Why physicians will never learn to like EMRs

EMRs are not designed for patient care. Is there anyone working in health IT who can honestly say that he or she never heard this statement being made hundreds or thousands of times? Is there any clinician actually working with patients and EMRs who can state that such thought never crossed his or her mind? This includes health IT evangelists and physicians spearheading IT initiatives at the most excellent of centers of excellence. People complained that EMRs are not designed for patient care seven years ago, when the first EMR certification body was created. They said the same thing four years ago when billions of dollars were made available for the purchase of EMRs. They kept insisting even as use of EMRs was becoming widespread two years ago, and the chorus remains unchanged today: EMRs are not designed for patient care.

Seven years is an eternity in the world of computer technology. Seven years ago Motorola and Blackberry ruled the world and the iPhone was getting ready to be born. Seven years ago something called Twttr was released and Facebook launched a high school version of itself. Seven years ago Ken Jennings was undisputed king of Jeopardy and IBM’s Watson was wrong 85% of the time. We’ve come a long way, baby, but EMRs are still not designed for patient care. Why is that?

The most common explanation is that EMRs were designed for billing and cannot be changed. But if a program designed to play Jeopardy can be expanded to practice medicine, surely seven years is more than enough to refocus EMRs on something other than billing. The second most common reason given for the inadequacy of EMRs is the inadequacy of those who build them; because we all know that all great programmers work at Apple, unless of course, they work at Twitter or IBM or somewhere in Verona, Wisconsin. More seriously, the third explanation for EMRs failure to help with patient care is the onslaught of government regulations for EMR design.

Many, including yours truly, are arguing that EMR vendors are so busy meeting regulatory mandates that there are no resources available to make customers happy. On second thought though, are we saying that giants like GE that owns half the planet, or McKesson with its astronomic CEO compensation, or that one place in Verona, are unable to spring a few bucks for half a dozen developers to make EMRs better for patient care? Are we saying that a market chock full of very wealthy customers railing for a solution cannot attract even one manufacturer willing to solve the problem and collect billions of dollars in return?

Surely we are not saying that seven years is not enough time for writing an EMR that is designed for patient care. On September 12, 1962, President John F. Kennedy, in a speech at Rice University, officially launched the race to the moon. On July 20, 1969, Neil Armstrong and Buzz Aldrin walked on the moon. It took seven years.

EMRs are not designed for patient care because our medical system is no longer designed for patient care. Our medical system is being redesigned to provide health services to consumers, and EMRs are morphing into superb tools for a service industry.

  • EMRs are designed to collect increasingly detailed customer information.
  • EMRs are designed to facilitate market research.
  • EMRs are designed to standardize and automate transactional complexity.
  • EMRs are designed to smooth handoffs across the supply chain.
  • EMRs are designed to orchestrate and monitor production lines.
  • EMRs are designed to minimize production costs and maximize revenues.
  • EMRs are designed to provide quality assurance based on exact specifications.
  • EMRs are designed to prevent and quickly detect malfunction and non-compliance with specifications.

To be clear, most EMRs can’t do all these things just yet, but they are being redesigned along these lines, because these new EMRs are foundational to what David Cutler, a Harvard applied economics professor and one of the most influential health care policy makers, calls the “information technology revolution.”

In a surprisingly candid article Professor Cutler is describing the future health care system as designed by him and his distinguished colleagues, and as currently implemented by our government. The title of his article is self-explanatory: “Why Medicine Will Be More Like Walmart.” It is very possible that as EMRs are being carefully repurposed, they will also be made more intuitive, more iPhone like, glossier, faster, more colorful, and generally more appealing, because it is imperative right now that physicians use them consistently, and preferably without much turmoil. Why?

Let’s hear from Professor Cutler:

The introduction of information technology into the core operations of hospitals and doctors’ offices is likely to make health care much more like the retail sector or financial services. Health care will be provided by big institutions, in a more standardized fashion, with less overall cost, but less of a personal touch.

And, if I may respectfully add, increased convenience and instant consumer gratification to be balanced by lower quality, lower wages, rampant fraud and mass exploitation of both workers and customers. A veritable paradise for well-adjusted proletariat.

Yes, physicians will be using EMRs in larger and larger numbers, but there is zero probability that today’s doctors will ever like using EMRs, because nobody goes to medical school (or any school) hoping one day to land a job at a Walmart lookalike. So the logical remedy for doctors’ dislike of emerging Walmart EMRs is very simple: get rid of doctors.

Right now we are told that there is a looming shortage of physicians, so we must find ways to deliver medical services without doctors, and hence we must automate, computerize and delegate medical care. Very clever idea, because once we downgrade services and have people accept this new paradigm, we can make the circular argument that we need even fewer doctors.

Indeed Professor Cutler goes on to prophesize the demise of small independent practice and small hospitals along with most conventional doctoring, which will be replaced by computer-aided self-diagnosis and crowd sourced clinical advice (something to do with Amazon, I think …). He still sees a need for a few doctors here and there, mainly “to direct patients to the right specialized resources, to reassure those in need, and to comfort the terminally ill,” which we are told “is a noble calling nonetheless.”

Noble calling indeed, but it should not require an MD or fifteen years of preparation, and hence it will not command much attention or compensation. The Walmart “doctors” in David Cutler’s future of health care will be happy to like their EMRs, or whatever else they are told to like.

Oh, by the way, no need for panic. I am fairly certain that they will have separate little venues serving Dom Perignon and Beluga caviar with Harvard Medical School educated physicians on the side.

Margalit Gur-Arie is founder, BizMed. She blogs at On Healthcare Technology.

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  • Thomas D Guastavino

    Well said. It should be obvious to anyone by now that that the purpose of EMR was not to improve patient care, but to create a tapable database for the government and pushed through prematurely so it would be in place by the time of full implementation of the ACA. That is why physicians were first bribed, eventually will be punished, if these systems were not in place in time.
    An IT friend of mine once said “Computers are like spouses. When they work with you it can make your life wonderfull, but when they work against you can make your life a living hell”

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

      Thank you. I think your IT friend was a very wise man. We could have done it differently. We probably still can, but there seems to be no money, or interest, behind that.

  • edwinleap

    A recent study in the American Journal of Emergency Medicine said that the average community ED doc, on a 10 hour shift, performs 4000 mouse clicks. I have no doubt. We spend far more time worried about data entry than diagnostics. A tragedy, endlessly advanced by government and administrators, who find it easy to understand and control, compared with the nuance and complexity of actually providing medical care. Thanks for the article! Well done.

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

      Thanks, Dr. Leap. The enormity of that number is staggering, that’s six or seven clicks per minute on average, and accounting for time to decide on what to click on, it seems that a huge amount of time is spent “computing”….

  • Deceased MD

    Great article Margalit. So glad you in particular wrote this. Of course MD’s are reacting negatively to EHR’s but I think too much of the focus is on its use for billing or simply complaints about its design by MD’s. But I think it obscures the actual reason it is here which I am delighted someone is finally discussing. Data Mining.

    I just had a most unpleasant pt appt myself in one of these systems. As I was getting my labs, I was asked whether i was in private practice or worked in an institution. This seemed very important to this institution to distinguish for their data analysis on their EHR. It’s ironic they ask the question as the hospital is killing us off anyway. I suppose as you say they are probably measuring how quickly we are dying off.

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

      Thanks Dr. Deceased :-) I think they take your demise for granted at this point, and what they are measuring is how much more money can be extracted from unsuspecting “consumers”:….

      • Deceased MD

        your post sounds like a Ray Bradbury novel…..

        Sad but true.

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

          Try also the Player Piano by Kurt Vonnegut. Not the best literature, and a bit simplistic, but disturbing in a strange way… :-)

  • Deceased MD

    I actually think that the entire reason for the push for EHR’s was for data mining. I think the reason the ACA got passed was Obama promised the healthcare industry free big data from EHR’s in exchange for passing the ACA. The timing of it coincides with HIPAA which conveniently makes it perfectly legal for “non covered entities

  • buzzkillerjsmith

    Great article and right on. And as Dr. Leap said below, another huge factor, perhaps the biggest to me, is the hassle getting info into the EHR. It can cost another hour or more per day with little or no improvement in pt care.

    This a huge morale killer. We docs (and nurses and other people who provide care) will spend more time taking care of the sick, even at a personal cost. But I never signed up to be a clerk. It’s infuriating.

    • Deceased MD

      Completely agree its dehumanizing and demoralizing. This may sound paranoid, but I think Obama threw PCP’s under the bus with EHR’s. He probably did not consider that it would make doctors lives hell. But rather bartered with Big Pharma and Industry in general. They get free data mining and he gets ACA.

      • buzzkillerjsmith

        I think that politicians and bureaucrats at that level neither know nor care about the details of the systems they’re messing with except that they want more control. They hand-wave problems away unless the mess they create gets too big to ignore. Also they listen to those who either have lots of money or a fueled by ideology or both.

        The data mining factor is there. They want to monitor so as to control.

        • Deceased MD

          Big brother is finally here. Remember when 1984 was just a novel?

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

      Thanks buzz. Maybe that’s where the legendary 30% waste in health care is coming from… matches rather well with the 4000 clicks Dr. Leap mentioned.

  • ninguem

    Margalit – “…..Professor Cutler goes on to prophesize…….crowd sourced clinical advice…..”

    Back to the future.

    Herodotus wrote of this diagnostic technique during his travels to Babylonia in the fifth century B.C. See “The Histories” Book 1:

    197. The following custom seems to me the wisest of their institutions
    next to the one lately praised. They have no physicians, but when a man is ill, they lay him in the public square, and the passers-by come up to him, and if they have ever had his disease themselves or have known any one who has suffered from it, they give him advice, recommending him to do whatever they found good in their own case, or in the case known to them; and no one is allowed to pass the sick man in silence without asking him what his ailment is.


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

      So all we accomplished over the millennia is to increase the size of the Babylonian public square… I think the Ecclesiastes 1:9 should be considered a law of nature :-)

  • buzzkillerjsmith

    From Cutler: “There is little the primary care doctor does that can’t—and
    increasingly isn’t—being done by a nurse practitioner, perhaps at a
    clinic in a Walmart or CVS.”

    And yet the feds are talking about how valuable we PCPs are and how much we will be needed. And Cutler has advised Obama.

    I’ve said it before and I’ll say it again: Any medical student who goes into primary care is a fool. First you will be caged, then you will be replaced. Eleven years of post-high school education and countless hours of lost sleep, lost fun,-lost life- right down a rathole.

    Young medstud: Cut people open , put catheters in them, blast them with chemo, scan their brains, but never ever treat HTN, DM, dyslipidemia. Do not try to prevent disease. It’s not what this country wants from you.

    • Dr. Drake Ramoray

      Agree wholeheartedly buzz, especially the last paragraph. There is a growing movement in the Endocrine Community (myself included should things get bad enough in my current group practice) to go thyroid and general endocrine only. Reimbursement, red tape, and EMR requirements are getting so bad that some Endocrinologists have decided to no longer see any diabetic patients. No lipids, no A1cs,no prior authorizations, and the pay is actuall better not to mention the absence of headaches.

      It’s a sorry state of medicine when even the specialists in diabetes don’t want to see the DM, HTN, lipid patients anymore

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

        I should probably know this, but how is DM different than other things from an administrative/reimbursement point of view?

  • Ron Smith

    [Long post but I beg your patience! I think it will be worth it!]

    I would beg to argue against the premise that EMRs cannot be great tools, and preferable to pen and paper, but only if they are truly designed by physician-database programmers. I created mine and deployed it in 2000. We have one other physician’s office using it at present and we are preparing for the wave of currently dissatisfied MDs and the new up and coming MDs who might really want to think about solo practice.

    I’m a Pediatrician, with 30 years experience in medicine and also in database programming. Let me illustrate how much more pleasant and fluid it can be when systems are designed correctly and for maximum performance and efficiency.

    Mrs. Mom walks into the foyer and before she ever gets to the window, she slips her Pedikey(R) into our kiosk computer. She updates all her children’s records on this keychain device in about 15 seconds. Then she clicks the express checkin button. She proceeds to the waiting room but doesn’t sit very long before the front office staff has seen her automatic checkin. A blank physical exam sheet is created. Her insurance was verified the day before her appointment because the office staff is prepared. They take seriously our goal of every patient in the room at their appointment time. The staff nurse calls her to the front window, swipes her card which records the copayment with the history and physical exma. We in the back will have to keep the part that says we’ll get them out in an hour.

    The front desk who is also one of the nurses that rotates in the back, hands the chart of with a couple of clicks to the nurse facilitator. She is like the conductor of the orchestra. We have 2 to 3 nurses working with 2 to 3 providers and an extra nurse to jump in at a moments notice. The nurse facilitator greets the patient at the waiting room door. The children will gripe because they want to watch more of the movie that’s showing.

    Once the nurse facilitator has them in their assigned room for their checkup, she goes over the vaccines that are preplanned weeks or even months in advance in our EMR. She has already generated the appropriate vaccine information sheets which are downloaded in real time from the CDC so the information is all fresh. Answering questions and discussing the visit will take her 3 to 4 minutes on average.

    Before she leaves the room she turns the patient over to the nurse attending with a couple of clicks in the EMR. It notifies her on her laptop wherever she is so there is no need to run her down. Within another 1 or 2 minutes, the nurse attending has fleshed out the HPI and chief complaints. She clicks another button in the child’s e-record, and I get a notice on my laptop wherever I am that the patient is ready.

    Within a minute or two, I’m in the room. I generally am the one where time can slip though…I have to be careful, because I have adequate time to talk to parents and thoroughly discuss my exam findings. I like to teach and I am enjoying medicine better than I have ever in 30 years. During the exam I find there is a red throat. I click another button or two, and the nurse attending gets the notice on her laptop that the patient in this room needs a lab test. Often before I can get out of the room to go on to the next patient, she is there reaching around me to get the throat swab.

    Minutes later while I’m seeing the next patient, I get the notice again on my laptop that the lab is done for that patient in that room. I proceed there when I get finished. The strep test is negative. I finish some thoughts on growth, development, eating, and the like. I like teaching so this part is good for me. That done, its time for shots. Another button click and the nurse attending has appeared in the doorway as I’m leaving with the vaccines. The patient is done and out within our goal of one hour.

    During this time, the nurse facilitator has repeated this with all the other patients we are seeing right then, the other providers and nurse attendings are doing the same thing that I’m doing.

    My nurse triage does nothing but answer patient calls, mange the ADD med prescriptions to be printed for me to sign, and help me coordinate care and questions for patients not being seen that day. We swap patients charts with a couple of clicks. She is a second pair of hands and eyes and we have this part of the practice down pat. She loves her job. All the staff do.

    During this time, my practice manager, has downloaded and processed electronic claims payments (EOBs). She can process even the longest ones in about 15 seconds. All payments are credited to the correct exam record that was created at the front desk. She manages payment plans and can do credit card processing on a scheduled basis so that parents can more easily keep from running up big debts. The last thing we want to do is to crush our young families with high bills. Even financially we try to take good care of them. Everything is still done all within the same EMR.

    The staff persons in the front are busy taking new appointments and verifying insurance. The nurses are busy between patients creating new health plans for these new visits that are like the musical score sheet for that visit.

    Vaccines are barcoded and scanned into the physical exam record for accuracy. When you spend $250,000 a year on vaccines this is not a luxury feature. New patients have their vaccinations records downloaded within the EMR chart in real time from the Georgia GRITS database. Those vaccines that we have given are uploaded in real time as well.

    The physical exam section that I work on is designed for efficiency. It will stay out of my way until I select the positives. Then I can choose among my own custom examination templates to fill in the negatives. I enter additional comments and a fully handwritten disposition at the end summarizing the exam, my conclusions, and click on a button to create any prescriptions. We have a fully customizable formulary that lets us easily pick from a body of meds. We rarely have to change anything on the prescription and we can even have dosages calculated for the patients most recent weight. I select the pharmacy that the parent wants me to fax their prescriptions and one click of button and sixty seconds later, their prescription sitting in their pharmacy’s fax tray, complete with detailed patient demographics and a current scanned copy of the front and back of their insurance card.

    I’m solo with two wonderful nurse practitioners who also love this EMR. I can get away. With my laptop and my Verizon MIFI, I can even be accessing patient records securely and dialing them through SKype as we drive down the interstate at 70 miles an to check on my Mom and Dad in Arkansas. Faxing prescriptions is the same. If I can get to the internet…I can take care of my patients, even when I’m not in the office.

    I thoroughly enjoy taking care of my patients! I love my EMR. It does what a doctor needs done. It doesn’t make money…none do, but it saves me about $75,000 a year in labor costs. I could care less about the meaningful use subsidies which will be gone in a couple of years.

    Just this week we decided to get NCQA Patient Centered Medical Home certification. Heck we are probably at a level 1 or 2 if we just did what we do. I love my EMR.

    Ron Smith, MD
    www (a dot) ronsmithmd (a dot) com

    • buzzkillerjsmith

      IF you like your EHR, keep it. As a solo doc it is your call. Most of us have crappy systems foisted on us

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

      Dr. Smith,
      Thank you for a great description of a great practice. Your story is an illustration of my outrage. EMRs or whatever we want to call clinical software, can be amazingly helpful in a practice. I am a techie at heart and in the not so distant past, I believed that technology can do exactly what you are doing with your software, and perhaps a lot more. However, as time went on, I began to realize that yours is the road not taken by the so called national initiative. EMRs were hijacked from patient care and are being made to serve policies, politics and monied interests.
      What was once supposed to be “secondary” use of data incidentally collected by clinical software, has become the primary raison d’être for the existence of computers in a medical facility. It is destructive, and it is not “creative destruction”, unless creative refers to a few IT (or political) fortunes here and there.
      I so wish we could turn the clock back, or at the very least stop the madness and allow clinicians to pick, choose and shape the future of medical software (and medicine in general).
      I am not trying to discourage you, but you must know that you are representative of a very small minority. It is possible, I guess, that events will unfold and practices like yours, and software like yours, will flourish, but you are up against impossible odds.

      • Ron Smith

        Thanks, Margalit. I promise this reply won’t be as long as the original post.

        This is very important. We have discovered a scurrilous business plan that many EMR providers are engaging.

        Beware when they ask you what your outstanding claims percentages are. They are about to try and put their hook in your mouth!

        In our practice, if I’m remember the weeks correctly, we have around 10% of claims, or less, that are unpaid before 6 weeks, at 6 to 8 weeks we have less than 2% unpaid, and beyond 8 weeks there are less than 0.01% unpaid. This is extremely good and we have had EMR sales people comment ‘well you don’t need us’ when trying to sell us on their service.

        Most practices claims percentages are not nearly this good. Their EMRs are *intentionally* designed to make claims processing difficult to drive them into the ‘claims processing’ arms of their EMR provider.

        These claims services are based on a percentage of either charged revenue or collections. In my practice, we would pay them $55,000 per year. Our solution of good policy, good software, and good people make it so we put that in the practice as profit instead.

        Practices should stay away from EMR providers who do this. I won’t name names, but most of the major ones we believe are focused on poor EMR design specifically to focus on these profits.

        Warmest regards,

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

    • SarahJ89

      Honestly? I’d feel like a widget in a factory in this system. It would not be a good match for me at all.

  • southerndoc1

    “EMRs are not designed for patient care because our medical system is no longer designed for patient care.”

    One can understand the entrepreneurs and for-profits coming in to make a buck: that’s what they do. And one can even understand the politicians responding to the biggest check dangled in front of their face: that’s what they do.

    But what is absolutely incomprehensible is the profound, all-pervasive stupidity of the medical “thought leaders” and medical socieities who have gladly delivered their peers and patients up to the whims of the hucksters and the charlatans. A stupidity so completely dense and all-encompassing that it can fairly be described as evil.

    Powerful post, Ms. Gur-Arie.

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

      Thanks. To this point, there is a nice essay today in the New York Times (it’s part 2 of another very nice article). Here are some pertinent pearls:

      “Physicians must stand up, specialty by specialty, and refuse to accept this ridiculous system that rewards electronic care, rather than patient care.”

      “Could physicians come together to overthrow the current order — to start a movement to, say, Occupy Medicine? If they did, what would be the unifying cry? Down with health insurers? Tort reform or bust? Or would it begin by expressing the thing that is most precious to them that has been lost: the opportunity to practice medicine in a way that is worthy of their dedication and love. Reclaiming a sense of meaning in medicine could be the first step to rescuing the profession.”

      If the associations won’t stand up, and they won’t, who will?

  • ErnieG

    I admire this, and other posts by Ms. Gur-Arie. What I think
    is going wrong in medicine today is the tendency to devalue a medical education.
    I will entertain the premise that perhaps non-physicians can do what primary physicians (and I would argue many NP’s) do. This premise is important for EMR (as defined by regulators) to go forward, simply because as mentioned, EMR is about collection of digital data to be analyzed by third parties.

    The amount of data captured by a technology is great,
    perhaps bigger than the human brain can capture. Think of photography. Quickly, close your eyes or turn off the
    lights, and describe everything you just saw. A picture from a camera can capture infinite data about what you just
    saw, more than your memory.

    BUT, what a photo can’t do is tell you what is important
    about what you just saw. Take aside the emotional content of a photo, but rather the significance of what is going on in that photo.

    EMR’s are like photos—capturing endless data, most of which
    means nothing.

    Physicians are like the brain- they can process information
    and interpret what that means. While it takes at least above average intelligence to be a physician, it take numerous
    other skills to practice, whether it be surgical skills, listening skills, analytical skills, non-verbal skills, etc, in addition to daily exposure to people with potential medical problems.

    What EMRs are doing is turning physicians into cameras. Physicians are people, and giving additional tasks means taking away time from another. In addition,
    EMR are asking physicians to perform skills they are not optimally trained for. But more importantly, there is no
    other individual in medicine that can be the brain. Third parties, with their regulations, are trying to be that brain. They assume physicians and providers can take good photos, and that they third parties can interpret the photos.

    I think medicine is more like a story- the patient has a
    story about their signs and symptoms, and physicians use limited cameras, and can interpret the photo in the setting of that story. Physicians are trained to get a story, interpret that story, and use data to diagnose a disease, and if still not able, then get a better story, or refer to someone who can.

    Nothing good for patients and physicians will come out of the present attempts to make patients into data.

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

      Thanks ErnieG. I think your photo analogy is right on the money (some pun intended :-). The thing with brains is that we as a species bought into the idea that computers are, or will soon be, electronic brains of some sort, and we are being sold this sci-fi vision a bit prematurely (a century or two)… and not just in health care.

      • ninguem

        Peterson Guides to North American birds.

        Usually they use paintings of the birds, not photographs.

        The detail you need to identify the birds will not be reliably found on a photo of any one particular bird.

        So you get paintings, where the artist makes sure to put in all the detail you need to distinguish the Western or Bullock’s Oriole, compared to the Eastern or Baltimore Oriole. No one bird will have all the details available on one photograph of one bird.

        So the image is interpreted by a human, into color plates of the bird.

        So yes, maybe the EHR is a photograph with lots of detail, lots of which is not useful.

  • morebuzzkills

    Excellent post Margalit. You highlight some very grim truths. If only physicians could unite and stand up against the EMR hypocrisy! Or, Heaven forbid, patients also took a stand…or are they now called health care consumers?

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

      Yep, consumers vs. providers, buyers vs. sellers, supply and demand. micro and macro, and all sorts of visible and invisible hands in the pot….

  • Chris Gates

    Salient posting. OHSU’s Dr Jeffery Gold is doing exciting research about EMR usage and it’s effect on the patient’s outcome. http://tinyurl.com/nm9zz4q

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

    Thanks for the detailed explanation. I’m sure this falls somehow under the unintended consequences rubric…

  • southerndoc1

    An excellent, but very sad, explanation of much that is wrong with medicine today. The only solution, I think, is for patients to be educated about how much is being taken away from them in this system. Thanks.

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

      hmm…. great blog idea :-)

    • buzzkillerjsmith

      Very well-put and informative summary. Your experiences with DM are similar to those of us PCPs. All those damn flow-sheets drive me nuts. HTN and dyslipidemia are administrative cakewalks compared with DM, same with heart disease. I have very little hassle treating or referring for heart disease.

      DM is also tough because much of it is out of a doc’s control. If the pt can’t or won’t comply, you’re lost. Thyroids are much preferable–simple, clean, bottom-line. I say go for it.

  • Daryl G. Harrison

    An interesting read and I thank all as I absorb the experience and knowledge of each. Although I am not a physician I have been part of writing an EMR for WOC nurses that has been on the market for one year. It is app based thus, fully mobile. A year ago, when it was presented to wound, ostomy, and continence nurses the reaction was one of -?app based?-. This year when I presented it to a young nurse her reaction was, “of course it would be app based.” A second interesting incident was two nurses working in tandem. The eldest was easily viewed as being in charge of a large system. She took the iPad and HANDED IT TO THE YOUNGER COLLEAGUE. The young nurse took the device and in a matter of minutes was mastering the app. I can honestly say we have never had a nurse criticize the app rather, they laud its completeness, flexibility, and logical flow of use in documentation. The common comment is, “You didn’t forget anything!” The app is based on the documentation practices of a W.O.C. nurse and the app was designed by a fabulous company that was excellent at graphic representation. The app includes among other things an ability to integrate photography and includes a methodology for consent. Obviously, I could go on and on. I won’t give you the name for that would be advertising and that is not my point in writing. My point is: 1, the app gains validity and excellence through having been written under the direction of a W.O.C. documentation expert that daily practices in the field. 2. A year ago the concept of an app based EMR was looked upon by wound professionals the way a 1950′s Nebraska farmer would of looked at an iPhone5. 3. Those that do the purchasing much of the time do not understand the latest in EMR technology. Understandable. What I read here is what I am experiencing in the presentation of the app. This is a time equivalent to Piaget’s state of disequilibrium. The whole concept of EMR is fluid as it continues to evolve. The users vary in their technological literacy across a broad spectrum. The power to create or purchase excellence is in the hands of those who are not actively practicing. Many if not most medical professionals are lost in a sea of uncertainty as the landscape continues to morph into what most of us have yet to imagine. Oh, and Dr. Leap….no more mouse clicking :)! Thanks, Dr. Gur-Arie for letting me vent frustration from another angle.

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

      I am not a doctor Daryl. Kudos for approaching software building the way it should be, and best of luck with the “app” :-).

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

    It does. There is a very vocal marketing effort to convince patients that they need to be able to get their “damn data” (no kidding) from their physicians and hospitals, and that this will somehow improve their care.
    I think patients should definitely be able to access their medical records, and HIPAA supports this, but I just can’t get on board with the “e-patient” obsession, particularly since all the money and resources spent on that, could be spent on actual care for the way too many people who have no “damn data” whatsoever because they receive no care.

    • Deceased MD

      First of all I am sorry that your article is off the front page. i had just responded to some of the posts on here last night only to discover it’s gone! So delighted to get a reply from you.
      What a catch phrase “damn data”. There is so much I will call it “dumb data” that it becomes meaningless after awhile.
      An example is bone density. Most MD’s don’t interpret the data right anyway unfortunately as it is complicated to interpret with its various T and Z scores. Many pts get put on bisphosphonates like fosamax for the wrong reason and don’t need it or vice versa.
      So they can have their dumb data but what does it mean?

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

        I remember a few years ago getting into an argument about this with some militant e-patients and after lots of back and forth about the benefits of getting raw data to patients, I just copied and pasted anonymous CMP results and said here you go, now what. The only reply after that was hilariously from a doc saying that “grandma” better make an appointment soon because the numbers don’t look too good.

        So now the rhetoric is about “apps” that can analyze these things for patients so they don’t have to google the significance of having, say, the chloride be marked “high” because it’s one unit out of range. Or that patients can just transfer their labs to a specialist if they want to, whenever they want to.
        Of course those “apps” are all about collecting data for sale, and not bound by even the minimal HIPAA protections, but it may seem empowering to some people to be able to verify that their physician knows his stuff.
        The funny (or not so funny) thing is that in this new, reformed, accountable and managed health care system, fewer and fewer people are able to just go to a specialist whenever they feel like it. Just like all “policy makers” and “thought leaders” nowadays, the largely educated and reasonably wealthy e-patients seem a bit removed from the reality of most people in this country, particularly the oldest and sickest which most of the time are also the poorest and largely silent.

        • Deceased MD

          yes! Thank you for your thoughtful response. And as you say these app users are being used as”unsuspecting customers”. Eye roll. It’s absurd. I find myself disliking those apps.

          What I find confusing is the EHR data being given to third parties for data mining. When I have spoken with the HIPAA representative at the local hospital or even the resident, they were aware of data mining but very much minimized it saying that “it was for research purposes”. Excuse my french but what the hell does that mean? I am unable to think like marketing people but my first reaction was what good lingo. “Research.” Sounds great. But must be research for Big Pharma. The paranoid part of me wonders how this data is authentically being used. If it was for physicians and doctors then it would be made transparent. I am not anti technology but i certainly object to the way I perceive it is being used.

  • Ava Marie Wensko George

    I see complaints about the EMR, but no solutions. How would you solve this issue (given the fact that you cannot make EMRs disappear)?

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