the requirements for billing have resulted in largely meaningless EMR notes. In addition, I’d like to add that the fear of medical malpractice has also resulted in the idea that if something is not documented, it never happened. Because notes are legal documents, they take on at least three functions- billing, legal, and medical. Unfortunately, documenting something you did in today’s billing and legal climate can take just as long as actually doing that thing. And physicians are finding it harder not only to chase the money for visits that are increasingly centered on endless inane documentation, but understanding from another physician note what the hell s/he is thinking. Same for nurses notes (just witness the endless irrelevant questions nurses have to document in computers on admissions).

    It is very important to understand that physicians are uniquely trained to manage and diagnose patients and their diseases. Physicians welcome technology that advances those goals, but documentation and EMR as presently implemented hinder the physician and the nurses. Insurance companies and government agencies don’t provide medical care- physicians and nurses do.

  • Dennis (Investigator/Negotiator) at MedicalBillDog

    Recognizing the problem helps, but now what? As long as CPT is in place, EHRs will have to respond to CPT requirements or the doctors will have to go back to downcoding their work. Bollen makes a good point that’s not out of line with Koriwchak’s. Mayo has their physicians on salary, so they don’t give a damn what CPT requires and can concentrate on a decent EHR. The problem isn’t CPT, per se, it’s fee-for-service pay systems.

    In the HIT front, is there no way the EHR can encapsulate and separate the useful information from the CPT-required B/S? It strikes me that such an EHR set would be a terrific way to demonstrate how useless the CPT info really is.

    • r watkins

      Doesn’t Mayo have to submit CPT-correct claims (backed up by documentation) to Medicare and other insurers to get paid?

  • Marc Gorayeb, MD

    Who says you need a boilerplate electronic narrative?
    Use a paper or electronic template to check off the routine history and physical exam items to satisfy documentation requirements for reimbursement and legal. No need to send this to your colleagues.
    Labs and other testing data are already in electronic form. Let them know what you ordered, and they can retrieve the information.
    Then dictate a short note that is directed to the essence of your work-up and conclusions. Send that.
    In my opinion, boilerplate or cut-and-paste narrative to document history and physical exam is superfluous, because it conveys no more information than a check-mark on a template.

  • David Hager, M.D.

    From my state-level workgroup activity and my hospital level EHR daily use, I am left with the strong impression that the people with the strongest investment in EHR adoption are NOT the clinicians working at the sharp end of care.

    Rather, it seems that administrators, bureaucrats, politicians and vendors carry a disproportionate interest in our use of EHRs.

    I think this contributes significantly to a near absence of “usability” considerations in EHR design and implementation.

    Clinicians want a usable, reliable, secure, affordable EHR system that feels intuitive and smooth, and makes us work faster, smarter, safer, and more profitably at the point of care.

    Give clinicians these things, and federal incentives won’t be needed. (The phenomenon of smart phone adoption by physicians is evidence of our spontaneous willingness to adopt usable, useful technologies.)

    Don’t give clinicians these things, and federal incentives won’t be enough.

    * * *

    I think a simple solution would be standardization of patient database structures.

    Do this, and clinicians could feel free to interchange EHR application/GUI layers at will. The current idiosyncracies of proprietary product database structures render EHR product change prohibitively expensive due to the cost of data migration.

    On the other hand, if vendors know I can easily ditch their products in favor of better ones, market forces will drive improvements in product quality and cost.

  • Bob Coli, MD

    America needs more pragmatic, computer-literate clinicians like Dr. Hager. It also needs more free and more competitive HIT/interoperable HIE markets characterized by free entry and exit, price and quality transparency and no seller or buyer of HIT products or services big enough to dictate price.

    The core problem is that American EHR, PHR and HIE platform markets are still fragmented and immature with sellers not yet competing on price and quality/value. In a consumer-centered, value-driven HIT marketplace of the future, success for both EHR sellers and buyers will depend on the availability of many simple and more affordable solutions that can drive both sales and market share for vendors and productivity and quality care for physicians and patients.

    One important usability-limiting EHR design flaw in both ambulatory and inpatient EHRs that will ultimately be improved in a more competitive market is the current use of infinitely variable formats to report cumulative diagnostic test results as fragmented, incomplete and hard-to-read data.

    The simple solution is using a standard reporting and content exchange format that can display all test results as clinically integrated, complete, easy-to-read actionable information on up to 80 percent fewer screens and printed pages.

    The good news is that the combination of unsustainable healthcare cost, quality and patient safety problems, federal subsidies and growing consumerism are incentivizing vendors to produce EHR, PHR and HIE platforms that can actually help physicians reduce costs and improve patient outcomes because they are specifically designed to be affordable, simple to learn and easy to use.

    As Ronald Reagan said: “There are simple solutions, just no easy solutions.”

  • #1 Dinosaur

    Spot on, both post and comments.

  • Diane Brown

    As a human factors engineer that worked many years in the medical arena (but now in consumer software) a primary problem with EMRs is that the people designing the systems do not sufficiently understand HOW physicians do their work. If they don’t understand how physicians work – in detail – they cannot design products/systems that support that work. Thus, they support products that hinder rather than help. Companies that design consumer software have known this for years and employ many design research methods & experts to understand work practice. No, you cannot just hold focus groups and interviews and expect doctors to tell you what they do – people talk in abstracts and they generalize – which conflicts with the details needed for good design. People also don’t analyze how they do their work, where they work-around poor design, nor understand the human factors involved. And, no, you can’t just hire a doctor and have them tell you how to design the system. Just because I can drive a car doesn’t mean I know how to design one. The medical industry is about 15 years behind consumer software in adopting “user-centered design” practices and hiring people in my field. Until the culture of the companies that create the EMR products really embrace user-centered design and the user experience (UX) in their development process – and hire the people with the (UX) expertise – truly useful EMR products will continue to remain elusive.

    • gzuckier

      true indeed.

      for years people have been baffled and annoyed by software that apparently required a programmer to operate it; of course, when you realize that programmers wrote it, and (like anyone) they have difficulty putting themselves in other people’s shoes.

      now think; how many programmers who are also MDs do you know? I’m still amazed that I know even 1.

  • doctor

    Interesting to see the disconnect between practicing physicians and everyone else. Then the inevitable charges that all doctors should be on salary (and assume make too much money). BTW, some Mayo locations don’t accept Medicare. Medical records are not written for other doctors, but to protect oneself for lawyers, and read like contracts. Consults routinely go on for 10-15 pages (for one visit). Radiology reports 3-5 pages (one study). EMR just encourages this. The main way big institutions like Mayo adopt EMRs is to have Physician Assistants actually see the patients while the doctor spends the time filling out the emr/medical reconciliation.

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