Why EMR is a dirty word to many doctors

Don’t get me wrong, EMRs (electronic medical records) are inevitable. Over the long-run they are almost certainly good for physicians, patients and the healthcare industry.

However, their origin and the ulterior motives currently driving their adoption is sowing the seeds of their failure.  First, what is actually happening out there?  The most recent CDC data would seem to be encouraging for EMR adoption, with EMR use (finally) passing 50%.

Too bad there is more to the story.

If you look at adoption rates for so called “fully functional EMRs,” the adoption rate remains in the low teens (full data for 2011 is not yet available).  So why is there an almost 4-fold discrepancy between “any EMR” and “fully functional EMR”?  If EMRs are so great, why does the government have to essentially “bribe” physicians to adopt them through incentives such as the meaningful use incentive program?  Why is this so important to them that they didn’t even wait for the healthcare affordability act to implement this “incentive”? (They put it in the stimulus package after Obama had only been in office a few months.)

The 50% adoption rates seen in the first link reflect the presence of any type of an EMR-like technology. While it is a great headline for sure, the second link shows that this is an overly broad declaration.  When we look at “fully functional systems,” meaning they are being used for a full work-flow solution, we get numbers in the low teens instead. (When you subtract out unique situations such as Kaiser, the VA, and a few large independent doctor networks, I suspect the actual number is much lower.)

One reason that incentives and threats of decreased payment are necessary for EMR adoption is that the industry and physicians have known for years that EMRs do not improve productivity and that it is highly questionable that EMRs lead to better patient outcomes.  So why is all this taxpayer debt being accrued by throwing borrowed money at the healthcare industry to drive EMR adoption, if the end users are so disenchanted?  As Jonathan Bush, the Founder-CEO of AthenaHealth (a major EMR supplier) famously said, “It’s healthcare information technology’s version of cash-for-clunkers,” and because it is actually all about control.

The goal of EMRs is to wrestle control of healthcare away from the doctor-patient relationship into the hands of third parties who can then implement their policies by simply removing a button or an option in the EMR.  If you can’t select a particular treatment option, for all intents and purposes the option doesn’t exist or the red tape to choose it is so painful that there is little incentive to “fight the system.”

For patients, this means that they will only be able to consume the healthcare that they “qualify” for or be forced to find another way to obtain the care that they want and need.  It is the second outcome that is the most intriguing, because as “shoppers,” patients will want to be informed and have choices as they take on more responsibility for the cost and quality of their own care.  This approach works very well with Health Savings Accounts, which were conveniently de-emphasized in the healthcare reform effort.  Like the lightning going to ground, this is the inevitable future for healthcare in this country (assuming the other alternative, an acceleration to a single-payer system does not occur first).

For physicians … well, it isn’t hard to figure out where this is all heading.  EMRs are quickly becoming the instrument by which we are controlled and managed.  As an example, many organizations are already starting to restrict diagnostic testing and therapies via EMR.

What’s next? Patient referrals?  It will be the final step in subjugating physicians.

So why is genuine EMR adoption struggling so much?  After all, one may argue that the accessibility of instant data that technology now enables is the greatest single advance in patient care so far this century.  With so much money being thrown at the problem, one might expect a much greater adoption. Why hasn’t it played out in a much more positive way?

This comes back to the origin and ulterior motives of EMRs.  First, EMRs have been largely a top down effort.  Rather than working with physicians to design the technologies and drive adoption, the experience (and almost universally the perception) is that the technology has been thrust upon physicians by administrators.  Compounding this is the unintended consequences of the meaningful use government incentives (or cash-for-clunkers program to use Jonathan Bush’s, more colorful language).  Having left the guidelines vague and largely written by a small group of industry insiders, most products have become a Tower of Babel with atrocious user interfaces and user experiences that … well, I don’t blame my fellow physicians for not wanting to use them. In addition to being expensive, they are complex, inefficient, and do not make physicians or their staff more productive.

Widespread adoption of an EMR (or multiple compatible EMRs) that is intuitive and easy to use, that empowers the end user and patients, and that actually helps to make the healthcare system more efficient would be a good thing for doctors, patients, and the industry.  However, unless we recognize what the ultimate goals are and better involve the people most critical to their effective use (physicians), I believe Jonathan’s prediction will be true and cash-for-clunkers applied to the healthcare sector will turn out about as successful as that other government program — TARP.

Adam Sharp is founder of par8o.

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  • David Olalekan

    This is the best part of what you wrote:
    “Widespread adoption of an EMR (or multiple compatible EMRs) that is intuitive and easy to use, that empowers the end user and patients, and that actually helps to make the healthcare system more efficient would be a good thing for doctors, patients, and the industry.”

    The real problem out there now is that there are not many good EMRs available. The “fair” ones are extremely and unnecessarily expensive. I am involved with a group of others who are developing a most innovative EMR that, hopefully, address these issues. And, there is no “control” that the health insurance companies can have with widespread adoption of EMRs that they can’t achieve without them. Let’s get rid of that conspiracy theory right away.

    • Anonymous

      It is not a conspiracy theory. The problem with people like you is that you do not understand business and greed. Health insurance companies are businesses first….they exist to make profits period. You can’t even start to imagine the power and control that insurance companies will wield if we all adopt EMRs.

      • http://pulse.yahoo.com/_27HQZHWJS53LZ644AMBW2NRROQ Hockeyref1

        He’s right. Sure they maynot have a man inside each EMR vendor’s working groups creating things, but we already have the concept of Centralized Servers kept at regional stations with the goal of creating ONE and ONLY ONE chart. The days of saying, I don’t like or agree with this doctor, or a teen outgrowing his dangerous or rebellious past, or getting free of some quacks misdiagnosis, especially in Mental Health, are almost gone! This is a Civil Liberties issues as much as anything else. I want to be able to walk out of some one’s office one day, and think “This guys’s Nuts or completely off base” and LEAVE that newly started chart with bad data in it to Rot, never to follow me to every doctor and hospital I ever try to obtain care from…. Combined with us professionals doing the data collecting for them, the Insurance Carriers will have access to this data via the REC’s as laid out in the legislation. Doctors are not Slaves for their corporate masters collecting the data that will be used against them in ever more invassive and prevelant Chart Reviews without some like ME, a Practice Manager even getting a request to review and see if the carrier is entited to it or consult with the patient and see fi they want to pay the rejected claim because the carrier is on some Pre-existing condition Fishing  Trip????

        We use a wonderful inexpensive EMR in our solo FP office and my wife and I LOVE IT. But it was designed by a doc who still uses it personally in his own practice, and pays for a user board for users to exchange ideas, work arounds, solutions, templates and constantly give the company, vendor excellent hand on the pulse of their users needs and frustrations open dialog with us users as compared to almost any other similar product in almost any industry. Its almost user vendor positive cult thing…. Amazing Charts. And even AC had to go and put bells and whistles in their product or loose the war of user purchases they were winning Prior to this Corporate Welfare for the large much worse vendors many of you others speak of. If the Market was left alone to mature and let some winners and loosers get weeded out and Vetted by a real Market set of Influences, like many docs avoiding expensive risks of high cost and no more proven alternatives, Creative and Responsive Vendors like Amazing Charts would still be one of the first second place leaders in their segments. This Cash for Clunkers program is just that it was a bailout for the Clunkiest of those Monsterous products that couldn’t actually compete by providing a product that other users would consistantly like and praise. Where as that is EXACTLY what Amazing Charts is most of the time…. A product that most small and modest sized offices would make you pry it out of their bloodly finger tips to take it away from them….

        I say the lets trash this program and any requirements to use one, and lets allow the vendors to make due by making good products at reasonable prices that are in line with the present horrible market their customers are in, and satisfy the wants and needs of those that actually have to use them…. US, the professionals Docs, support staff and other healthcare providers who will vet them every day in real world conditions. Trust me that will air this entire process out faster and better than any force it down our throat program with insane and stupid requirements created with no consideration for the user or healthcare being effected by it; that’s for darn sure….
        Paul

    • Anonymous

      I think standardizing data contructs = a solution.

      Currently, there’s no easy way out of a bad EHR purchase.  Don’t like it?  Too bad.  It costs too much to buy a new product, and THEN to migrate the data from old to new.  Might as well dump back to paper.

      When docs can change EHR products at will, with little or no data migration cost, EHR vendors, under the pitiless lash of market competition, will become much more tuned to what we want, and at more affordable prices.

      I am hopeful that growth of HIE standards will be a foot-in-the-door in this direction.

  • http://www.facebook.com/profile.php?id=558041620 Vikas Desai

    Awesome!

  • http://twitter.com/clinappsman John Dzivak

    I am a clinical IT manager in a Level 7 healthcare system. The only comment I have is that in a recent conversation with our Trauma and ED leadership about documentation on trauma cases, someone mentioned the possibility of going back to paper and the clinical staff roundly dismissed the idea immediately. I agree that we have made more progress with nursing documentation than we have from the provider perspective. I believe that is caused by the fact that, at least in our organization, the nurses are employees.

    • Michael Appel

      I wouldn’t call nursing documentation “progress”.

      More is not better.

      Do you ever look at what is documented? Does anyone?

      Whose needs do the reams of nursing documents serve in healthcare?

      • http://profile.yahoo.com/6S3C3MBJNGHBIXV3QPLXBCQFRM Anonymous

        As a nurse, I believe that while we are sometimes required to document more than before EMR, the real issue is sorting through what is relevant and what is not. Nurses and doctors just want to know the patient story; what has happened to the patient – the stuff that matters. EMR systems (or at least the ones I’ve used) do not make this easy. You must read through virtual reams of data and then piece it together to understand what’s really going on.

        • Anonymous

          We document now for the bean counters.  It is currently very difficult for me to use my system’s EHR to learn a patient’s story, and how he has done over time.  In my experience, a paper chart is actually more useful.

          I think this primarily reflects an immature technology, which is why we weren’t rushing to the store to by this stuff.

      • Anonymous

        Michael,
        I couldn’t agree more. In the hospital you used to be able to go to the nurses station or patient’s door and find the trifold with all the pertinent information concerning your patient all right there to see. Now the nursing documentation is scattered throughout the electronic medical record in literally hundreds of notes throughout multiple tabs. I don’t even bother trying to find any of these except for the vitals signs, MAR, and labs. I find the nurse and ask how the patient is doing, and anything happen over night. You just hope she had a good sign out from the prior shift.  To go through all the EMR documentation would literally take at least 1 hour per patient and I could see maybe 5 patients per day. Cash for Clunkers is right!!

        • Anonymous

          However, a plaintiff’s attorney, armed with a well paid forensic nurse specialist, will comb all those details out for us … post facto.

          And we shall be held accountable for every needle we missed in that EHR haystack.

      • Anonymous

        My eyes glaze over when confronted with the homogeneous copy/paste content, formatting, typeface, and verbiage.

        Got a patient back from a consultant who is described to be very good in her field.  Unfortunately, her “psychiatric” pre-written verbiage discredited her note.  It was a normal mental status examination left in place for an extraordinarily psychotic, disorganized, and confused person.

        Oops.

        In my conversations with attorneys, this example epitomizes their new goldmine for successful litigation.

  • http://www.facebook.com/people/Ardella-Eagle/840440226 Ardella Eagle

    Excellent Op-Ed ‘article’.  I,too, believe that, in the end, EMR will be a better thing. It will take 2 generations of med grads for it to be a smooth transition, but in the mean time, it’s ‘Old School’ practioners who have to work out the bugs and slog through the different versions and edits until something comes up clean and workable.  Perhaps if it wasn’t a government mandated ‘improvement’ and if practioners were consulted and if the EMRs would be compatible with each other, it would be smoother.  Let’s hope we can make our voices heard to get what’s needed done. 

    • Anonymous

      I disagree with “2 generations of med grads.”

      An onus should not be upon the med grad to embrace EHR technologies any more than it should be upon Joe Public to embrace smart phone technologies. 

      Notably, it did not take “generations” to adopt smartphones.  Industry made something people want.  They bought.  They are still buying.  No onus.

      The EHR industry was not successful in this way, but was mighty glad to see the feds decide there should be an onus.  What incentive does the EHR industry now have to adapt to clinical reality? 

      Competitive, innovative market forces have been scrapped in favor of leaden federal mandates and taxpayer subsidies.

      We are told 3 to 5 days of training should minimally be expected to proceed with the mechanics of documenting our patient encounters in an EHR. (Training for paper took minutes.)  

      What other industry has had such nonsense forced upon it … and without evidence of a favorable cost/benefit ratio?  Yes, other industries have very complex technologies, some of which require months or years of training … but the associated industry has decided the technology is profitable, and worth the capital expenditure (e.g., the auto industry and robots.)

      A worrisome arrogance can be heard from the IT world.  Clinicians are supposed to adapt to IT reality rather than the reverse!  

      Failure to do so results in condescensing head shakes, finger wagging and “Luddite” labelling by the coding gnomes and their sales force, who have decided now that THEY should shape a clinical reality about which they have demonstrated little understanding.

  • Anonymous

    The author is right that current EHRs probably do not improve patient care much, at least in an office setting, and he is right they don’t do much if anything for physician productivity, again at least in the office.  But I find the idea of a grand conspiracy involving insurance companies a bit much.  EHR vendors are in it for the money and influence naive or corrupt opinion makers, sure.  They are the main culprits here.  That said, if insurance companies can twist things to their advantage they will of course try to do so.

    • Anonymous

      As poorly coordinated as our health care system is presently, a miracle would be required to achieve a level of integration sufficient to create a successful cabal.  But the author highlights well how the push to EHRs has been chiefly fueled by non-clinicians for non-clinical reasons.

      “Cash for clunkers” piquant resonates powerfully with my own daily experience..

      • Anonymous

        Gee, I wonder why our health care system is so “poorly coordinated”? Is it the consumer’s fault? Gee, it must be, right? How in the world could it be the fault of the highly educated and highly experienced “professionals” that provide health services and care? These “professionals” spent many years studying and practicing to put numerous prestigious letters behind their names, how could they have screwed up our health care system? So, it must be the consumer’s fault that our health care system is so broken, right? Especially patients on Medicare, right? It’s those old people that are screwing up the works, right? It couldn’t possibly be greedy doctors and greedy drug companies and greedy hospitals and greedy insurance companies that’s screwing things up, right? It must be those darn consumers!

  • Anonymous

    I will be happy to use EMRs when the technology and interfaces are smooth and doctor / patient friendly. We simply aren’t there yet. Better handwriting recognition software would be a big step. Having poorly functional technology crammed down on us just further interferes with patient care.

    • http://profile.yahoo.com/DFA3B7NLU6XAC5Y2BBRCS7WRCI Maniappan

      Actually we offer some service to convert handwritten notes to digital format(we find these recognition tools are poor). True, fancy gadgets can hinder if the solutions are not worked out properly.

    • Anonymous

      Data input is a big bugaboo.  The company that truly solves this will leapfrog ahead of the competition.

  • http://profile.yahoo.com/DFA3B7NLU6XAC5Y2BBRCS7WRCI Maniappan

    EMR has been made into a complex exercise, I remember encountering some older practioners keeping diary/notes of cases for personal learning/use later.  Even with lot’s of new tools the time spent by practioners on this exercise of notes taking for their consumption seems to be less and that I guess is the reason why data capture exercise seems to be less interesting!.

  • http://www.facebook.com/people/Huxley-Miller/1367945400 Huxley Miller

    I am a 61 year old internist in a 100 person multi specialty group in Cincinnati.  We have used Epic since 2002.  I like Epic.  I don’t want to go back to paper.  Even so, “meaningful use” is driving me crazy.  The devil is in the details.  For example, as an internist I obviously review the med list in each of my patients.  Will you trust me on this?  But for meaningful use I’m required to click a button at each visit to confirm that I’ve done so.  But the devilish detail is that the “reviewed” button is available on only one screen, not the screen I’m using, and it’s 10 steps to get to the button and back.  ”Cash for clunkers”.  I love it!

  • Anonymous

    I can’t possibly disagree more.  Our clinic happily adopted a physician-designed EMR nine years ago as most of our providers were turning fifty, so we were not young grads.  No one compelled us; we wanted to be on the forefront of a new technology.  We are far more productive, not less, our patients benefit from nearly instant access to their chart notes, labs and other chart information, our communication with patients is automatically documented through a secure patient portal.  We are able to pull clinical information about our patient population, looking at outcomes with a few clicks.  We can contact identified patient populations for educational messages in a matter of seconds.  Have there been problems with the design, the functionality, and with network outages?  sure.  Have we ever lost a chart?  never.  

    I am baffled by the stubbornness of physicians unwilling to take the step to adapt to EMR documentation for the benefit of patients and their care. Must have been something like this when motorcars started replacing horse and buggy.

    • Anonymous

      Its funny, in over 10 hospitals I visited, I could barely find any physician who was willing to say anything other than “its ok” regarding their EMR. 

      So please tell me which EMR you use, your initial cost and ongoing maintenance costs? Maybe I can explain to you (as a techie myself) why physicians are too “stubborn” to adapt. 

      • Anonymous

        You can go to the McKesson Practice Partner website for the costs–our initial start up cost was nine years ago, so not relevant to current costs, and maintenance is per license so that is practice dependent.  We run 36 licenses in our clinic. 

        • Anonymous

          Ah,…the details….well let me pour some numbers for you. Today, some of these systems cost anywhere between $400,000 and $500,000….not including a one time installation fee in the six figures and not including ANNUAL maintenance fees of approx. 20% of cost. By the way, there is NO guarantee that after paying these amounts that your vendor will be around in 10 years….or that their systems will actually be interoperable with whatever system eventually wins the EMR race. Can you see why my five co-workers and I may be a little “slow” to adapt?

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

            I don’t know where you are shopping, but for 6 licenses (you and your five co-workers) + training and installation, should cost you less than $100,000 and yearly maintenance should run less than $15,000, for all 6 of you.

            No, there’s no guarantee that your vendor will be around in 10 years (some are more likely to be around than others though), but there should be a guarantee that for as long as it is around, it will comply with regulations, interoperability included.

          • Anonymous

            As you are probably aware it is almost impossible to make an apples to apples comparison when it comes to EHRs (a dirty trick if you ask me). So what you have found for under $100,000 may very well be my $400,000. It is all in the details once again. 

            But even using your figures, that is still a steep investment for a small office….in a field that is changing daily. Remember the first time you saw a computer being wheeled into a patient’s room. Wow, didn’t that look cool. Couple of years later, oops the ipad. 

             

            My point is…jump in if you feel you can afford it even at the risk of owning obsolete or unsupported technology in five to ten years. For me the cost to benefit ratio is way too high to justify investing in any of the products today. 

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

            Yes, it is a steep investment, and it will become obsolete eventually, as all technology does, and even the iPad will look like a dinosaur in a few short years.
            So you could stay on the sidelines forever waiting for the next best thing. The hard part is to identify the point where the pros outweigh the cons. I think we are there now, but the pros are not what you would expect.
            You can be a better doctor without EMR and you can provide better care without it, but you will not be allowed to play without electronic data for much longer.
            If you choose well and get lucky, you may be able to derive some utility from the thing, but honestly, this is not the point right now. I know it should be, but it isn’t.

            And all these counter scare tactics from folks trying to sell you something are the same old dirty tricks as everybody in this business is using, because no product has true merit and the only way to sell one is to label all other clunkers or to promise protection from imaginary conspiracies….

          • Anonymous

            Has anybody published a head-to-head TCO comparison between paper and electronic records for various practice environmnets?

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

            Sure. Every EMR vendor has one and they are all showing EMRs (or whatever the vendor is selling) to be cheaper, and they are all laughable.
            EMR is not cheaper than paper, and so called “cloud based” EMRs are not cheaper than paper. Everything is about the same, because the biggest cost is your payroll and EMRs cannot reduce payroll (they can only shift job descriptions), and your only revenue is your time, and EMRs cannot possibly cut your visit time even further than the current miserable standard.

            When the policy folks say that EMRs will reduce costs, they mean costs to the system (i.e. public and private payers), not your costs of doing business.

          • Anonymous

            All EMR vendors lie about the comparisons.

      • Anonymous

        it is not our stubbornness—-it is that the computer programmers don’t understand how we work—-Here is an analogy—look at Blackberry and Apple—-the reason that so many people have I-phones is that it was designed for the end user.  Design is the issue!!!!

    • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

      Does your system qualify for Meaningful Use or carry the latest certification to even be able to qualify for meaningful use?

      • Anonymous

        McKesson Practice Partner which has been in existence for 30+ years designed originally by a family doctor.  It has its issues, as all EMRs do, but we are using all features maximally and would never turn back.  Are there things I wish it did?  you bet.  We are patiently waiting for updates.

        According to the website, it is 2011/2012 compliant and was certified as a Complete EHR by the Certification Commission for Health Information Technology in accordance with the applicable certification criteria for eligible providers adopted by the Secretary of Health and Human Services

        Emily Gibson M.D.

    • Anonymous

      “I am baffled by the stubbornness of physicians unwilling to take the step to adapt to EMR documentation for the benefit of patients and their care.”
      Because, being scientists, physicians know that after all these years, there is still no evidence showing that EMRs save time, reduce costs, or improve patient care. 

      We’re dealing with anecdotes, and, for every favorable anecdote such as yours, there are, as noanlyst indicates, 10 unfavorable ones.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    In 2008 I received a call from a physician in a French built hospital in Ho Chi Min City that one of my patients had been brought in off a cruise ship with atrial fibrillation. She had given him her USB flash drive copy of her pertinent medical records and he had faxed me her ship board EKG and ER EKG to talk about. I thought how wonderful our EMR system was and praised MediNotes and my partner for having the courage to invest in the system four years prior. It was a $100,000 expense for us and with virtually no transcription to eliminate since we were ” PCP’s” it was a straight cost not eventual cost savings. When ARRA was signed into law it created a ” feeding frenzy” in the field. Doctors wanted the $44K paid for meaningful use. Hospitals wanted the $11 million dollars to capitalize information system upgrades. MediNotes sold to Ecclypsis and ” Peak Performance.” who in turn sold to All Scripts. I would have been content to keep runniing MediNotes but All Scripts made a point of letting us know that all support for the system would end in a year.All Scripts My Way became the most cost effective way for our office to have a functioning EHR system having already invested $100K in one system.  I can truly say the experience has been a nightmare. The software is not fully functioning and ready for prime time. It is not yet fully compatible and bridging with our business practice management system.  The health maintenance core section is still not functioning. The outsourced e prescribing software is incomplete with regard to medications and pharmacies in our area. The personnel trained to train us were very narrowly trained in specific areas of the software but not others with no real ability to understand how their section effected the other area of the software. None of them were taught how to use the icons and drop down menus to trigger the audit system so that you actually got credit for meaningful use while you were entering data. Some of their trainers ( particularly the ones responsible for setting up and training on the lab interface with the commercial labs) had no idea what meaningful use actually is. The patient portal login for patients to obtain their records works well , as does the clinical summary each patient is given after the visit to comply with meaningful use. The problem is that the data provided to meet meaningful use , is so basic , so incomplete and so overloaded with garbage in the ” problem ” lists that it is far less useful than the USB flash drive data   
    I gave my patient before her trip to SE Asia in 2008. I have no basis to comment on the conspiracy theory expounded by the author of this article but do agree that physicians do not like software that is cumbersome, poorly designed from a practice standpoint and subject to contraction of the vendors without the selling or buying companies being responsible for implementing the new software for users already ahead of the curve on EHR. If ARRA had witheld payment from the manufacturers and vendors until the physicians offices achieved meaningful use standards the rollout , training and learning curve for providers and their staff would have been far gentler.

  • Anonymous

    As a physician and a trainer for our health system’s role out of Epic, I have seen the dichotomy of physician acceptance of EHR. There are the typical younger, computer-savy docs who actually excited to use the new EHR. Then there are those who  are fearful of the change and either lash out or rebel. Several physicians actual chose early retirement instead of learning our new EHR. These doctors are quick to point out all the faults of EHR’s. More work for the physician, pretending that patient care is being improved and being forced to alter our practicing methods are all legitimate criticisms of EHRs. However, a survey of these same physicians 6 months later identified over a 75% acceptance rate; many stating they could not imagine returing to our previous system.
    I believe as a profession that we need to accept this change (whether for the better or not) in the way we practice as long as we don’t allow EHR to disrupt the relationship we have with our patients. Additonally, the adoption of EHRs needs to led by physicians instead of administrators. Lastly, in order to accept EHRs, we need to recognize their true purpose:  Transparency. Transparency to payors to insure that their dollars are spent appropriately and transparency to the patients to allow them to be educated consumers.

    • midwestdoc

      I must comment on this as I have been using Epic for over 8 months….It is a non-intuitive system that is not designed well for the end user. I am all for EMR that works!!!  If Apple got into EMR, they would put Epic out of business.  Check the post on Sermo.com  “Epic is my new 4 letter word”. It is easy to blame it on the age of the physicians—-but the real problem is poor design and a disregard for the end user.  Read this comment by a designer firm—–http://www.electronicink.com/a-better-system/an-epic-morning-in-the-exam-room-2/

    • http://twitter.com/laccheo Michael

      I’m a young doctor, a programmer, and I’ve used Epic. It’s a piece of junk from both the viewpoint of a clinician and a programmer.

      I’m can’t wait until there is actually a decent EMR, but trying to pretend that the reluctance to adopt now is about being unfamiliar with EMRs or tech, or that it’s due to luddite old doctors is patronizing and ridiculous. 

      • Anonymous

        Hopefully someday there will be a “decent EMR”, but in the meantime, the reality is that as physicians, our hand is being forced by payers and meaningful use criteria. Unless a group of docs create their own ideal EMR (perhaps yourself), we are at the mercy of the available products on the market. We can chose to reject EMRs base on their current deficiencies or we can play an active role in shaping the industry to produce an EMR that really works.

  • http://twitter.com/BPMForReal Chris Taylor

    As a patient who is on the other side of the issue, I’m not so concerned about productivity (not concerned about that at all, in fact). I’m very concerned about whether my doctor is ‘coin operated’ or is more part of a collaborative healthcare system that can share data between providers. Beyond collaboration, I want that data to be used to improve healthcare outcomes in a broader sense, when we have the ability to compare symptoms, treatments and outcomes. That is impossible with paper records. Lastly, I want predictive analytics to be enabled so that we don’t find out by accident that an aspirin immediately given to a heart attack patient stops being an anecdotal discovery and becomes part of the science of medicine, driven by the ability to analyze aggregate data across populations, facilities, and treatment providers. 

    It should be about the patient outcome and I have doubts that it is about control of doctors by Payers.

    • Anonymous

      “Collaborative healthcare system.”  “Share data between, (amongst) providers.”  That is, if the data “fits.”  I see, you want to compare symptoms, treatments and outcomes for all patients.  Fine.  Let those analytics be done by computers.  But the nuances possible in a physical, handwritten chart, cannot be disputed, nor can that kind of information fit just so in whatever crazy EMR application someone in IT has invented.

      Patient outcome?  You mean did the patient live or die?  Yes or no?  What about all that in-between stuff? Additionally, what about wrong information put into that EMR? A patient can review his or her chart, and if there is a dispute, can have that added to the chart. How are patients going to fight this new form of “permanent record?”

      • Anonymous

        Wrong information is a new and vexing problem with EHRs.  In an attempt to compensate for the productivity hit, clinicians resort to canned verbiage, or the last note’s text, that they then strive to edit to suit that encounter.

        Problem:  It’s too easy for the human mind to miss the things that need changing, resulting in copy/paste documentation errors.  I speak from my own, personal experience here, too.

        It’s pretty hard to duplicate that kind of error in a handwritten chart.

        • Anonymous

          I’ll take “canned verbiage” over deciphering medical hieroglyphics any day of the week.

          • Anonymous

            Man, you are really hot under the collar. Horseshrink was just stating his or her opinion.

          • Anonymous

            Me too!

      • http://www.successfulworkplace.com/ Chris Taylor

        Not a data expert, but anything you can write down, even in free-form (nuances) can be captured in a medical record. The fact that it doesn’t sit in a paper record is a huge step forward.

  • Anonymous

    Why am I not surprised at the complaining and the whining and the crying coming from small office doctors who can’t (won’t) afford to migrate to EHR. My experience, of decades of doctor visits, is that doctors should be welcoming EHR to lessen the incidents of mistakes and to enhance the experience of their patients. I am shocked when I still see small solo practices with tons and tons of paper records on file. One of my specialists has an entire room dedicated just to medical records. It’s a very large room. Most of the time, the office staff pulls the wrong file because the folder was misfiled or misplaced. In their haste to pack in as many patients as possible in their busy day, solo doctors and small staffs are making more and more mistakes with record keeping. I don’t see a solo doctor any longer. I go to a large practice where EHRs are used and where they have dedicated people serving many primary care doctors and many specialists. I walk in the front door, give them my name and date of birth and from that point on, there’s never a mistake. In fact, the office I visit has my picture on file so hey can compare me to the photo. Small offices will soon be history. It has to happen. Health care is risky enough. Why would anyone refuse EHRs and make it 1000 times more risky?

    • Anonymous

      I use one of those “clunkers.”  It is truly not a clinical tool and seriously reduces productivity.

      It’s interesting how often the “lost” paper chart is used to malign the paper record in contrasting it with an EHR.

      One temporarily lost chart beats the heck out of tens of thousands of lost charts … because the power went out in another town where the servers live … or the power went out during maintenance procedures on site, or the system was compromised by a trojan, or the system is being updated, or the EHR is being upgraded (and is still unstable), or …

      I’m actually OK with moving toward EHRs, but have no illusions that they are some magical panacea.  They aren’t – and especially as currently designed.

      At this time they are very expensive, fiddly, insecure, productivity albatrosses written by non-clinicians who lack understanding re: clinical workflows and what clinicians really want from a computer.

      • Anonymous

        p.s. – I still remember the time we lost our EHR because of a backhoe operator in a town 20-30 miles away.  He sliced through the cable being used for WAN traffic for that region.

        No medical record for over a day.

        Lends a nostalgic hue to the memory of a wayward paper chart.

    • Anonymous

      “I walk in the front door, give them my name and date of birth and from that point on, there’s never a mistake”
      lol…omg…not to make fun of you but you are really naive. Some friendly advice, mistakes can happen. It is just a different type….example below…
      http://www.chicagotribune.com/health/ct-met-technology-errors-20110627,0,5447654.story 

      • Anonymous

        Computer software is only as smart as the guy who writes the code and software code is like a spider’s web; you can change something over here and cause something to fail over there and not know it.

  • Anonymous

    As someone who was in the EMR business for 13 years, I
    think the main reason there is such poor adoption is that 90% of EMR’s suck!
    They are kludges and force you to think in a totally alien way and document the
    way some software engineer thinks is logical. The input into the design of the
    user interface and workflow is far removed from clinician’s actual
    documentation and work flow. Rarely do they work with the clinician; mostly
    they force the clinician to add to their work load. The are marketed as this wonderful tool with all of these advantages and bells and whistles and in reality they suck.

    • Anonymous

      Yeah, maybe 90 percent of EHR programs suck. However, any one of these “sucky” programs is light years ahead of the neanderthal record keeping that health care consumers have had to endure in the past. Just one example? The worst prescription printed out by any of today’s “sucky” EHR system printers is 1000 times better than a doctor’s handwritten script any day of the week! Face facts Molly, EHRs are long overdue and some docs are too darn cheap to spend a dime on progress. The best thing to happen to these small office cheapskates is for them to go bankrupt from the tsunami of competition headed their way with the advent of huge big-box WalMart style and Home Depot style ACOs.

      • Anonymous

        Unfortunately the law of computers still applies: garbage in garbage out. So when the program is horrible to work with people do the very minimum interactions because the hate it and don’t want to use it. Then you get crap for documentation. I don’t think it is being cheap. By the way I still work in software. If EMR’s or EHR’s worked like the iPhone or the iPad, there would be no problem.

      • Gil Holmes

        So a prescription for the wrong drug in the wrong dose is better than a difficult to read prescription?
        Sometimes the computer just doesn’t have the dose, or sometimes the drug, you want to give as an option and you therefore cannot prescribe that drug. You are OK with that? That’s better than a handwritten script? Sometimes the finger slips and you accidentally click the next item down the list. Sometimes you accidentally send the script to the CVS in the next town over(once again just the next item in the scroll). These mistakes don’t happen with paper charts and handwritten scripts. Do errors occur with them? Absolutely. But EMRs create their own.
        You are just trading one type of error for another. No doctor has ever handwritten doxazosin when he meant doxepin. Never ever happened. Has happened with EMRs.

        • Anonymous

          Yea … and when’s the last time someone hacked into a paper chart, or stole 10,000 such charts at a time?

          Security breaches now of hundreds of thousands (millions?) of patient records is unprecedented.  Cost to the medical industry of these breaches, per health IT publications, is measured in the billions of dollars.

          • Anonymous

            Is that the best excuse you have? Tell that to Visa and Mastercard. I don’t see them losing customers in droves. Or, is there some sort of movement among doctors to burn our credit cards, huh?

        • Anonymous

          Just minor bumps in the highway of progress. Tell me, why are you so frightened of change?

    • Anonymous

      Ma’am … you are hearby charged with heresy.  Upon conviction, you shall be sentenced to daily use of my system’s EHR for the next 20 years.  May God have mercy upon your soul.

      • Anonymous

        Only 20?

        • Anonymous

          Don’t worry, most neanderthals retire in frustration before they let anyone force them to move into the 21st Century.

          • Anonymous

            You missed what I said that I do for a living. I am in software. All the more reason to recognize crap when I see it and to know that software has flaws, can break and can force errors. I have been in the 21st century for some time now. I thought it was time that someone who was in the business admitted that there is a lot of crap out there and that hurts everyone and makes adoption of the EMR slow.

          • Anonymous

            Even the “crap” you speak of is far better than stacks of paper folders piled high to the ceiling. Modern health care consumers want more. They are tired of the 1950′s time warp. They are tired of visiting offices manned by a keyboard phobic Marcus Welby types. They are tried of always having to make appointments with a slow witted neanderthal staff.

          • Anonymous

            Had a bad experience lately. I was just trying to explain why may physicians and nurses hate EMR’s. I love computers, smart phones, iPads, etc. You are painting with a broad brush. When you have only so much time for patient care and you eat a lot of it up fighting the EMR to document that care, people give up.

          • Anonymous

            Blame it on the fact that we have way too many Marcus Welby types practicing medicine and not enough docs with a little bit of Steve Jobs mentality built in. At least Steve Jobs could walk and chew gum at the same time. The problem is, change is hard. Especially for docs who have been on cruise control for the past 30 plus years.

          • Anonymous

            Unless the server crashed or there was a virus or worm…..

          • Anonymous

            Or wayward backhoe in another county.

          • Anonymous

            Or maybe a boogieman is hiding behind that tree, huh?

          • Anonymous

            See post below.  Backhoe is true story.

          • Anonymous

            That will do it.

          • Anonymous

            I forgot to mention that at least Marcus Welby could solve any medical problem in 60 minutes minus the commercials. No matter if they had the plague, Lou Gehrig’s disease, piss poor protein diagnosis or a simple fracture, he was the man.

          • Anonymous

            My guess, Welby could have lessened the suffering of his patients by at least 30 minutes had he and his staff some experience working with EHRs, huh? Sadly, many Welby types are still practicing in that neanderthal model.

          • Anonymous

            Give me a choice between Marcus Welby with a paper chart or an assembly line doc with an EHR …

            Dr. Welby wins hands down.

            Much of what is valuable in the healing arts is the relationship, a process with which EHR technologies are known to interfere.

          • Anonymous

            Healing arts? More like witchcraft and voodoo medicine if you ask me. My guess is, maybe some docs need to clean up their crystal ball once in a while. Claiming typical medicine as “healing arts”? That’s a joke! Get real! Today’s primary care is nothing more than military triage, at best!

          • Anonymous

            “Modernization” has included a shift to assembly line “military triage” care. I don’t like it.

            Like you, apparently, I also mourn the loss of the healing arts. 

          • Anonymous

            Healing arts? Most primary docs must push at least 50 patients a day through their office just to make ends meet. My PCP says 85 percent of his patients could go to a local neighborhood welfare clinic for their health care and a nurse would give them as good, or better attention. At least a clinic nurse would offer them more face time. On average, he says, the other 15 percent of his patients are referred out to specialists. If you think “healing arts” has anything to do with most primary care these days, think again! Only the high end boutique type offices with the expensive designer care are offering anything that resembles “healing arts”. Get real!

          • Anonymous

            Absolutely!
            We agree.

          • Anonymous

            Easy to pass judgement from afar.

            I’ve written de novo image analysis code in C, do website design from the ground up, write scripts/macros, build my own workstations and networks, work comfortably in Linux, etc.

            I was a definite nerd growing up, playing Star Trek on a teletype and writing space battle games for my HP 41C.  I come from a computer family; my dad ate, drank and dreamed in assembly language for the space shuttle.

            Like Molly, I’m no Luddite.

            Like Molly, my frustration is knowing what software can do … and what it’s not when it comes to EHRs.

            Thus my contrarian attitude.

          • http://www.eepd.info/ Rupert David Fawdry

            This neanderthal is busier with facilitating good IT than before he “retired” 

            He remains convinced that Individual patient care must come first. And he refuses to be trampled in the rush to be “modern” especially by those who claim to be “with it” but have clearly never been involved in the tedium and rigidity of writing usable computer software programs.

  • Anonymous

    And if EMRs are so great, why haven’t patients had their own records on a disk that they could carry from physician to physician to specialist.  As it is, (and I wonder about the HIPPA take on this), physicians will not take a new patient without them first filling out, and submitting a lengthy paper medical history, weeks or months before an appointment, which then has to be put into the right fields – if there are fields for the particular bit.  If it works so well, let the patients input their history and send it directly to the docs office – at least those who can and wish to do so.

    Around here, because of the implementation of EMR, NO NEW PATIENTS ARE BEING ACCEPTED BY ANY PHYSICIAN  in the medical conglomerate for the first two weeks of the month – at least.

    • Anonymous

      Interesting that Google pulled it’s PHR project … due to lack of interest by the public.

    • Anonymous

      Uh, you can do that today. I won’t mention the web site that I use but you can find many secure web sites that offer free space to store your entire personal health record (PHR). Do a web search for “PHR” and you’ll see what I mean. In fact, most of these free services offer space to download documents such a lab reports, your living will, advanced directives, etc., etc., etc.  When I go to my primary care doc, all we need is his office computer (or my iPad) to see everything I’ve entered since my last visit. Also, in case there’s an emergency, where I’ve been taken to the emergency room, the hospital has access by logging onto my PHR using the information contained on my wallet card. Regarding “HIPPA”, it’s a scam! In today’s broken health care system, consumers need privacy only because they fear that if insurance companies know their history, they will be refused a policy. That could be fixed very easily. Eliminate insurance companies and go to a single-payer system where everyone is included and nobody can be refused or rescinded. The problem isn’t privacy. The problem is insurance companies not wanting to be honest and accountable and insure sick people. It’s called “cherry-picking” and it must stop. The Affordable Care Act begins the process of forcing insurance companies to stop cherry-picking and to be honest, fair, accountable and inclusive! Insurance companies have caused “all” of the problems that exist today in our health care system. Unless they begin to clean up their act, they need to be eliminated. 

    • Anonymous

      Heck why need a disk when many patients have a smart phone. We used to talk about the patient having a smart card or a smart phone with the whole medical history and record on it that could be updated at every visit.

  • Gil Holmes

    Doctors have flocked to smartphones and iPads in droves. They do not fear technical electronic progress.

    They hate crappy EMRs that don’t work and waste time.

    Once again, no one had to incentivize anyone to buy a smartphone. Their use was obvious and people willingly paid for them.

    If and when EMRs are as easy to enter and find info as a well-organized paper chart and if and when EMRs at various hospitals and clinics can talk to each other and if and when EMRs can be modified on the fly by actual practicing clinicians, then doctors won’t need to be incentivized to use them.

  • Anonymous

    I am a nurse, clinical analyst, that has implemented 2 different brands of EMRs at 2 different practices…one a small primary care practice and one a large multi-specialty clinic.  Yes, a lot of the EMRs out there do suck, but there is generally a lot we can tweak in the system to make it usable for you.   What I have found frustrating  is that many providers and especially physicians are not willing to get involved early in the process. If this is something that affects your livelihood, your day-to-day practice, then you need to dedicate some time to make sure, first, that it’s personalized where possible to work the best for you, and second that you feel comfortable using it.  We made a test system available to users more than 6 months out but no one really used it except for coming for short bursts of training.  The excuse I heard most often was “you just need to be in clinic to see how to use it”—well, you mean to tell me that you don’t have enough imagination to go thru a couple of the patient visits you had during the day on a test patient or your own patients that are available in the test system? I certainly do understand that it may not be the same, but if you are not willing to even try and then want to cry and complain when suddenly you have to work with the new EMR system, it is hard to take your concerns seriously.

    • Anonymous

      I agree with you that physicians need to be more involved. However I disagree that a lab demo can  approximate real life usage. This is part of the reason they suck….because someone in some lab somewhere has built a system without any real clinical testing.  

      You know for the amount of money these EHRs charge, you would think we would have the option of trying their products live before committing to a purchase. 

  • Anonymous

    Our office transitioned to EMR almost a year ago.  While it’s been difficult, I can see the light at the end of the tunnel. I wasn’t sure how my patients would feel about my typing during their encounter, and was pleasantly surprised to find that most of them didn’t even notice the change.

    • Anonymous

      Yep, the same way I don’t expect the “sales person” at my local electronics store to know anything other than the price of the product. Two decades ago, you could walk in and be educated by the sales staff. Now I do my own research so that I just need them to direct me to where the product is located….and sometimes they can’t do that. The point is that after a while of seeing mediocrity, you kind of get used to it. 

  • Anonymous

    Just like anything technical, there will always be neanderthals that refuse to conform. As if conforming is just caving in to progress. How ridiculous! Within the past 20 years, as computers began to show up on desks at the work place, there were those that were frightened to death! Many choose to retire or quit rather than get company paid training and learn to conform to the new standard. That’s exactly what we are seeing in the small office medical practice today. Fear and dread mixed with just plain stinginess. How in the world can small office practices be defended when the large ACO type hospital operations are spending tons of money to incorporate state-of-the-art EHRs and state-of-the-art imaging and diagnostic services all under one roof. The handwriting is on the wall for the solo docs. 

    • Gil Holmes

      No ACO model has saved money. No ACO model has shown improved outcomes. No EMR study has saved money. No EMR study has shown improved outcomes.
      I have an EMR. I trained in residency with an EMR.
      The discernable benefits of an EMR:
      1)you can find the chart(assuming no power outage, server outage, backhoe accident, etc)
      2)the chart is legible
      3) with great effort it can be well-organized
      4) the government and insurers can data mine(this is NOT a benefit)

      The negatives:
      1)  extremely more expensive than pen and paper
      2) a well-organized(emphasis on organized) paper chart is still easier to use when trying to quickly look at the patient’s last lipid panel, stress test, ECHO, and visit to the cardiologist or some other historical info.  To do that with our current EMR takes a minimum of 2-3 minutes(and sometimes longer) as you have to open and close each item. With paper chart you flip to relevent sections in under 30 seconds
      3) E-prescribing has just as many(though different) errors than handwritten prescriptions
      4) the promised transferring of info between systems has absolutely not happened and there is no current short-term plan to have it happen
      5)one often has to enter the same info 2-3 times. It doesn’t cross-populate. And if you don’t enter the info the way the computer wants you to enter it then it just isn’t happening. No subtleties of diagnosis or physical exam are allowed.
      6) it shuts down/slows down/server crashes entirely too often.

      • Anonymous

        We don’t have the ACO model yet. We’ve never had a health care delivery model that dumps fee-for-service care completely. We’ve never had a true team approach to health care delivery where a patient’s wellness and good outcomes equate to a good patient rating which makes that ACO more attractive to more patients and thus creates a better profit margin for the ACO team. We aren’t there yet! Again, you keep reverting back to small office solo doctor boutique delivery. One doctor and a small staff will never be able to make a “modern” practice work efficiently and effectively. As health care becomes more and more complex, doctors in small practices are falling more and more behind. I emphasize the word “modern”. Most small operations are not modern by today’s demanding standards. A solo doc does not have the time or the resources to equip and operate an efficient and effective practice that sees all and knows all. One person can’t do the entire job. You need a team. You need more eyes, ears, hands and brains today than in the days of Marcus Welby. Your conversion to EHR will never be full and complete. You don’t have the time to absorb what’s there today, not to mention the many software upgrades that are rapidly coming down the road. My PCP threw in the towel and will soon join our local ACO. He has seen the handwriting on the wall for many years. He says, life is way too short for such stress. 

        • Gil Holmes

          I see you didn’t reply to any of my points.

          • Anonymous

            I’m not going to argue points that continue to defend our broken status quo health care system. Until fee-for-service is completely eliminated, until we eliminate insurance companies that have caused outrageous damage to our health care system from decades of taking profits and not improving benefits and delivery, until we begin to see that value of how economies of scale can have a positive direct effect on efficiency and effectiveness in health care delivery, people will continue to ask stupid questions. A tsunami of change is coming for the small office practice. You can’t stop it. Will it be Obamacare that encourages this change? Who knows? One thing for sure. Our unsustainable health care system must change. The method or the legislation matters not. Consumers aren’t settling for the abuse, the cost and the disrespect any longer. The consumer is finally standing up and taking control. You guys who’ve been on cruise control for 30 plus years are about to find out what it means to compete. It was not the consumer that killed the cow. You guys conspired over decades to kill the cow. Like the small town hardware store, the small town grocery store and the small town clothing store of the 50s and 60s and 70s, WalMart style health care is coming. Home Depot style health care is coming. It’s just a matter of time. We will soon see the beginning of an endless winter for small boutique practices. I say, good riddance! 

          • Gil Holmes

            You seem to think that small private practices set their prices. They don’t. You seem to think they set the computer policy. They don’t. You think they pick the insurance coverage policies. They don’t. You seem to think that doctors and insurance companies are on the same side. They aren’t. You seem to think that most doctors are in the pockets of the pharmaceutical companies. They aren’t. You seem to think that doctors and hospitals are in cohoots against the patient. They aren’t. In fact, for most of these things that you seem to think are true, the exact opposite is in fact the case.

          • Anonymous

            Tripe! Nothing but rubbish! Doctors? Honesty? Integrity? Do no harm? Doctors? GET REAL! I guess the next lie you will be telling us is that pharma sales reps don’t bribe corrupt doctors to push their brands, right? I must admit, some posts here deserve a Grammy in the category of “Most Untruthful”. Hypocrites!

          • Anonymous

            You are not going to argue his points because you can’t. Other than cliche statements, you actually have not defended any points. I am actually surprised people keep responding to you. 

        • Anonymous

          You keep repeating the lie that ACOs “dump fee-for-service completely.”This is absolutely not true. Medicare ACOs will continue to be paid primarily by FFS.

  • Anonymous

    Like other industry sector’s software, EMR suffers from lack of user-centered design from the ground up. The software implementation model rules the day. Thus, EMR don’t deliver what MDs, RNs and other clincians and ultimeately what patients need from them.

    I’ve worked as MD in several systems. The administrators, who control the purse, don’t involve the end-user (clinicians) before choosing a system. As a result, mediocrity reigns when choosing a system. And, unfortunately, opportunity costs are such that the clinicians are stuck with the poorly designed systems once administrators make their bad purchasing decisions.

    As a medical informaticist and programmer, I’ve taught IT folks about these issues and found IT folks also to be largely unmoved from their modus operandi, i.e. sticking to their implementation model design methodologies from the ground up leaving user-centered design as a mere afterthought. Moreover, the antiquated programming languages often in use prohibit the inclusion of helpful technology in the system – e.g. fuzzy inference engines and ontology engines to help fire alerts in a more appropriate fashion, and event stream engines to help perform realtime clinical monitoring and QI - are unavailable with many of the current EMR due to their technical limitations.

    As cynical as I am, I haven’t thought about Adam’s take…control, narrowing of choice, etc. However, one certainly could turn EMR on its head and use it for this purpose going forward. Perhaps this is a good reason not to allow the third party payers to get too involved.

    I find I’m often less productive when I use the various EMR systems that I have used at various organizations where I’ve worked as clinician. I also find that the one-size-fits-all window for all users – e.g. for one view of Intake & output – is extremely impeding of understanding a patient situation when rounding on patients. And hiding data from view without cueing that data is hidden has led me to make erroneous decisions on behalf of my patients. None of this is helpful.

    Moreover, if I were in a small practice, trying to find quality IT support to keep the system running while I see patients would be a hurdle that may be too high. (Its hard for my attorney spouse to find someone who really knows what they’re doing to keep the small law practice system up and running.)

    Bottom line, Healthcare IT has a long way to go before it’s as user-friendly and useful as it needs to be to make it worth the $$$$$$$$$$$$$$$$$$$$!

    • Anonymous

      Bingo.

      I believe the most effective place for us to be heard is the market place.

      Fed involvement should, at most, focus on data standards – and not upon pushing any mediocrity out there.  While that is good for burning superfluous tax dollars, and helping promotion-seeking bureaucrats to generate performance evaluation bullet statements, it’s not good for end-users.

      Standardized data constructs are critical to HIE … and to relinquishing vendor lock upon patient data.

      Currently, if I hate the product I buy, too bad.  So sad.  It’s too expensive to buy a new product and then migrate my old patient data to it.

      When clinicians can change EHR products at will, market competition will heat up accordingly.  Then, the only surviving vendors will be those who give us what we ACTUALLY want, and at more affordable prices.

  • Anonymous

    After the EHR we selected withdrew their product,- and I was having misgivings as we were transitioning because it was clear that there real problems , and we have interviewed and tried out more- the cash cow for the EHR companies is billing- why not throw out anything- we will gwt a percentage of it, and many of the notes are advertised first as capturing revenue.

  • Anonymous

    No, the point of an EMR is not to “wrestle control of healthcare away from the doctor-patient relationship.” It’s not even primarily about doctors at all. Won’t somebody think of the nurses?

    Looking something up in a decent EMR is a hundred times faster than in the best-organized paper chart I’ve ever seen.

    • Gil Holmes

      I have at least some experience with 4 different EMRs and extensive experience with 2. Neither one can touch a well-organized paper chart as far as speed of locating info. I haven’t seen an EMR yet that is quicker for lab review or finding that ECHO from 6 months ago. Admittedly this is all dependant on an organized paper chart. Papers loosely thrown in a file folder don’t count as a chart. But I can flip through 20 pages of labs in a couple of minutes and find the info I am looking for. It would take 5-10 minutes to look at as many labs in any EMR I have seen.
      Handwriting is an issue as I listed previously in this comment thread. Lab reports aren’t handwritten. Neither are dicated ECHO reports, etc. In other words, when technology is good and useful(typed dictation, printed lab reports) it is used. When it isn’t, it shouldn’t be.
      And don’t get me started on nurse documentation. 90% of it isn’t looked at ever again 1 second after it is entered. It is filling in boxes for the sake of filling in boxes. The nurse has been so busy filling in boxes they can’t tell me about the patient.

      • Anonymous

        I can’t fathom how your computer systems are that much slower than paper. A couple of minutes is quite good for hardcopy charts; yours must be far more consistently organized than any I saw. But in the EMR at my hospital, I can find most any lab result in twenty seconds. The odd outlier may take 45 seconds if it’s an old historical result or if I don’t know how to spell it. A whole block of results is even faster than looking up a single specific one. Perhaps I’m an unusual example because of my strong computer skills, but it’s hard to believe I’m *that* good.
        As for the nurse who’s more focused on the flowsheet than on the patient, that’s just a sign that the nurse isn’t very good. We can’t blame the charting system for that, and no charting system will fix it.

        • Anonymous

          Scrub, let’s face it…

          You will always have Marcus Welby types who still carry a pencil with an eraser in their coat pocket. These types are still struggling with email. EMRs? Forget about it! Some folks will never get it. It requires them to breath and think at the same time. 

        • Anonymous

          If EHRs are so much more efficient, why do they demand more clinical staff to do the same amount of patient care?
          http://www.modernhealthcare.com/article/20100430/NEWS/304309962

      • Anonymous

        I have to agree. Nurses are taking care of the EMR more than taking care of the patient.  My employer has implented Soarian, which is a nightmare.   Finding and entering information takes more steps and ultimately more time away from where I want to be, which is the bedside.

    • horseshrink
  • Anonymous

    Had the current health care system existed back in the 1920s and 1930s, Willie Sutton would never have robbed banks. Al Capone would never have become a bootlegger. Back then, Congress didn’t support organized crime like it does today. Had Willie Sutton and Al Capone lived in the current era, they would simply go to medical school and become doctors. Robbing banks and bootlegging has nothing on our current health care system. Consumers simply walk into the doctors office and hand over their wallet and credit cards. No guns or violence is needed. It’s all legal! Organized crime is a whole lot safer today than it was back in the 20s and 30s. 

  • http://www.eepd.info/ Rupert David Fawdry

    Has the world of medicine gone completely mad. 

    35 years after the introduction of microcomputers, there is, in the whole of Britain, only one single group of people in receipt of health care who have a fully inter-operative medical record.  Anyone ready to guess which group that might be?  
    A whole group of “patients” who, everywhere in the whole of Britain (and even if they go abroad), have a medical record which is totally inter-operative between both the patient and all her health care providers?

    A record though which any health care worker anywhere worldwide can find out all important information about the whole medical and obstetric history, the full results of all screening and other blood tests, the actual scan and x-ray reports, all the recent blood pressure readings etc, etc

    A record which any clinician can add to or correct whenever the “patient” is seen.

    and even access full information about what happened during an antenatal admission 3 months previously, in a hospital 1000 miles away.

    No need for expensive hardware, thousands of lines of expensive and indecipherable software, unreliable internet connections, system unique training programmes, etc. Any alterations always being clearly visible. No worry about flat batteries, stolen equipment, deleted text or multiple incompatible master copies.
    Any guesses what this unique record is?  One of the world’s greatest advances in medical IT In Britain it is known as the Pregnancy Health Record.  and it is looked after like precious jewellery by any woman carrying one.Yes that’s right all over Britain, starting in the 80s and now universally, all pregnant women in the U.K. carry, not a pale imitation of the hospital or primary health centre record, but the one and only master copy itself!!!In the 70s there was a general belief that, because it was obvious that everyone travelling to Australia would like to arrive in 4 hours rather that 24, every effort was made to create a supersonic future.  But the fact that people would have liked to travel faster did not make it practical for all travellers to fly, the future rather surprisingly turned out not to be supersonic but for better and bigger but still slow old Jumbos. In the same way, although it may be practical for those clinicians who are able to spend all day logged on to a single terminal, to use electronic records instead of paper, this will never be as easy for those whose work involves moving from place to place, of for patients with multiple different carers.The cost and rigidity of the thousands of lines of software required both to be created and then regularly upgraded, both for each different departmental system and for all the rigid links between them, it will never, ever, ever, be practical or financially feasible for co-operative medical care to be purely electronic.So after nearly 50 years of front line Obs/Gyn medical experience in labour wards all over England, Scotland & Wales, also Iran (71-79) and also in Canada (BC & Newfoundland) I simply do not believe your opening statements that “EMRs (electronic medical records) are inevitable. Over the long-run they are almost certainly good for physicians, patients and the healthcare industry.” . Not true. Such records, although beloved of administrators, are, and will remain, hugely damaging to the shared care of individual patient. (but only if they replace paper, not if sensibly used as complementary)

    For more about our true future do look at our recent letters in the BMJ & the American O&G Green journal but above all at our recent major review article in the Journal of the Royal Society of Medicine. “Data re-entry overload: time for a paradigm shift in maternity (and all other hospital/community) IT” Oct 2011

    Do also look at http://www.eepdwiki.org.uk to see what we are trying to do co-operatively towards creating a balanced hybrid of patient-held paper records and electronic databases (with in future much of the obstetric history recorded using a cost free universal App, provisionally called PAMApp – Programmed Assistant in Maternity) for the flow-patterned detailed history; this then being output to large sticky labels.  These then to be stuck in the locally used paper Pregnancy Health Record with the resulting document being used as the basis for the initial pregnancy assessment.  The relevant pages of the agreed result can then be photographed so that clerks can enter the rigid data that admin needs into their inaccessible, costly hospital departmental electronic systems for them to analyse all that mass of accurate secondary data.TV has not replaced the radio,  Cars have not replaced shoes. and despite our hopes supersonic has not replaced sub-sonic.And electronic “chips” will never be an adequate replacement for high quality “paper”. ”Chips and paper are complementary, not alternatives!”Rupert Fawdry, FRSC, FRCOG,  Honorary Consultant Obstetrician (IT Research), Coventry University Hospital (UHCW), UKP.S. Having a)provided the medical knowledge used in one of the most popular maternity systems in the UK, b) having also in 1984 pioneered using the hand-held pregnancy record as the master copy, and c) having since then virtually single-handedly provided the solid foundations required in a massive and growing website compendium of medical data (try googling “Perinatal Data’ Recently, at least in the UK, http://www.eepd.info comes first out of over 8 million hits) That website seems to be about the only one which recognises that “EVERY EXTRA KEYSTROKE COSTS” – all the other being almost exclusively concerned with analysing the data someone else has collected, and d) having been ever since 1979 been a major fan of using computers to improve the quality of patient care, – for many years using the wonderful Acorn Risc PCs  with the original ARM processors (Google “Virtual Acorn” for an emulator still in daily use on my PC and my Mac)  and now being at total fan of Macs, iPhones, and iTabs, I do not feel that in any way I deserve the title “Neanderthal” just because I want to put the needs of individual patients first.

  • Jon Nixon

    Some upsides of EMR-
    1) Elimating paper charts has freed up space that was converted to an exam room and small lab area
    2)Two full-time staff, who formerly spent thier time lugging armloads of charts back and forth have shifted to patient-care positions
    3) After I type an encounter SOAP note I bill for the visit afterwards. Saves a significant amount of manpower
    4) I can finish up by logging in at home, review labs, refill medications, and send messages on my off- days, instead of coming back to a huge stack of charts. (And I can bill my employer for the time I spend)
    Downsides_
    1) Expensive. And changing EMRs is a huge hassle
    2) Probably not the EMR’s fault, but one is limited to the CPT codes provided by the maker, which are antiquated and sometimes downright stupid. (The whole CPT system is outdated, IMO)
    3) Server goes down, you are screwed. Patients are not sympathetic………….

  • Daniel H Beegan

    I disagree in part with Dr Sharp. My back specialist uses EMR and makes all information available to his patients, who log into a web site, use the user name and passwork they picked, and read what the doctor wrote. He does not hold back. My records list me as a heavy drinker, which is accurate. To me, the way Dr. G uses EMR strengthens doctor-patiet relationships as I can protest an inaccuracy or talk about a proposed treatment plan. I will grant it takes a doctor with a strong ego to do what Dr. G does and a patient who is not overly sensitive to take full advantage of it.

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