10 ways to make an EMR truly meaningful for doctors

I am an EMR geek who isn’t so thrilled with the direction of EMR.  So what, I have been asked, would make EMR something that is really meaningful?  What would be the things that would truly help, and not just make more hoops for me to jump through?  A lot of this is not in the hands of the gods of meaningful use, but in the realm of the demons of reimbursement, but I will give it a try anyhow.

Here’s my list:

1. Require all visits to have a simple summary.  One of the biggest problems I have with EMR is the “data diarrhea” it creates, throwing piles of words into notes that is not useful for anything but assuring compliance with billing codes.  I waste a huge amount of time trying to figure out what specialists, colleagues, and even my own assessment and plan was for any given visit.  Each note should have an easily accessible visit summary (but not at the bottom of 5 pages of droll historical data I already know because I sent them the patient in the first place!).

2. Allow coding gibberish to be hidden. Related to #1 would be the ability to hide as much “fluff” in notes as possible.  I only care about the review of systems and a repetition of past histories 1 out of 100 times.  Most of the time I am only interested in the history of the present illness, pertinent physical findings, and the plan generated from any given encounter.  The rest of the note (which is about 75% of the words used) should be hidden, accessed only if needed.  It is only input into the note for billing purposes.

3. Require all ancillary reports to be available to the patient. Patients are already the information interface between providers, so why not use them as our interface?  Why not have them able to give the ER doc permission to see recent labs, or give the specialists access to their x-ray reports?  Why do I have to get permission from them to get the information sent to me from the lab or the radiologist?  The patient is there in the room, so why can’t they just say, “Here are my results.  You can look at them.”  While they are showing me them I can explain how I interpret them.

4. Require integration with a comprehensive and unified patient calendar. We have the technology to give each patient a comprehensive care calendar to look toward the future and into the past as to what tests are due and what was done.  When I order a test and get the results back (thyroid tests for example) I should be able to queue up the next test on a calendar that the patient can see and use.  This is the “GPS” idea I’ve had in the past, and  would be simple to even share between providers.

5. Put most of the chart in the hands of the patient. Patient information, such as family history, medication list, social history (where they work, are they married, etc), and even a list of past surgeries should be managed by the person who knows it best: the patient.  Keeping track of this is next to impossible in a busy practice (especially for pediatrics), and is re-transcribed for every visit the patient makes to a new provider.  This is burdensome on everyone and leads to significant inaccuracies that would be easily fixed if a unified patient record centered on one managed by the one with the most to gain from its accuracy.

6. Pay for e-visits and make them simple for all involved. One of the worst parts of my practice is that I must force patients to come to see me so I can be paid for the care I give.  This is especially unfortunate because the Internet allows easy communication, making many (if not most) of these visits unnecessary.   It is a waste of my time, it wastes lots of patient time, and it greatly increases absenteeism from work.  Yet I need to be paid for my services, as I am taking significant risk and using my training for their benefit.  The technology would make this easy, but the reimbursement model stands in the way.  CMS would have to do the changes to make this happen, but doing so would give a huge yield to doctors, patients, and employers.

7. Allow e-prescription of all controlled drugs. This falls under the “duh” category.  Why is it safer to hand a physical copy of a controlled drug prescription to a patient than to send it electronically?  Is it safer to hand a person a check and have them bring it to the bank, or to send it electronically for deposit?  Come on, folks, this is just so obvious.

8. Require patients’ records to be easily searchable. I spend huge amounts of time searching for answers to questions like: “were they ever on drug x,” or “when was their last y procedure?”  I would love to be able to do a ctrl-f (or cmd-f) search on patients charts to get that information.  It should be standard in all EMR’s to allow this, as we all spend way too much time searching, and probably order unnecessary tests because it’s just too dang hard to search.

9. Standardize database nomenclature and decentralize it. Let’s stop the proprietary nonsense.  EMR products should be able to interact well with each other, retrieving information about the patient at various settings.  I personally don’t think the centralized database is the best approach, as it is far more risky to have all data in one location.  Just have each EMR able to go (with patient permission) and get information wherever it is.  I shouldn’t have to store the CBC results in my record; I should just have easy access to the lab’s records.  This has actually been done to a smaller extent with e-prescribing, which can give a unified view into the patient’s prescription history (which is often useful, although it is still quite slow).  Having data in proprietary silos is a foolish and inefficient storage method.

10. Outlaw faxing. I hate faxes, and with the Internet enabled communication (like you reading this), faxes should not be needed.  They are difficult to transcribe to digital format, usually ending up as PDF files instead of searchable data.   Most faxed medical information (ironically) starts in digital format (word documents, etc), and then is converted to paper or PDF, only to be re-imported as non-searchable image files.  This is stupid, but it is so easy that the only way to prevent it is to not allow it.

So there’s my dream “meaningful use” list.  I would be interested to hear what other ideas you all have.

Rob Lamberts is an internal medicine-pediatrics physician who blogs at More Musings (of a Distractible Kind).

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  • http://twitter.com/DrBonesMD Stephen Rockower

    I couldn’t have said it better! EMR’s are designed by non-physicians (geeks) to please non-physicians (government and insurance hacks). Nothing is designed to be easy for the DOCTOR to use!

  • http://drrjv.wordpress.com/ drrjv

    Very nice article!

    1. Dump .Net 2. Get a User Interface expert (or bring Steve Jobs back from the dead!)
    PS: Can not agree more re: faxing – literally 1846 technology!

  • http://www.thehappymd.com/ Dike Drummond MD

    The most stressful thing about EMR for my clients is that there is never Just One.

    They are all implementing one platform in their practice while the hospital is upgrading to a completely different system and the surgicenter or student health center has a third. And – Of Course – none of them talk with each other … so faxes still exist and paper gets carried from site to site. ARRGGGHHH

    Dike Drummond MD

  • http://www.facebook.com/anna.liwanag.71 Anna Liwanag

    I was a physician EPIC tutor and all of the issues were the same ones I heard during implementation! MUST.DO.SOMETHING.NOW!

  • Jack Cain

    Dr. Lamberts, would you be interested in the job of EMR Surgeon General?

    As an IT geek, I cringe at the effort my primary care providers have to go through to do simple things. Why don’t programmers understand that they are creating a system that will be used by humans to treat humans in life & death matters? Why is the prescription medication list in (name omitted) single spaced and impossible to read? A single slip of a mouse and the patient gets the wrong variation of the medication – then often doesn’t even know it because they assume the doctor knew what they were doing.

    I could go on and on – but when the insurance bill is paid faster than I can get the prescription, something is wrong. When a prescription error can be filled and taken out of my bank account 10 days before the medication arrives and I find the error, something is wrong. When I mail a
    class II prescription to the mandated mail order firm and they mail it back to me instead of clarifying things with my doctor over the phone, something is wrong. When I was just asked to sign a permission contract to share EMRs with other entities and it says that the data may go to companies not bound by HIPPA, something is wrong.

    The goal is to assist in creating improvements in the treatment of living humans, not to make it easier to violate privacy laws, allow mistakes without even basic data validation and make it harder for the physician to do their job.

    • http://doctor-rob.org/ Dr. Rob

      My mom would be so proud of me. I can say that the folks over at ONC have communicated with me and are interested in what I’ve said. There are people there (and I believe the coordinator himself (who I’ve met) understands the poison that goes along with the good of standardization. The real problem, in my opinion, stems not from the folks making the EHR rules, but the malignant payment system that puts documentation front and center and care in the background.

      I appreciate all of the excellent comments!

      • southerndoc1

        “The real problem, in my opinion, stems not from the folks making the EHR rules, but the malignant payment system”
        But your gripe is with the meaningless MU criteria that are not a direct result of the “malignant payment system,” but a whole new level of bureaucratic busy work.
        I don’t understand why you keep giving pats on the back to the ONC folks: I think their actions speak much louder than their words!

  • CorpAvenger

    BTW, There USED to be and still sort of is a Great EMR designed by a well intended and fairly well executed Doctor, Dr. Jon Bertman at Amazing Charts. AC as we call is a Wonderful and fairly Easy to use product and was truly AMAZING before Jon had NO CHOICE but to bow down the Steamroller aimed directly at his #1 selling to small and solo practices products by the Corporate Welfare types that lobbied to Save their taxing, ill designed bloated with extra crap that is NOT needed and makes the final product a Monster to deal and live with.
    This is the only reason I even take half a notch away from Jon and AC as it too had to Bloat Up to meet new regulations (as no doctors chasing the Bribes and fearing the Wipe and Rod that is coming) to compete and stay “Viable” in the now Forced and Mandated landscape. AC and Dr Jon were Kicking their Butts all over the place with great tidy product that even the slowest of Medical Assistance could learn in just a day or so… And that most doctors and managers without a degree in Computer Science could take care of themselves. To this day we Still don’t have a “Real” server, server running expense CAL’s and Server OS on it. The newest SQL version of AC still works really well on our Very Stout Dual Xeon Chips, XP Pro Dell Percision workstation we bought back in 2008. And it runs and works on a modest but well buttoned up sercurity wise Windows XP home P2P network too….
    And how did Dr Jon achieve this wonder of EMR design? Simply by doing two very similar things. 1) He was and still is a practicing Family Doc in R.I. and so he too was upset, pissed off by the attitude of the vendors, the price of their product, the way the ripped doctors off and designed systems that DID’T work for Doctors because they were designed by programmers of those that were chasing attempting to create the “Meaningless Use” of the Future, CCHIT certificed products, attempting to guess as to what might be required or demanded of all one day…
    2) He very early on implimented on his own Dime a User Board where we users swap ideas, suggest improvements and desires for features, discuss what works or does not work, help one another with tech issues, networking, features, upkeep, hardware, software and all the rest. He actually KNOWS many of his doctors and Practice Managers, or tech support people on a first name, actual relationship basis. And many users are Glad, Proud to be Beta Testers giving their input, suggestions and feedback…. Basically he and AC are the Primary Care Version of a Vendor of an EMR. Jon listens to and asks the right questions of his client users. And he KNOWS in his gut that his present owner, users are his BEST advertising. Like a good primary care doctor “The Word” gets around fast enough…. And he makes his client users feel heard and concerned, wanted and appreciated….
    Just to give you the idea of the almost “Love Fest” going on at AC between vendor and users. A couple of years ago a couple of docs from the midwest started the idea of creating a “Home Grown” user created “First Amazing Charts User Conference” or the ACUC as it is now well known to be… This was not Jon or the Company’s doing this was started and implimented by AC’s, Jon’s Client Users all on their very own!!! I dare ANY Other EMR vendor out there to Actually be able to claim this, self actuated kind of expression of Oneness and Dedication to the vision and plateform that is not first started ala “Astro Turf” as opposed to actually being Grassroots in origins. Eventually Jon and some of his staff were “Invited” and Thrilled to be a part of this grassroots outpouring of a desire to continue to grow and make stronger the community the User Board had given a home to, to start a “Family” practically. So after the First ACUC today we are on our fourth conference I believe and Jon has taken the reins to help make sure they go off well. And so today we have an annual conference, with CME credits and every like too, that got it start because that is how much AC Users like, many love, speak of it in personal terms even…. Those doctor professors started and went so darn well.
    It is time to have Folks like the good Doctor Lamberts here who I agree with him on almost all he said here with one or two tweaks or exceptions and Dr. Jon Bertman of Amazing Charts at the helm and the forefront of designing product and systems, lead by actually Listening to fellow small practice doctors who have to actually live or die based upon the product they have at the heart and center of their practices.
    And this is the concept that to this day most of the Gov’t types ignore or don’t get… These products and systems are, become the Center and Nuclius, of the practices they are installed in. If they EMR doesn’t work the entire practice can come to a Crawling, Screeching Halt. The costs related to most of these Server Based, too complicated and bloated to take care of yourself systems, just to keep them up and running no less smoothly is far more than any gov’t or insurance carrier is ever going to be willing to actually foot the bill for…. Our fees will NEVER go up nearly enough to pay for all the internet security package licenses, experts coming and going, required hardware upgrades and software upgrades to keep up with Next Gens and Green Garbage programs out there, that were basically Bailed Out, thrown a life vest to be able to beat down the little engine that could, that did it the Old Fashioned American Way, with market awareness and customer relations and most importantly….
    “They Earned It”….
    Night Everyone,

  • southerndoc1

    As others have pointed out, CMS admits in the Meaningful Use 2 guidelines that there is no evidence of any benefits resulting from MU, but “nevertheless, we BELIEVE . . . ”
    Gotta love that scientific attitude.

  • Greg Weidner

    Thanks for the post. Here’s one additional thought: imagine if physicians were no longer paid by how many “elements” they included in their encounter note? Current E and M guidelines drive EMR system design and provider use and misuse. What if instead physicians were compensated based on how well the evaluation and plan of care were communicated to patients and other providers? The concept of a personalized data set and care plan for each patient that is shared and maintained collaboratively should be what the future of HIT looks like. There’s no reason we can’t build the tools to achieve that aim, but it will take a re-alignment of incentives for EMR vendors and providers.

    • southerndoc1

      Current EMRs are “lousy” because they’re very well designed to work in a lousy system.

  • southerndoc1

    Check out “Health Care Renewal” blog for evidence of EMR vendors lobbying those nice people at ONC to specifically EXCLUDE a search function from MU criteria.

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