A doctor creates his own EMR out of pure survival

The question has been raised: Why re-invent the EMR wheel?  What is so different about what I am doing that makes it necessary to go through such a painful venture?  I ask myself this same question, actually.

Here’s my answer to that question.

What medical records offer:
High focus on capturing billing codes so physicians can be paid maximum for the minimum amount of work.

What I need:
No focus on billing codes, instead a focus on work-flow.

What medical records offer:
Complex documentation to satisfy the E/M coding rules put forth by CMS.This assures physicians are not at risk of fraud allegation should there be an audit.  It results in massive over-documentation and obfuscation of pertinent information.


What I need:
Documentation should only be for the sake of patient care. I need to know what went on and what the patient’s story is at any given time.

What medical records offer:
Focus on acute care and reminders centered around the patient in the office (which is the place where the majority of the care happens, since that is the only place it is reimbursed)

What I need:
Focus on chronic care, communication tools, and patient reminders for all patients, regardless of whether they are in the office or not. My goal is to keep them out of the office because they are healthy.

What medical records offer:
Patient access to information is fully at the physician’s discretion through the use of a “portal,” where patients are given access to limited to what the doctor actively sends them.

What I need:
A collaborative record, sharing most/all information with patients so they can use it in other settings for their care. Also, I want patients to have edit privileges for things they better suited to maintain, like medication lists, demographics, insurance information, and past history items.

What medical records offer:
Organization of information is not a high priority, as physicians are not reimbursed for organized records. The main focus is instead on meeting the “meaningful use” criteria, which gives financial incentive to physicians who use a qualified record system.

What I need:
Since the goal is to share the record and to maximize care quality to make communication more efficient, organization of the record is crucial. The goal is to put the most important information up front and to give easy access to the details sought.  I am the “curator” of the record, organizing it and prioritizing information in a way that is useful to both me and my patients.

What medical records offer:
Top priority is paid to billing workflow, with second billing given to in-office patient management.  The least attention is given to clinical workflows for patients outside of the office.

What I need:
My priorities are 180 degrees from this. My top priority is keeping people outside of the office healthy and happy. which will keep them paying their monthly payments), so maximizing organization and communication need to be the focus of my records.  Certainly in-office care needs to be efficient, but not in the same way as the rest of the healthcare system (efficient documentation for payment); it must focus on getting the most accurate information into the system and making it easiest to get information out.  Billing is almost a non-issue, as it is very simple in my system.

What medical records offer:
Task management is again a low priority, as it increases potential non-reimbursed work for physicians (and staff) in the typical office.  For example, there is not much emphasis put on phone office follow-up or making sure the plan is communicated to the patient.  This is not strictly avoided, as most medical professionals do want to give good care, but the high-stress overworked atmosphere in most offices makes most medical personnel reject any tool that gives “extra work.”

What I need:
Task management is near to the top. I am focused on coming up with a care plan for each patient and making sure the patient understands that plan.  The goal is to reduce the chance of misunderstanding, as it increases my work and decreases the patient’s chance for health.  So an integrated task-management tool is very important, as is education resources which can be accessed directly from the patient record and given to the patient to keep (ideally) in an online “folder.”

What medical records offer:
Mobile communication is becoming more available, but it is very much system centric., meaning that it is built by the EMR vendor to only be used by patients of physicians who use that EMR and to only be for viewing information from the physician, not as a patient-centered tool.

What I need:

My goal is to give patient access to accurate medical information and access to me in a way that is easy and efficient. Mobile technology is the most obvious means to this end.  I want patients to be able to access their entire record, not just what I generate, from a mobile application (or at least a web application).  I want any place they get information to also be the communications hub, as it allows them to communicate with as much information as possible.  In short, I am looking to have a “one stop shop” for all patients’ needs, not a “walled-garden” that only gives them access as long as they see a doctor that uses the system.

What medical records offer:
Mobile communication is becoming more available, but it is very much system-centric, meaning that it is built by the EMR vendor to only be used by patients of physicians who use that EMR and to only be for viewing information from the physician, not as a patient-centered tool.

What I need:
My goal is to give patient access to accurate medical information and access to me in a way that is easy and efficient. Mobile technology is the most obvious means to this end.  I want patients to be able to access their entire record, not just what I generate, from a mobile application (or at least a web application).  I want any place they get information to also be the communications hub, as it allows them to communicate with as much information as possible.  In short, I am looking to have a “one stop shop” for all patients’ needs, not a “walled-garden” that only gives them access as long as they see a doctor that uses the system.

What medical records offer:
Payment for health services generally depends on two things: a problem being treated and a procedure code and are therefore the focus of the record system.  Problem lists are in the record, not primarily because they help with care, but to allow billing for services.

What I need:
I believe we should focus far more on reducing risk factors than on treating “problems.” My goal is to avoid problems and do fewer procedures when and where at all possible.  Problem lists should not be focused on code, but instead to give the most accurate information to lead to the best decisions, and to help understand the risks the patient faces so problems can be avoided.  If this happens, I will have less procedures, a fact that will make both me and my patients happy.

Optimistically, the ultimate goal of the typical EMR is to allow a physician to practice the best medicine possible while not going out of business. It allows physicians to give good care despite the system that rewards them for bad care.

The goal of my record system is to promote the success of a new business model: pay doctors more to keep people well and to keep people out of the rest of the health care system. The ultimate goal of this record system is not to make money for me as software I can sell, but to make it so I can extend the model efficiently to a larger population, ultimately making this new system of care an attractive enough alternative to physicians, employers, and patients to make the switch.  Perhaps in doing so the “do more, spend more” system can be replaced by a welcome alternative.

So here is the goal:

  • Create a prototype of a system that allows me to give my system of care efficiently to a large population.
  • Use that prototype to “prove concept” – that the care I give is better for patients, better for me, and saves money.
  • Create enough interest in the model that people are willing to develop the system. I think this is best done through making it open source and setting up a foundation to fund the program (and let me gladly hand it off to people who are better at this than I am).
  • This will ultimately lead to more adoption of the practice model (by making it easier to make the transition), which will in turn lead to more interest and funding in the software.

I don’t believe we can retro-fit a standard EMR product to do this job; I think their focus is too different from the goals of this practice model. I may be wrong, but I looked at numerous systems and found that they fought against my goals instead of enabling them. I turned to this idea not out of ambition, but out of a desire to survive and see my practice model succeed.

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

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  • Ron Smith

    Hi, Rob.

    I think I did just that for myself in 2000 with PaperCutPro, my EMR. Maybe worth a look to see what you want to do for yours. We are all about high inefficiency and patient flow. We like our patients, but we want them to stay out of the office.

    My EMR is developed for primary care (I’m a Pediatrician). I have about 6000+ hours development time in it also.

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • ninguem

      Where do I find out about your PaperCut EHR?

      • Ron Smith

        Tried to post the link, but KevinMD won’t post my comment. Strange that a site that is so gung-ho on posting that won’t let you post URLs. Seems hypocritical, but it is their site so they are just hawking their stuff and that must be what they are interested in.

        Look at www (adot) papercutpro (adot) com under the features menu highlight for ideas about what can be done.

        Ron Smith, MD

        • ninguem

          What’s up with that, Kevin?

          I post links all the time. There is a delay to review the link.

          Does this have something to do with this being a commercial interest?

  • Michael Chen, MD

    Rob,

    All of the points you mentioned are valid and prescient, especially in these times when we need an infusion of new ideas in our healthcare system to improve care and lower costs. I stand with your with philosophy and as a fellow physician who has been in your shoes as a solo independent primary care physician, I’d like to offer an opportunity to see my project that happens to also be a tool. Firstly, as opposed to other EHRs, mine is open source (as you indicated a preference of how such a prototype would be conceived). I’ll go over a brief checklist to show you that such a prototype already exists and let’s combine our cognitive efforts to make this even better. I’ll be referencing some these comments to my blog (google NOSH ChartingSystem) and you’ll see what I’m talking about.

    “No focus on billing codes, instead a focus on work-flow.” – NOSH is designed to be workflow aware from a physician’s point of view. Billing is secondary and billing companies don’t like my system for just that reason (I’ve had to work with some of them and they are certainly confused because it’s not like any other EHR they have seen).

    “Documentation should only be for the sake of patient care. I need to know what went on and what the patient’s story is at any given time.” – I agree. NOSH isn’t designed to make sure you bill correctly and have all the documentation needed to meet the level of service, etc. It was designed to allow a physician to view pertinent clinical data in as little steps as possible to get it.

    “Focus on chronic care, communication tools, and patient reminders for all patients, regardless of whether they are in the office or not.” – NOSH has a built-in reminders system (for any orders you make for instance, automatically without additional input, so that you don’t lose track of orders that were made and needing results). NOSH is completely web-based so that you can access it from anywhere, securely, as long as you have a web browser.

    “A collaborative record, sharing most/all information with patients so they can use it in other settings for their care. Also, I want patients to have edit privileges for things they better suited to maintain, like medication lists, demographics, insurance information, and past history items.” – NOSH has a built in patient portal that does most of what you just mentioned. Patients can message to your provider securely within its own network with this portal feature, schedule appointments, review results, and pretty soon, patient forms that get incorporated into your chart/encounter without having the extra step of re-entering data from paper to digital.

    “Since the goal is to share the record and to maximize care quality to make communication more efficient, organization of the record is crucial” – Check out my live demo (the real thing, not a screenshot or a need to contact me to schedule a meeting). You’ll see that organization of the record is geared to a clinical first and foremost in a simple, uncluttered interface.

    “Task management is near to the top.” – The first screen you see when you log into NOSH is a task list.

    “My goal is to give patient access to accurate medical information and access to me in a way that is easy and efficient. Mobile technology is the most obvious means to this end.” – NOSH is totally usable for mobile devices (iPads, tablets, and phones) out of the box because it is web-based.

    “I believe we should focus far more on reducing risk factors than on treating “problems.”” – I totally agree. One of the new features being developed currently is the ability to do tagging of any element of the chart and encounter. Tagging allows physicians (like the way tags work on blog systems) to categorize any aspect of the chart so that it can be analyzed later for any reason. It the tag is not restricted to diagnoses codes or problems (it can if you want). That is the total power of personalization that NOSH can accomplish.

    “I think this is best done through making it open source and setting up a foundation to fund the program (and let me gladly hand it off to people who are better at this than I am).” – I agree. The cool thing about open source is the ability to collaborate openly. And there is no right way to do it and open source gives anyone the ability to agree to disagree about how a product should work. I give full license to anyone who wants to fork my project for other purposes because I know that every health care provider is different. As an open source project leader, software coder, developer, and a practicing physician, I totally get what you are looking for. I’m already working with some other health care providers that get this too (locally in Portland and all across the world and through this project, we are building a community. Come join us. Google “nosh chartingsystem indiegogo” to know more about my project and my current Indiegogo crowdfunding campaign to spread the word about my quest to change the health care IT landscape for the benefit of independent and outpatient health care providers of any specialty.

    • ninguem

      Where do I find out about your NOSH EHR?

      • Michael Chen, MD

        Google NOSH ChartingSystem and the first link is my project page that tells you all about the origins of my project, and updates. I’m the project developer and lead so if you want to discuss more info about my project or how it can help your practice, contact me at shihjay2 at gmail dot com.

        • ninguem

          Kevin, what’s up with that?

          I post links all the time. There is a delay to review the link.

          Does this have something to do with this being a commercial interest?

          • Michael Chen, MD

            I suspect that to be the case. I’d be curious though what KevinMD considers “commercial”. I only gain monetary reimbursement for services rendered to my clients (who happen to be other physicians, just like a physician offering services to their patients). I don’t charge anything for my “product” which happens to be the open source EHR since it is technically free for anyone to use, peer, poke, and modify and even improve if anyone wants to try it. I’ve been posting articles on my blog regularly but they have been rejected often by KevinMD, probably because of this association. However, I would urge anyone to look at it as I believe my articles pertain to issues regarding independent physicians and the impact of health IT on our practices. Like I’ve said before, my whole aim of my project is to build a community of physician users, not for profit or market gain, but to help everyone who is struggling, like me.

          • Hannah

            It probably depends on who’s doing “moderator” duty. Someone has to go in and fish comments out of the moderation queue and either approve them for publishing or consign them to the bin, and that’s a task that often gets put at the bottom of bloggers’ “to do” lists.

      • Michael Chen, MD

        Seems like the comments system is rejecting my content with any links. So follow the Google instructions to get to my project page and blog.

    • NewMexicoRam

      I looked at this NOSH.
      Sorry, I don’t see it to be any easier than Allscripts.

      • Michael Chen, MD

        What would make it easier for you? That is the great thing about open source. Suggestions and quick implementation of changes are the rule, not the exception. Let me know!

  • http://www.mightycasey.com/ MightyCasey

    Doc, if you build this, I predict there will be beaucoup other small practices out there anxious to use what you’ve built. Figure out a price point, and sustainable updating, in your development plan, against the demand that just might arise.

  • Andrew Schechtman, M.D.

    No doubt that a lot of the legacy EMR’s miserably fail to prioritize patient care and physician workflow, sacrificing these for bullet points and administrativa. I’ve used 4 EMR’s over the past 8 years across two practices and have found that my favorite of these (ElationEMR) has addressed most of the concerns in your post. I have no financial interest in Elation but am a satisfied user. I also have an interest in helping docs find tools that will make their lives better.

    I won’t go through your post point-by-point but will just say that it’s an inexpensive, intuitive, fast system that lets the doctor do what needs to be done at any time instead of forcing the workflow and it also has a text message/email-enabled patient portal for great collaboration.

    In the past, out of frustration, I too have considered creating an EMR to correct all of the deficiencies I’ve encountered. I’m so thrilled to have found a solution that has taken away all of my interest in doing so.