Let’s mourn the death an EMR evangelist

It feels like part of me is dying.  I am losing something that has been a part of me for nearly 20 years.

I bought in to the idea of electronic records in the early 90′s and was enthusiastic enough to implement in my practice in 1996.  My initial motivation was selfish: I am not an organized person by nature (distractible, in case you forgot), and computers do much of the heavy lifting in organization.  I saw electronics as an excellent organization system for documents.  Templates could make documentation quicker and I could keep better track of labs and x-rays.  I could give better care, and that was a good enough reason to use it.

But the EMR product we bought, as it came out of the box, was sorely lacking.  Instead of making it easier to document I had to use templates generated by someone else – someone who obviously was not a physician (engineers, I later discovered).  So we made a compromise: since it was easier to format printed data, we took that data and made a printed template.  We would then write in the vitals, dictate our history, circle options on the review of systems and physical exam, and dictate our plan.  That written record would then be put into the EMR as a finished note by the transcriptionist.  It was a strange way to do things, but it was far more efficient.  At the first user group meeting (after 9 months of use), we were using the product better than anyone else.

For us, the bottom line was not computers, it was patient care.  Our record system was a tool to let us eliminate inefficiency and focus more on care quality.  We were spending less time and doing a better job.  Within two years I was elected president of the national user group for our EMR and became an evangelist for the benefits of computerized records.  I was proof that doctors could adopt technology and not just survive, but thrive.  My peers thought I was eccentric (shocking) and I made few converts.

There is one moment during those first years I will never forget: one of the “aha” moments in my life, a time when things snapped into focus.  I was trying to figure out how to milk more efficiency out of our system and was thinking about using the data for more than just documentation.  My zeal for process improvement earned me the right to be one of the first to have access to the content customization tool for the EMR and I quickly produced content that was very popular (our vendor wisely gave the tool only if we were willing to share our creations).  While I was thinking about ways to improve efficiency, I thought about all of the data at my disposal.  I had years of structured data on thousands of patients: vitals, lab results, medications, problem lists, and other pertinent patient information.  Whoa!  What if I could put all that data together and really coordinate care?  What if I could, instead of using the EMR as a fancy word processing program, I used the data I collected to improve care?  It was like moving from two to three dimensions.  Nobody was talking about this at all; the focus was entirely on documentation, not data.  I remember the room I was in when the thought it me.

Armed with my new vision of EMR, I called my vendor (I was, after all, the president of the user group) and made a pitch to the engineers and company executives. I was clearly one of the top users of their product, but I felt like I was only using a fraction of the product’s potential.  Yet I was in private practice and so had no access to the resources to tap that potential.  I proposed that the vendor fund my effort to make the product work on all cylinders, to really show what it could do if its full potential was harnessed. The investment wouldn’t be much, since we were still a small practice.  In exchange for their support, they could use what I made to show the world what really good care looked like.  I expected astonished gasps from the other end of the line, but was met by silence.  Eventually one of the executives told me that the product was already being used to its full potential.  They did, after all, have an E/M coding advisor.

Frustrated at their blindness to my insight, I set out to prove them wrong, spending countless hours wrestling with the system to make it do what I want: improve the care I was giving without taking extra time.  The systems I developed helped us offer better care (double the national average on colonoscopy, pneumococcal vaccine, A1c monitoring), and still be in the top 10% of income for primary care.  This accomplishment earned us the Davies Award from HIMSS, and earned me a permanent spot on the EMR speaking circuit.  Still, I was never really satisfied with the care I gave, and always looked for ways to do it better.

Unfortunately, the increasing popularity of EMR caused increased focus from the government.  PQRI, NCQA, HIPAA, and CCHIT all took focus of our vendor from clinical development, instead focusing on regulatory requirements.  When the HITECH act passed I was still (delusionally) optimistic that the focus would eventually turn to patient care.  But the last update I saw on the product I bought in 1996 showed the truth: the product was certified for “meaningful use,” but it was bad. Really bad.  We even nicknamed it “Vista.”  Previously simple tasks were difficult, and data was harder to use, and was not moving at all toward better patient care.

My inability to accept mediocre care (and my obnoxious obsession with improving it, from my partners’ perspective) eventually drove me from the world of meaningful use and E/M coding to my current home: a practice that accepts only monthly payments between $30 and $60 a month in exchange for an undiluted attention to patient care.  Without the overhead caused by the ridiculous complexity of our payment system, I can finally realize my dream of showing the world what good care actually looks like.

But here’s the hitch: EMR has never left the world of note generation.  Yes, it does submit data so the doctor can get the check for (ironically) achieving “meaningful use,” but that data is still very hard to actually use to improve care.  My attempts at using other EMR products to accomplish my goal have proven to me once and for all that to truly give good care I’d have to abandon EMR as I knew it.  I’ve got to look beyond EMR to something better, more focused on the patient and less on the payment.  But it’s really been a hard search.  I know what I want to do, but the road to that goal is not yet evident.

So what do I think really good electronic records should look like?  I’m up to 1144 words now, so that will have to wait for a future post.  Instead, let me take this moment to throw a flower on the grave of the EMR enthusiast.  It’s been quite a ride.  I don’t join those who look back to the “good old days” of paper records (It’s like longing for the “good old days” before indoor plumbing).  No, I still look to use technology to make my care better; it just won’t include EMR’s in the form they are now.  In truth, it’s never been about computers; it’s about the person sitting across from me: the one who is putting their life in my hands.  Perhaps the death of this evangelist can prevent other deaths, the real ones.

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

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  • adh1729

    Welcome to the truth, Dr Lamberts, and thanks for the openness and honesty. Neither the government nor the corporate world are our friends. Money and power drive the world; love of humanity rarely does.

  • njfamilydoc

    I totally agree with you. I have used more than one EMR/EHR in the past few years but never liked any one of them. The biggest problem is that I come from a generation that grew up thinking/doing/working on paper. It is not natural for me to think on a computer. I need to sit in front of a patient, give them undivided attention, take some notes while I listen and then spend a few minutes explaining to them what is wrong, how I will treat it and how to avoid it in the future. This usually takes about 10-15 minutes but my notes are complete and I am “done” when I am done with the patient. No EMR has allowed me to do that…
    So, why do I need an EMR? Until now, nobody has needed to read my notes except the insurance companies or lawyers. The specialists never request my notes… they call me once in a while to clarify why I sent them the patient… and I really really miss the dictated notes that I used to get from my specialists which would usually describe the whole visit and actually help me include their “consult” in my care. Now I get a whole bunch of electronic garbage which is also full of poor grammar, too many ICD and CPT codes all over… you know what I mean….
    It is just sad that the EMR are being forced upon us at the cost of patient care… as if getting paid for patient care was not complicated enough…

  • buzzkillerjsmith

    Yes, you were delusional. But here’s the thing: You’re still delusional. You’re still focused on giving “really good care” by farting around with computers. Let’s look at this a bit, shall we?

    If you and others like you are successful, will we doctors will earn more for less work while providing better care? Hell no! The bar will be set higher and, inexorably, we will have to do more as the payments go to ground, as they always do. Of course the problem is that we have a doctor shortage, especially in primary care, and more computer work will only drive out more med students. You need to look at the second-order effects, doc.

    Your huge mistake, which those of us who are not blinded by irrational technophilia see immediately, is that you misdiagnose the main problem. You think it’s poor technical tools, but it’s really a lack of warm medical bodies.

    And wait just another cotton pickin’ minute. You have found that CorpMed has taken a good idea and turned it into a bad idea so as to earn more profits. Will this never happen again? I submit that it will happen every damn time. You make the same assumption of our idiotic government overlords. The same guys who gave us a couple nasty wars recently. The same guys who are focused on their own career advancement, not on making life better for doctors and patients. Come on, Dr. L., you’re a smart guy. Get another epiphany here!

    Of course things might work out well for you in your practice. Great if they do, and I wish you the best of luck. But keep it on the qt–unless of coursr you’re jonesing to be one of the overlords. Give up the delusion that any success you have will be generalizable. Give up delusion number 2.

    • http://doctor-rob.org/ Dr. Rob

      So, why didn’t you just write out your comment and mail it to me?

      • Caitlin Peebles

        BOOM!

      • buzzkillerjsmith

        So you realize that your argument makes no sense and have resorted to snark. Wise of you to give up.

        • http://doctor-rob.org/ Dr. Rob

          It does make sense. The number #1 reason to use tech is for better communication. If I give up computers in my practice, I give up the tools they provide to communicate (which we are doing right now). I want to give my patients online access to their records, which cannot be done with a paper record (unless it’s scanned in, uploaded, and indexed; all of which makes paper charts kind of pointless).

          The second benefit from tech is organization of information (as Wikipedia and Google) can attest. It is far better to use computers to organize data and tasks than to do it on paper. I want to know who has had what test done and when. I want to know who is due for what. I want to access the latest recommendations for care and make that part of the care plans for patients. Again, try doing this without a good IT system.

          Now, I will agree with the fact that the EMR systems out there do very little of these tasks, but this is an indictment of the state of EMR’s, not of computers in general. In fact, it is the whole point of this post.

          Finally, as for being accused of snark, let’s look at what you said:

          ‘You’re still delusional. You’re still focused on giving “really good care” by farting around with computers. Let’s look at this a bit, shall we?’

          Taking a patronizing tone is not a good way to engage a discussion. I am not content with hitting the “eject” button, leaving the system to play in my own little world; I am trying to build something that is scalable and into which other doctors can move without totally bringing down the system. I intend to grow this model back to where I once was, but doing so without the government or insurance “overlords” standing between me and my patients.

          Fortunately, I don’t give up even when the EMR systems out there are crap. I am not content to take my toys and go home. My patients deserve better than that, as do the other primary care docs facing the intolerable system that I left. I’ve gotten an incredible number of emails from docs encouraging me to push on and build something viable so that they can follow me into care that is far better for both doctor and patient.

          • buzzkillerjsmith

            Shorter Dr.Rob: Most EHRs are crap but mine is OK.

            Agreed.

            But most EHRs are yours, never have been, never will be. This is your delusion.

            But ” I am trying to build…” Big sigh. This would be a good idea if and only if doctors got the economic benefit of the innovation.(together with the patients’ clinical benefit, of course). Even a casual glance at the real world shows any old fool that ain’t how it works. Come on, you know this, and that’s why you’re going solo. In the real world, most docs won’t go solo. They’ll end of working for CorpMed, which will try to squeeze every last bit of juice out. And don’t give me any crap about empowering physicians, blah, blah, blah. Won’t buy that crazy.

            You, sir, if you are successful, will contribute to the ever worsening electronic enserfment of your fellow docs. Absolutely textbook techie blindness to the big picture. Fortunately you will almost certainly fail.

          • buzzkillerjsmith

            are not yours , end up

  • Radiance

    If you want to go back to a place of having quality time with your patients, hire back your transcriptionists. We consistently provide accurate medical records and monitor you for accuracy. Seriously, they don’t call us medical language specialists for nothing.

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