Why doctors need an EHR, and why they should buy it now

The regulators have completed their work. CMS has defined how you should use technology in your practice or hospital (Meaningful Use) and technical requirements for EHRs have been finalized.

Centers for Medicare & Medicaid Services (CMS) and Office of the National Coordinator for Health IT (ONC) have removed all ambiguity regarding Government financial assistance to those purchasing EHRs, and ONC certified EHRs will start appearing shortly.

A national network of federally funded EHR adoption assistance centers for underserved Primary Care docs is slowly beginning to take shape. Everything you need to know to start your “EHR Journey” is in place. The only open questions left, for physicians with inquiring minds, are why should I buy an EHR, and why should I buy it now. Below, we will try to explore the answers provided by Government regulators, payers, patients and even early adopting physicians who completed the EHR journey or are in the last mile of the Meaningful Use race.

The Government

I cannot remember a similar situation in the past, where an entire election and much political capital has been invested in the software buying habits of a particular segment of the economy. Of course, the Federal government has been engaged in oversight and best practice dissemination in multiple cases, such as farming, public roads and education to name a few. However, you don’t see any Federal mandates for all schools, public and private, to adopt software, become paperless and collect and exchange terabytes of data. One could argue that such effort will bring enormous benefits to our, not so great, education system, probably as much if not more than to our health care system. Education, just like health care, suffers from lack of funds, poor quality and extreme disparities. The only difference between the two is the sheer amount of money involved.

This observation leads us to the inescapable conclusion that the national EHR effort is first and foremost about reducing, or containing, health care costs. In these turbulent economic times, the Federal government is betting the farm on the promise that computerizing medicine will put a significant dent in our runaway health care costs. Improving quality and reducing disparities, the other two stated objectives, are window dressing, or “nice to have”. To be fair, this is not a bad gamble. Computer technology has been shown over and over again to be capable of cutting costs in many other sectors, and the identified cost cutting targets in health care (duplication of tests, care coordination, administrative simplification, error reduction and standardization on Evidence Based Medicine) lend themselves very well to technological assistance.

Back to the physician contemplating an EHR purchase, the Government wants you to buy an EHR so you can provide care for your patients at a lower cost. As simple as that. The EHR must reduce your overhead, thus reducing cost per unit of service, and must reduce the direct treatment costs, presumably by helping you identify waste and less costly options for achieving the same results (or close enough). With these goals in mind, and ignoring the moral/philosophical arguments, EHR shopping just became significantly more challenging. To be sure, there are no EHRs on the market today, that can actually deliver on all these goals, but some may be able to provide a good start, and once interoperability is widely established, we should see more meaningful gains in cost containment.

Note: There have been more than a few grumblings out there on how a national network of EHRs is really aimed at obtaining patients and physician data to be eventually used for financially penalizing doctors. While I have no doubt that various quality and performance measures will eventually be used for payment purposes by both private and Government payers, I just don’t see this sinister, and very expensive, government plot to either spy on docs or nationalize health care unfolding in the midst of a recession, and with both the 2010 and 2012 elections very much on the line.

The Patient

Notwithstanding the vocal minority of e-patients and patients turned consumers, the vast majority of folks seeking medical care are interested in quality of care, convenient delivery and easy access. For the uninsured, the increasing numbers of underinsured and those with complex out of pocket arrangements (i.e. almost everybody but the exceedingly wealthy), costs of services are quickly becoming an important factor as well. Interestingly enough, this particular patient interest is very well aligned with the Government objective. The avant-garde of e-patients also wants access to their medical records and ability to participate in their own care. While not widespread just yet, it is conceivable that in the not too far future more patients will come to appreciate the convenience of communicating with health care providers over the Internet.

In a nutshell, your patients want to you to buy that EHR so you can reduce the price of care and save them time (and money) by allowing them to manage their medical care in a manner similar to how they now manage their finances. Your patients are a bit more selective than the Government though, and they are placing a more stringent constraint on maintaining and even improving quality of care while you cut costs and increase convenience. They are also planning on holding you to your sworn promises, and will expect that you protect their privacy while computerizing your records. Of course, the many underserved and really sick people in rural areas and inner cities couldn’t care less about your EHR. They will be grateful to just see a doctor outside the ED.

The “Industry”

Corporations on the periphery of actual care for patients, most notably payers, pharmaceutical and device companies and data mining companies, are really and truly only interested in your data. Private payers are also mildly interested in your ability to lower both your overhead (so they can cut your payments) and the total cost of care (so they can keep a larger percentage of the premiums). However, since the new regulations are forcing payers to spend a minimum percentage of their premiums on patient care, it is arguably better to have more expensive care and larger premiums. So for private payers this will be an intricate dance around the Medical Loss Ratio (MLR). As usual, private payers’ interests do not necessarily align with either patients or the Government. Payers also want you to computerize your records in order to reduce their own administrative costs (and again, keep a larger percentage of the premiums). There is little need to discuss EHR vendors here, since their motives are blatantly obvious and fairly legitimate in a capitalist economy.

All in all, the “Industry” wants you to buy an interoperable EHR, so they can collect, buy, sell and mine the vast array of personal and clinical information residing in your medical records, and worth many billions of dollars.

Note: Recently, the safety of EHRs, particularly hospital EHRs and their CPOE modules, has been the subject of various studies and much heated debate with no conclusive results. The possibility of FDA oversight has been suggested, and hopefully such oversight will be implemented sooner rather than later. However, here we are discussing private practice EHRs which are much simpler and restricted in scope.

The Early Adopters

These are your fellow docs who bought the EHR years ago and managed to make the endeavor successful. Their common denominator is mostly a personal willingness to invest time in molding the EHR to their needs, or the availability of an equally committed practice resource who was willing (or tasked) to do so. It is interesting to note that their EHRs come in a rainbow array of sizes and prices, ranging from $50 per month to tens of thousands of dollars in upfront investments. It’s not really about the product. There are perhaps three dozen credible EHR offerings out there (not the mythological several hundred), and as long as one is motivated and he/she plans early and plans well, there is a very good chance that the purchase of an EHR will add convenience for the physician and staff, quality and accessibility for patients, and if coupled with a decent billing system, even a bit of financial benefit.

Your early adopter colleagues are suggesting that you buy an EHR because theirs was a positive experience and they are now in a comfortable position to deal with the rapidly changing health care landscape. These doctors, unless working for a vendor, have no ulterior motives in their recommendations.

Note: As you are well aware, there are also physicians who failed in their EHR implementations and are bitterly warning against buying EHRs. I would venture to submit that it is not the idea of EHR that failed these folks, but the planning and implementation of it. Theirs is a very important learning experience on how not to buy an EHR and it needs to be listened to carefully.

Conclusion

The Government, the taxpayers (of which you are one) and your patients are all interested in reducing health care costs. At its core, EHR adoption is all about the economy, both on a national level and a household level, and with the approaching wave of value-based health care reorganization, it is on a medical practice level too. Since computer technology has been able to bring about cost reductions in many instances, it is reasonable to assume that it can do the same for health care, particularly once a critical mass of interconnected systems is reached. Your early adopter peers have shown that it is possible to introduce an EHR in one’s practice with some initial effort and inconvenience, but with no dire consequences and in some instances with marginal productivity gains. Since the overwhelming health care expenditures are accrued per “doctor’s orders” during millions of visits every day, and since an EHR need not be detrimental to your financial health, perhaps you should consider lending a hand to help rein in the Nation’s health care costs.

Perhaps it is simply the patriotic thing to do.

Margalit Gur-Arie is a partner at EHR pathway, LLC and Gross Technologies, Inc. She blogs at On Healthcare Technology.

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  • Vox Rusticus

    “Perhaps it is simply the patriotic thing to do.”

    And the last refuge of the scoundrel.

    Sorry, but for small practices, the cost of getting transition to EHR only half right (never mind if your vendor folds) can be ruinous. The bottom line I can see is that with all of these supposedly interested parties, only one substantially bears the costs and the risks, and it isn’t the government, or the patients, or the insurance companies, and only partly the vendors.

    I have been present for launches of these systems. It is disruptive and expensive in many ways for the small businesses that try in good faith to make this work. And the software even from the “best” vendors is really not as good as many web programs on commercial websites in other industries.

    Treating those holding out on these launches as hopeless Luddites is unfair and dishonest. This initiative places the cost burden unreasonably on practices and heaps the benefits on product vendors and those who would mine the data assembled at the expense of those who have to buy, implement and maintain these systems. Mind you, just how exactly am I to reap the savings for my patient by finding the results of tests I won’t mistakenly re-order? (Really, it is more a chore than you would think to get patients to remember if, when and where they had a particular study.) I hope a Google app capable of searching the wired universe will be able to do just that.

    This idea of a universally accessible medical database made up of individually searchable data points entered in hundreds of thousands of separate locations into dozens of different products (some of which in some fields will require truly customized software applications to be a part of this process) presupposes a level of interoperability and connectivity that does not exist right now. The Mayo Clinic is not at all a realistic model for the medical practice industry in the United States.

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      The cost “can ” be ruinous for a solo practice, but it absolutely does not have to be. There are solo practices with EHRs and many are doing rather well.

      I don’t subscribe to the Luddite argument. I believe too many docs are misinformed and have no idea how to make EHR adoption work for them. Much of this unfortunate situation is due to greedy vendors and their “hit-and-run” sales tactics. Solo docs don’t have the resources to research and deliberate on the solution like big practices usually do.

      But here is the biggest problem I see. With the advent of ACOs and other payment reform, solo docs with no ability to exchange information with a virtual network of peers, specialists and hospitals, will be driven out of business. The entire model of small private practice is currently under assault. So unless you think it is a good idea to sell to the hospital or some other for-profit health corporation, and do away with the “cottage industry”, then you better acquire the tools necessary to stay alive and stay competitive.
      I for one don’t want to see Walmart medicine in rural America and I am not too terribly happy with the rash of PCPs in their fifties contemplating retirement as a way to escape this entire mess.

      • Vox Rusticus

        Your last paragraph reads more as a threat than an enticement. Buy a program and get started implementing or get buried.

        News for ya: if you drive us out of business, you won’t necessarily get replacements, never mind ones that are willing to buy into the scheme as presented: costs borne by one side and benefits reaped by others. Saying that some big, bad ACO or other entity will steamroll me if I don’t roll over and have the software industry have their way with me isn’t going to make me want to change my mind or buy some crappy software product.

        If the government is so much behind this kind of thing, then let them bear all the costs, including the large downstream costs of having to buy mandatory upgrades that so many vendors require. Right now, with the frankly ridiculous “e-prescribing” initiatives and other duboius “incentives”, I see the CMS as a stalking horse for the software industry who have sold them a bill of goods and promises about all sorts of supposed benefits of widespread implementation of EHR. Except for closed systems of single hospitals, broader schemes like the VA system and the fairly reviled AHTLA in the military services have not proven really successful, and those cases have been largely single-vendor, not an attempt to integrate across multiple vendors. I see the software vendors getting rich, the private practice community having not-ready-for -prime-time product shoved at them at gold-plated prices, and years of unrealized “benefits” that have been promised with no one being held accountable.

        • Primary Care Internist

          I agree completely.

          Since the primary beneficiary of EHR adoption, in terms of savings, is medicare, wouldn’t it make the most sense if medicare just picked a winner, bought it and gave it to all practices / hospitals / labs / radiology facilities?

          That would solve the problems of 1) unaffordability for small practices; 2) interoperability; 3) ongoing maintenance issues etc.

          Of course, this will never happen, as there is too much many changing hands between various EMR vendors and gov’t officlas, including medicare. And typical of politicians, they’re easily influenced when their spending OPM (other people’s money)

          • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

            I agree. I think this would have been the most equitable solution. Suggested this several times and have nothing but cuts and bruises to show for it.

            Of course, you would then have those who will complain about the free market being harmed by such Government intrusion.

        • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

          I think you are misreading my comments. This is not a threat, since I have nothing to threaten with. It is an assessment of the situation. I don’t want to drive you out of business, but lots of big-money interests do. They would much prefer that you are employed by some IDN or large entity. Those are the same folks that believe in “economies of scale” that come with consolidation. Not sure who these economies of scale are for, but I can assure you they will not accrue to you or me.
          I am just trying to suggest a solution.

          The reason EHRs proved successful in closed systems is that their value is highly dependent on widespread participation. We all know that paper is faster and in many cases better. Without interoperability with everybody else, EHRs are not very useful. It’s the chicken and the egg thing.

  • Doc99

    Patient data security – what could go wrong?

  • http://warmsocks.wordpress.com/ WarmSocks

    In a nutshell, your patients want to you to buy that EHR so you can reduce the price of care and save them time (and money) by allowing them to manage their medical care in a manner similar to how they now manage their finances.

    Wrong. Admittedly, I’m only one person, but this patient much prefers my doctors who sit and look at me when we talk. I don’t like it when doctors sit and talk to their computer, typing as quickly as they can. When a doctor uses an EMR, the goal of the appointment is to complete the computer record; when doctors use paper charts, the goal of the appointment is to treat the patient.

    Nobody had to coerce doctors into buying scheduling software. Doctors made the switch because it’s more efficient than the old giant scheduling notebooks. Likewise, If electronic medical records made things easier for doctors, it would not be necessary to threaten them with fines for sticking with paper charts. They’d change if the benefits were there.

    In any industry, the best software is that which was designed by the end user. imo, doctors being forced to purchase an EMR should be looking for a system designed by a doctor.

    I want my doctors to run their medical practice in whatever manner is best for their particular circumstances. I definitely do not want my doctor to sink tons of money into unproven technology.

  • PCP MD

    Thanks for the advice on how I need to buy EMR and make things better for everyone.

    In reality, what I am going to do is continue my solo practice without it, for much the same reasons outlined in the comments.

    In a couple of years Medicare will cut my reimbursement a couple of percentage points. Reimbursement will be cut by five percent, then eight, then who knows. I don’t really care. I have been living like the millionaire next door for the last few years so that when my kids get out of high school in seven years, I won’t have any debt. At that point I will close my practice in the small town that I work, retired from medicine at 45. (I say that. No doubt I will do some missionary work abroad, and some part-term employed work, because I love medicine and think I still will). Most of my peers are thinking like me. Pay off that house. Save for college. Cheap vacations. Budget. I have sacrificed so much to get to where I am now, I can skimp a few more years for the payoff of not being a slave.

    Of course, when I’m retiring at 45, the boomer doctors will be retired already. Who does that leave to take care of us all?

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      I know most of your peers are thinking like you. I also know that those a couple of decades older than you are about to execute those thoughts. I’m sure you can see the problem.

      I don’t think Medicare will be cutting your reimbursement, but regardless of that, I think that computerizing records is the way of the future. Granted, most of the EHRs out there are less than desirable, but not all are.
      The simple fact that some docs made it work and are satisfied with their EHR tells me that it’s not so much about the actual software (within reason), as it is about the execution of the implementation.

      I cannot argue with the way you feel. The current health care reimbursement system has caused many to become bitter and disillusioned, but if we are going to change that, many things will need to change, and going electronic is just one of those things. It’s not a silver bullet solution. It is one small thing, or maybe not so small, that will have to be accomplished on the road to better things, both for you and for the rest of us.
      I hope we can be successful and you are not forced to retire in mid-career, and we are not forced to deal with the consequences.

  • DVT

    And if my EMR vendor goes bankrupt, then what? Start over with another vendor? That is not a pleasant thought. It can take a year or more to implement EMRs, particularly if you are seeking “meaningful use”. I wouldn’t want to do this more than one time.

    If there was a big gorilla of EMRs that was going to be here for the long haul, and was reasonably priced, secure, helped improve my efficiency and patient safety, I’d have one by now. Over the past five years I have demo’d several EMRs and I’m still looking.

    Why not give each patient a unique medical identification number and a central repository where all their medical data can be housed (i.e, central server), so that it can be easily retrieved from any physician’s office, ER, pharmacy, etc. Currently an individual patient’s info is scattered about in “silos” of information at the hospital, pharmacy, and different physician’s offices. These separate silos make it difficult to access this fragmented information.

    Currently web-based EMRs like Practice Fusion and Clear Practice make the most sense, but if data is housed on their servers, I come back to my original question: And if my EMR vendor goes bankrupt, then what? Start over with another vendor? But all my patient data is now on a server at a EMR company that is no longer in business!

    And I’m still waiting to be reassured about patient privacy.

    The government should give the EMRs a few more years to evolve to a more mature form before implementing the carrot and stick routine.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    There are a few big gorillas out there that will not go away. Unfortunately, their products are not the best. There also several mid size gorillas that are growing rapidly and have been around for over a decade. A small number of those (2 or 3) have very nice products, which seem to be getting better and better.
    If I was looking to buy, that’s what I would buy.

    The cloud paradigm is very sexy right now, but once your data is out of your control, so is patient privacy. Everybody is selling “de-identified” data and the Feds need to step in and put an end to what amounts to plain theft in my opinion.
    You can achieve almost all the benefits of a cloud system by using a private cloud (your server hosted somewhere else), without the risks, particularly if you can create a community cloud by having a bunch of private practices pull resources and do this together.

    Regarding the patient data repository, I believe several regional and State efforts (HIE) are on their way to creating a master patient index and pulling basic information in. But in order for this effort to be successful, your data has to go up there too, which means you will need to have electronic records. It just doesn’t work well if everybody waits for the data to magically become available. It won’t. This is why this entire EHR thing is so painful. There isn’t much value until everybody has one, and folks won’t get one because it is useless right now. Something has to break this vicious cycle.

  • imdoc

    “I cannot remember a similar situation in the past, where an entire election and much political capital has been invested in the software buying habits of a particular segment of the economy…” So let me get this right: the people trying to sell this product are having trouble communicating the value proposition. Maybe that is because the customer knows something. I haven’t noticed any doctors acting technophobic toward cell phones or PC’s. This article makes about as much sense as if Bill Gates or Steve Jobs had produced something nobody wanted, blamed the public for not buying, then went to Washington to get public money to get computers into use by private customers. This EHR industry has considerably more governmental support than is warranted and still struggles. My advice is to do what every other private enterprise must and figure out how to make something a user wants instead of force-feeding by government fiat. The burden here is solidly on the inventor/manufacturer. Be more innovative. Create something of value that doctors want to buy which improves the practice of medicine and then you shall deserve the rewards.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    It is of course true that EHR products are not as good as they probably should be. However, is there maybe another problem here?

    Are the interests of physicians and hospital really aligned with what the Government is proposing? Do doctors want to collect data and report on it? Do they see it as an integral part of taking care of patients? Are there any financial benefits for physicians who collect and report data, or maybe just the opposite is true?
    Do hospitals have any interest in sharing patient records? What are the benefits to both hospitals and physicians for giving patients full access to their medical records?

    I somehow think there is more to the EHR debacle than just the quality, or lack thereof, of the software. Some of the things that EHRs are supposed to do are really not for the benefit of those who are expected to pay for them. The stimulus incentives are only a partial answer, since I don’t think they cover more than half the potential costs and some say even less..

  • Marc Gorayeb, MD

    Still no logical or testable hypothesis, much less evidence, that this EHR boondogle will save costs for the average practitioner. The real money in this business has already been made/saved: electronic billing. Everything else is utopian fantasy.

  • Max

    There’s no better way to control costs than to see what a physician is prescribing and track it. Also they will be able to look over your charts electronically and audit them to see if you coded properly. Lastly, patient safety is a concern as well. Way way last. First is monitoring and tracking. That’s how you control cost. Patient safety? Who gives a rats… We want to track you, buddy. And you’ll pay for us to do it, too.

  • AK

    I have used many different paper charts and many different EHR’s. EHR’s reduce my productivity profoundly. I have also worked on a cognitive style that uses pen and paper for 10 years. I don’t think at this stage in my career I can switch easily. It’s not about a learning curve, it’s about no longer being in my “formative years.”

    Another fear I have is that EHR notes are more like a billing receipt than a true piece of cognitive work. Many such notes have an extremely poor signal-to-noise ratio that obfuscate salient points.

    My deep belief is that EHR’s will be embraced when they are better than pen-and-paper, not when there are outside forces pushing them.

    Some of the areas where I think EHR’s need help are:

    (A) Appropriate workstations. 22″+ monitors, utilization of touch screens, integrated dictaphones, etc. Look at the typical ultrasound machine and how it’s laid out. It’s not something designed to write “Harry Potter” on, but rather for the specific task at hand. How much time do you waste scrolling on your EHR station?

    (B) Natural language processing for Computerized Physician Order Entery (CPOE). You should type “PCXR – Cough, Zosyn 3.375 IV q6, MgSO4 2g IV X1 today at 3pm” and have the computer understand it, parse it and ask for order confirmation. You shouldn’t have to go through 80 menu tasks to get this done. This is a very basic point, within reach of current technology, that isn’t implemented.

    (C) Universal Health Container. EHR’s can’t really take off until this is established. I don’t care if there are different systems or companies that go into and out of business if the data is portable. Without a universal container, much like a PDF file, for medical records, there really is no portability or communication or the opportunity to say sianara to a lollygagging EHR company.

    (D) Disabling Copy-and-Paste. This is more of a pet peeve as I have to read the same note with just one new pertinent fact tucked in between carried-over and stale info.

    There are many more points. The bottom line is EHR’s aren’t being adopted because we are Luddites, but rather because they are incohate. They don’t meet the standards of interface and functionality in software written for much less mission-critical tasks. When they reach that level, incentives, coercion and stubbornness will all be irrelevant.

    • Dennis

      AK- As a midwest Family Physician, I agree completely with your points. I just don’t understand why the politicians, administrators, vendors and insurers don’t get it.

      • AK

        And I love asking residents why chloride, MCHC, RDW and percent histocytes are listed religiously every day in a 3 page note for someone who came in for a fractured elbow.

  • skeptikus

    As a privacy nut, I largely stopped going to the doctor. I’d rather die than have some government bureaucrat inspect my medical records.

    I think once privacy breaches become routine (which they will once e-records become more ubiquitous), more people will be like me.

    If worse comes to worse, I’ve purchased a health insurance policy under a pseudonym. That was tricky—but again, I suspect more people will follow my lead as Big Brother and his bud Big Doctor begin to take over our lives.

  • http://fertilityfile.com IVF-MD

    On one hand I’m grateful everyday that early in my medical career, I “randomly” stumbled into a field of medicine that is still desperately, but successfully, hanging on to the last vestiges of market freedom, making for a wonderful doctor-patient relationship. On the other hand, I’m practical enough to know that it could just be a matter of time before the planners will work their way into our field as well and make our jobs every bit as depressing as those of all the doctors on this board who talk of throwing in the towel and retiring early.

    Right now, I blissfully go to work every day enjoying the fact that the rules of the game in my world are still simple – “make the patient happy and you will be rewarded” whereas for my unfortunate colleagues, the rules have insidiously evolved into “rack up this and that CPT code and you will be rewarded”. What a revelation! I can empathize with what an empty feeling that would give me the day that I’m primarily forced to play that game. I can only hope that all of us, patients and doctors, by engaging in the free exchange of information on sites such as this, can wake up and peacefully fight to stop the forceful takeover of our lives and restore our innate right to the pursuit of happiness. :)

  • Jo

    There is not one EMR yet that is meaningfully useful even if certified as they are not on up to date technically savvy, intuitive platforms and most cannot operate on Windows 7 yet. Until the companies have better ideas and actually work optimally in a clinical setting with common sense results you will not have all doctors jumping on board and it is arrogant to expect them to when they are already having to jump through so many hoops to keep all of the plates spinning.

    EMR companies have taken advantage of physicians who are not IT experts. Clinicians are not consulted on what would be optimal in an EMR for their particular specialty (especially Family Practice that is more comprehensive than any other) and those who have used them, or read what comes out of them find them redundant, cumbersome and not very user friendly, with customization a nightmare and for small practices can be a practice killer.

    An optimal EMR would look like a paper chart (worked for many years) with tabs at sides or bottom for the different sections.

    It would auto populate orders from the Asses/Plan Lab names pulled down from a “labs’ drop down list with common names (CMP, CBC, Urinalysis, Retic count, CRP) and they would automatically be attached to LOINC codes that could be seen on the order and result and result values would autopopulate into searchabe fields in the pateint’s chart without the physician charged more for an “interface”. They should not have to go to another screen to order then when the results come in they should not have to manually “merge” the result with the order. Immunizations admin codes would trigger the “immunization given date” and auto populate into a printable, faxable sheet.

    At the end of the visit you would choose a lab to send to or print the req without having to go out of the visit to a seperate program to create the requisition and all diagnosis codes of problem list would be able to be added to the order if for physical exam labs. By the click of a button labs would print to a “fax” with number that could be entered, or to “hold” until the phlebotomist arrived on certain days then could print them then. Tests could also when “print” button is pushed have the option to print to printer or to be faxed. Then printed/faxed labs and tests would then be flagged to remind you that results should be in by now.

    (Quest Diagnostics has stated they send labs with LOINC codes monthly to the EMRs but the LOINC codes are not auto uploaded into the EMRs and EMR companies require clients to not only pay thousands for an interface, but they have to go in and “map” the labs for the EMR.)

    Tests ordered are flagged to remind at a certain time that the results should have arrived into the patient’s chart, point of care sheets would come up as face page when you pulled the chart from the schedule for that day’s visit.

    A list of unread results that have been attahed to a patient when scanned or arriving by electronic fax would have pop ups attached so that it would produce an instant message after so many days, on patient’s chart, when trying to schedule and also on a list that would print in a “Results Recieved Report”m each night.

    There would be pop up reminders of all patients who are due for tests, one when you tried to schedule the patient, one if the patient calls to cancel an appointment and also when a patient’s chart is pulled. This would also be a monthly report that would auto print, “Mammogram Needed Report”, Bone Mineral Density Needed Report, etc.

    Historical results that were done outside of the office and ordered by other physicians would also be in auto generated, timely reports and attached to flags, reminders and scheduling notes.

    All meaningful use, PQRI/patient centered medical home reporting would be a basic, in the background feature of the EMR. Falgs should be on the EMR that if they are doing such and such they are qualifying for a certain stimulus incentive program, or if they would just add this measure they would be able to qualify.

    Reports could be customizable, but a basic EMR would be required to report, how many active patients are in the practice, how many patients on any certain insurance company, how many patients with any diagnosis and those that are due for tests and all reports have last visit date and lists of tests due options, and date of future appointments.

    Customizing of an EMR should have specialty specific templates that are complete with the most often asked questions of any particular ailment. Physical Exams for primary care would only include all of the primary care verbiage and tests, not the specialty’s verbaige of their tests. Also all sections of the EMR would be customizable on the fly with drop downs and the different sections of a visit being able to be a template saved and customized. Customizability should not be so difficult that you need to be a software programmer to figure it out.

    The EMR companies are charging 10s of thousands of dollars and having the physician “customize” or program standard verbiage that ought to be basic/standard EMR.

    As stated above we are lightyears away from iPad technology in the Electronic Medical Records technology and some physicians are waiting for someone to come up with an affordable ($20-30,000 turn key, inclucing all future upgrades, test/lab interfaces, up to 3 physicians, with all training included in the price and no annual maintenance fees and customer service that encourages every client to upgrade to the latest version, not hide the fact that there is one available) . We need a comprehensive, technically savvy, intuitive, affordable EMR with a company behind it that has integrity.

    It is possible to do and in a few years someone will come up with the “Southwest Airlines” idea and make millions.

    Only in medicine is it allowed that the very person that all other entities surrounding it make money off of are taken advantage of in this way.

  • David Hager, M.D.

    As a lifetime geek, I opted against EHR technologies for our clinic in the late 90’s. Too expensive, awkward, buggy, unreliable, training intensive and slow. Additionally, in Florida, power outages are too frequent to ignore. Paper still works when the lights go out.

    There’s still MUCH faith involved in this process of mass conversion to EHR systems. Though people hope for improved productivity, studies so far don’t reveal that. In fact, more clinical and data entry personnel are hired to compensate for EHR inefficiencies.

    Better outcomes? Studies so far are rather mixed re: this. Definitely not a healthcare panacea so far.

    Additionally, patients have not been keen on the effect of the staff-sucking computer workstations. Nurses spend more time clattering keyboards than talking with patients. The inefficiencies of EHR documentation are real.

    Worrisome also is the effect of extensive, template-driven, radio button workarounds that attempt to speed note generation. Where then is the descriptive picture of a unique human being captured in the chart? Can you really tell one patient from another through the thicket of perseverative, canned statements?

    I work with an EHR on a daily basis at a state hospital and can testify, along with a mass of colleagues, about the obstacles it presents. We yearn for a paper chart instead. In fact, we have numerous full time positions throughout the state (one per treatment team) that exist as a human interface to the EHR in an attempt to compensate for its shortcomings.

    I’m not convinced that clinicians at the sharp end of care are nearly as invested in EHR systems presently as are administrators, bureaucrats, auditors and politicians. If we were, we’d already have them, in a manner similar to our nearly ubiquitous adoption of smart phone technologies.

    If EHR technologies can actually make clinicians more efficient, smarter, safer and profitable, there will be a lively market for them, regardless of governmental incentives.

    If EHR technologies cannot do these things, incentive-purchased EHR systems will merely become doorstops for the re-opened paper medical records room.