When will Doctors Enthusiastically Get and Use EMR Software and EMR Systems?

One Hundred Percent of Doctors and their offices use Practice Management Systems (PMS). Only 3% user “fully functional” EMR Systems. Why only 3% with EMRs and 100% with PM Systems?

The government is going to pay us $44,000 per doctor to use an EMR. They are going to give us a 2% Medicare bonus and other pay-for-performance incentives and they are going to penalize us in the future if we don’t use EMRs. In addition, hospitals are allowed to pay 85% of the cost of the software and training. Will all this money get us the use EMR? Can we be bought? Is it in our interest to use EMRs?

The CEO of SRSsoft tells us that this type of money is not significant if the EMR makes you less productive and less efficient. For example, if you bill $500,000 per year and your EMR makes you 10% less efficient, you lose $50,000 per year!

I agree with this CEO. We (doctors) will not embrace EMR systems until they are usable and they add value! “Usability is the effectiveness, efficiency, and satisfaction with which the intended users can achieve their tasks in the intended context of product use.” This definition comes from NIST, ISO and UserCentricity. Adding value means that it makes our jobs more enjoyable, shortens our work day or helps us provide better care.

Doctors use practice management systems because they are usable and they add value. Doctors do not use EMR Systems because most DO NOT add value and they are not usable. There are so many bad EMR systems on the market that the stench and confusion has caused many doctors to not even look (they ask their colleagues who have EMRs and these colleagues say “stay away, it is not worth the cost, aggravation and problems”).

I believe that there are some very good EMRs on the market. The challenge is to find them and promote them. If we (doctors) can find the good EMRs, word will spread and implementation will happen very rapidly!

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Dr. Jeff

20 Comments

  • Wow….”Adding value means that it makes our jobs more enjoyable, shortens our work day or helps us provide better care.” Patient care is listed last?
    What if CT Tech said “Setting up the machine using this console is not GUI enough”? Or if the IV Team said “These new wireless IV pumps have too many options, I am not using it”? Or if the Auto Mechanic you take your car to said “I really hate these computer analyzer things. I’ll try to do it all from memory”?
    The alternative of paper orders that nobody can read, so they page the MD who calls back 30 mins later when the RN is no longer on the floor, so they hang up only to get paged again 10 mins later for clarification on the dose which cannot be read. The order is written again, faxed to the pharmacy who then says there is an interaction, which prompts another page and on and on it goes as the patient remains untreated.
    Is it acceptable to continue the harm, near misses, break in continuity of care and delayed treatments because the software is too difficult to use? And what is too difficult? Was this determined after investing the appropriate amount of time for learning or after a half hearted 10 minute look over the shoulder of a disgruntled peer?
    And as far as “stay away, it is not worth the cost, aggravation and problems”, more often than not the groups with such comments have not invested the time to learn the application, have not reengineered the workflow and simply replicated a bad paper process on to the computer.
    Get onboard, invest the time, become savvy and beat the vendor up to be better.
    Here is one resource we found useful in getting some traction.
    The Physician-Computer Conundrum: Get Over It!
    by William F. Bria, II, MD, and Richard L. Rydell, MBA
    http://www.amdis.org/book.htm

  • 100% of doctors would use an EMR if all of the interfaces were subsidized. Right now a physician can invest up to $50K in an EMR and be marginally better than paper because it might cost 3 times that much to interface to hospitals, other physician offices, reference labs and 3rd party payers so that patient data doesn’t have to be entered denovo with each visit.
    If the government would stop paying for EMRs but 100% subsidize all interfaces then every doctor would purchase an EMR knowing that when that new patient walks in the door data about that patient from other systems would populate theirs. Likewise when they order a lab all of the results would come back electronically in discrete data elements that can be measured, graphed and trended.
    When that patient is sent to other physicians their consult results would pop into the patients’ chart automatically.
    In short, the government should pay for the HIT Interstate system instead of the cars. Does no good to subsidize cars if there aren’t any roads, let alone roads that connect to anything.

  • Jim,
    Sadly, the numbers seem to tell a different story. It would be one thing if just a certain number of doctors were holding out. However, with so few people having adopted an EMR, I think it’s logical to reason that part of the problem is the multitude of crappy EMR companies out there.

    I think Dr. Jeff’s point is good that there are good EMR companies out there, but they need to get more exposure.

  • David,
    I agree completely with your idea about government investment in HIT. It should be around interoperability since no one else is going to spend the money on that. They just don’t have the motivation to do it. That’s why it’s the perfect spot for government to encourage healthcare data interoperability.

  • Jim,

    Systems that are unusable and make the doctor’s job harder do not improve the quality of care and, in fact, make care MORE dangerous and more prone to errors! These type of EMRs steal the doctor’s time, cause the doctor to take his or her “eye off the ball” and interfere with the doctor patient relationship at the point of care.

    I believe that Dr. Jeff is talking about EMR Software in the physician’s office and not in the hospital. Care will NOT be improved if doctors are miserable and the main tool they use to care for patients does not work very well.

    The doctor’s quality of job satisfaction and the length of their work day MUST be factored in when you are talking about the quality of care they deliver. Quality care does not just happen without other critical ingredients.

  • Jim,

    Why learn a system which is overly complicated and adds hours to your work day (even when you are using it expertly)?

    EMR software has to be much better if you expect doctors to use it. It has to help us take care of patients more efficiently as well as help us provide an improved quality of care.

    Navigating through multiple screens and using multiple clicks to enter each phrase of a note is a ridiculous way to design an EMR!

    Don’t tell me to “just buck up” and learn “bad” systems, add hours to my day, pay for the software, the hardward, the training and then put up with decreased productivity AND cut my reimbursement!

    You sound like Obama and you sound like the millionaire executives from GE and Allscripts who “do lunch”, play golf, contribute hundreds of thousands of dollars to polical campaigns (and then get to go to the parties and get cushy, high paying jobs) while I am working my butt off to make payroll and make ends meet!

  • “Doctors use practice management systems because they are usable and they add value.”
    I have watched ambulatory practices. They use practice management systems because:
    1. Some insurance companies require them
    2. They reduce costs
    3. Most important: Doctors don’t have to use them. It is the office manager or billing person using the practice management system. I have hardly seen any doctor using the practice management system.

    PM and EMRs are usually designed by the same vendor and I don’t PM systems are any more useful than EMRs.

    Though do I agree, EMRs have to be usable for doctors to widely adopt them.

  • Good Comments and a Great Blog Post! Just to continue the discussion, the comparison of a practice management system to a ambulatory EMR is like comparing organgs to lazyboy chairs. Practice Management Systems are used by a different set of individuals with different characteristics and needs. The usability of a practice management application is not at the forefront of the needs assessment. Often there is an education process for anyone required to use the practice management system before they begin working with the system.

    On adoption from physician for an Ambulatory EMR, there has not been a “killer application or tool” – iphones are more widespread than EMRs. Usability is a key aspect as well as the device usability and hardware infrastructure. We are coming to a time where the governmental regulations are going to be a catalyst for a “sense of urgency” with practices, hospitals, and health systems. The questions should no longer be why it doesn’t work, but what needs to be changed in our implementation practices and application architecture to make it work.

    Hope this helps,
    Elyse

  • I think the point Dr. Jeff was making was that Doctor’s offices use practice management systems (PMS) because they are usable and the bring value to the practice (scheduling, billing, etc). When PMSs first came out, we had the same problems with them as we are having with EMRs. Computers were new, software was bad and they did not work well. Some doctors were early adopters and they got burned. Once the PMSs “were ready for prime-time) they were widely adopted and are currently used by most doctor offices. The parallels between PMSs back in the 1980s and EMR in the 2000s are interesting.

    The point is that unusable EMRs will never be widely accepted or used even if they are mandated (in this case, the doctors will just fight back, the same way we fight back when an idiot president wants to ruin our healthcare system). You can’t force us to use a tool which does not work well. You can try, but it won’t work. It takes a lot to get doctors “activated” because we work so hard and don’t have time to march on Washington, but when we do get angry, you have a bunch of pissed off bastards (and bitches) who are smart and tenacious. I wish we were like the unions and could just take days off to march and be more politically active. Unfortunately we are busy working our asses off taking care of patients, managing our practices and trying to make payroll!

  • Any idiot can design a PMS (scheduling and billing). It is much harder to design a tool which can help a doctor take care of a patient and document a progress note. Maybe the problem is that PMS companies are designing EMRs!

  • Interesting. There are lots of EHRs out there, and the irritating thing as a consultant is that most of them can be tweaked to a practice’s and particular doctor’s style if someone takes the time to do the design and analysis needed.

    The problem is, a lot of vendors don’t.

    Or if they do, the doctors and staff don’t see the value of a design and feedback loop to improve the product. The single most successful practice I’ve seen with this has monthly meetings for doctors and all other medical staff to identify issues and suggest corrections for their EHR. They’re constantly improving templates, data input and reports and as a result they’re a wonder to visit.

    In short, its got to be a process of continuous improvement after you’ve done the homework for a good selection.

  • Be more careful please. When you say that PMS’s are used because they are useful, that statement conceals so much more than it reveals you could start a thermonuclear explosion with the compression of facts that it requires. U.S. medical claiming has been the worlds longest train wreck. Maybe with HIPAA 5010, sane claiming will start to come into view. Scheduling in doctor’s offices is rather like queuing people up to play the lottery. We need EMRs because it is the best way to build an image of the patient’s condition and the treatment process over time. After all, the QUERTY keyboard was designed so that mechanical keys wouldn’t clash and we use it still even though it is the most counter productive layout of letters imaginable. If you can learn that, you can learn anything and get good at it. I once met a clinical director who recommended to me the ‘gun to the head’ rule for evaluating training. He said, “if the staff person could do the work, if they had a gun to their head, then they don’t need training, they need supervision.” The prospect of medicine bankrupting the whole country is enough of a ‘gun at the head’ for medical personnel to use EMRs. This is not a popular or widely held view, but dire necessity will drive it to the forefront.

  • Very interesting comments here.
    Having been involved in over 50 implementations of various systems over the last 5 years I agree with the following:

    1. Subsidizing the car when there is no road to put it on is a great analogy.
    2. There are absolutely no incentives or contractual obligations for the EMR vendors to provide quality ongoing support and/or product improvements once a system is purchased by the practice.
    3. Training of back office staff is often overlooked by Practice Managers and Monthly staff meetings are critical to the success of any EMR implementation period.

    The current stimulus package for physicians is simply the wrong legislation and puts the cart way before the horse and will ultimately increase the cost of practicing medicine because of the ongoing cost of ownership of EMR today. This all leads to the heart of the matter in healthcare in the US —- affordable access to enough bandwidth i.e — the highway.

  • I believe most of the fustration is spawn out of a lack of education. Many vendors are preoccupied with making a quata or getting that commision they forget about properly training the doctors and their staff on the system. I’ve seen implementation/training set as low as 16 hours. Now that’s ridiculos. It’s like you walk into these facilities drop off a huge puzzle and say, “Here put this together and you can’t see a patient until this is done.” And oh, by the way, if you need more training hours we’ll charge you $250 dollara an hour. I tell all my doctors hey look this might take every bit of one full year to learn this is completely but it’s worth it in the end. I will be here with you every step of the way and for the next six to eight months free of charge. Our system is robust, intuitive, attractive, user friendly and complete. The system fun and there’s nothing to fear.

  • I think Darryl’s comment is probably quite true. I think it also makes a case for having your paper imaged and having access online to the records. You then do not have to change your office practice other that setting up specific scanning schedules with your vendor, and manage which files will be tied up during this scanning cycle.

    I currently have this in place with several practices, Three that are planning on using this method until retirement, one that is using it as a controlled bridge to a full EMR that they are about to implement. Last case they are currently switching form one EMR system to a different system. Their experience from the first implementation taught them that imaging is best left to outsourcing.
    They will maintain a true online archive of their historical records and move the the images over as patients come in. This way inactive patients do not load the new system with useless information, and they have a full cradle to grave path of the records they imaged and migrated.

    And just for point of reference the costs associated with this was under $25000.00 for the scanning of the 8 historical years of records and $69.00 per month for 24/7 secure access.
    No additional hardware or software to buy. No $250.00 dollars an hour to help you use, it is set up with the same criteria you already use in your office or any way you choose.

    And lastly they will get their lunch room back as all the records stored in there were cluttering up the space.

  • As a physician who generally embraces technology I have some serious misgivings about EMRs. I think that the problems are more complex than they initially seem. Obviously the technological wrinkles can be ironed out to some degree by reducing the number of clicks, dialog boxes, screens etc that it takes to navigate through the exam. Nonetheless, there is some validity to the concept that perhaps an EMR should free us from the constraints of the way we are used to seeing an exam on paper. I personally am used to seeing patient exams unfold in one single page and value the ability to simply leaf through a chart to get a feel of what has come before. As I leaf through previous visits I get a gestalt of the patient which is more comprehensive than simply getting a list of previous diagnoses or a review of specific sections of the chart. This is, of course, a subjective issue much the same as those of us who prefer paper books to electronic media. I have reviewed many EMR’s and have not found one that captures this sensation of being able to leaf through a chart. Another issue is that all the EMR vendors attempt to comply with the coding requirements handed down by Medicare. Therefore, there is a great emphasis on seperating out CC, PMH, ROS, HPI, FHX, etc plus all the nitpicking “elements” of each of these sections and the requirements of indicating location, severity, associations, time frames etc. In the real world documentation does not always work in this way and many of us ignore some of these in the interest of better clarity and time constraints. Most EMR’s however force you to include all these elements which can lead to loss of time and to useless data clutter which can obscure relevant issues. Many EMR’s appear to luxuriate in the verbiage that they are capable of, consequently making the exam sheets very cumbersome to navigate. Also, the easy ability to import previous data or to populate whole sections of the exam with stock answers makes one question the reliability of the data. As a physician when I review previous notes in which I have handwritten certain assessments or observations, I can rest assured that at the time I wrote them I considered these important enough to go through the bother of writing. When I read my own notes I am not sifting through a haystack to find the pin (the impression that I get from a lot of EMRs). Perhaps this is still a technology in evolution?

  • Ilan Hartstein,
    Your views are shared by many. Plus, your point about it being quite complex are completely accurate. I think you also highlight the biggest problem I have with EMR software and that is that they have to comply with the terrible medicare/insurance/coding requirements. I’ve often described them as big billing engines instead of documentation engines. I think that’s an apt description of many.

    We are going through an evolution though where EMR vendors are making slow progress to resolve as best they can within the regulations the issues you describe.

    Of course, there are 300+ EHR vendors, so there are lots of interesting options.

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