Revealing Visit to EMR Using Doctor’s Office

I must admit that I’m a little reticent to post the following story that I was sent to by a regular reader of EMR and HIPAA. I’m not afraid for the story to be told (I’m sure you’ve read and/or experienced it already), but I’m concerned that stories like this ignore what could be done to avoid the situations described. There are often solutions to the issues you’ll read in this story. Let me provide a few of them up front, and then I’ll include some other commentary in the story in [italicized brackets].

1. Selecting an EMR that will maintain your efficiency is key. Certainly there’s some drop in efficiency during the beginnings of any EMR implementation, but 4 months after you shouldn’t still be at 50%. Selecting the right EMR can help avoid this.
2. Doctors need to be deliberate about how they use the computer in the exam room. Communication is the key here. Only chart what’s necessary and efficient in the exam room. Save the rest of that time for the patient. The problem is that most first time EMR users are overwhelmed by the EMR and the patient can see it. Get enough training up front so you can avoid feeling so overwhelmed by it.
3. Offload as much meaningful use items to your other staff (ie. seems like the nursing staff can ask the smoking question right?)

Ok, now for the story I was recently emailed. Also, this wasn’t probably intended to be published, so be generous with the writing style.

Had an interesting….well, maybe more REVEALING visit at a doctors office last week. Had to take my wife to an ENT for sinus and hearing issues. The office was part of 100+ ENT group and was fully electronic…no charts or stacks anywhere. But it took her 20 minutes to do “the clipboard” when we got there (my wife was aggravated by the time she was done. do you know how many times she had to put Name, Address, Phone Number, SSN, etc)…and when taken back to the exam room, the MA spent about 10 minutes on the terminal there, asking more questions (HPI, allergies, vitals, etc), plus entering some things from the clipboard. [Why aren’t more EMR software implementing patient kiosks for their paper work? I implemented it in a clinic and it was great! Walmart like signature pads and all.] I could see from my chair they used one of the “big names” for EMR, one I’m very familiar with. Very detailed, busy screens…and very data-hungry. Forget to fill in a box or try to move on without closing a box…”BEEP”.

Anyway the ENT comes in and went straight to the terminal, which was mounted on a cantilever arm on the wall. Pretty expensive set up, but took up no footprint on a counter or moving cart. He said “Hi”, introduced himself and rummaged on the screen for the Chief Complaint and medical history. I asked him if he liked using the EHR and his immediate response was “I hate it”. When he saw I was involved in the industry—even if with another product—he opened up. He had been using it for four months or so, and was clumsily navigating his way around. He said his patient load was down just about 50%. [This is a real travesty. 4 months later and still at 50%. Either this was implemented wrong or you need a new EMR software.] He said the financial impact was palpable..and that’s why they were “phasing” the implementation in his large group.

The first question he asked my poor wife whose head is exploding and she can’t hear much, is “What kind of smoker are you?”. I laughed out loud and he turned and looked at me…he smiled and said, “You know I HAVE to ask that question now, right?” Your meaningful use and up-coding dollars at work. [Of course, this was probably asked on the intake paperwork as well.]

He eventually got to the exam…and needed to order a hearing test…and went back to the terminal, where it took him more than 5 minutes to document his exam…and order a hearing test (which was done on site and immediately). He kept saying, “just a couple more things to enter….”. After the hearing test, he came back in with the results…and spent more than 5 minutes again, typing his results and impressions into the terminal, then spent a lot of clicks entering a prescription for steroids (prednisone) to knock out the infection. My wife told him she was already on a daily dose of the drug for other issues and was carefully managed by her Endocrinologist to deal with her thyroid issues. This information was “on the clipboard”, sitting on the counter. While distracted with typing in more data, he said, “…then get approval from your Endocrinologist before doing this”…and kept typing.

There is a big problem in there. No cross checking…pre-occupation with typing, clipboard data sitting there, and not really hearing some dangers…what if she can’t take the extra prednisone…no discussion of that. And a whole bunch of other things we don’t have to get into here.

This doctor was a very reputable doctor, in practice specialty for more than 25 years. Seemed very personable and professional. But what impact did the technology he had been using for about four months have on him? Loss of focus? Does pre-occupation with data, government requirements (smoking?) and documenting live during a patient visit distract more than it helps? Not only is he losing 50% of his patient volume, is he really losing more contact with the remaining 50%? What kind of “healthcare improvement” is that?

Your discussion this week about the daughter who was lobbying for her dad to use an EMR [here’s the post in case you missed it] may suggest why adoption rates have been so low for ten years…and NOW need government incentives to be used broadly in the market: THEY JUST DON’T ADAPT WELL TO THE USER’S ENVIRONMENT. That’s the way technology gets traction…it adapts to the user’s way of doing his/her job…and makes it easier and more accurate. Maybe the daughter doesn’t understand that quite as well as dear old Dad does. [Or maybe dad has only seen these “Jabba the Hutt” EMR vendors who as you describe don’t adapt well to the user environment. Hard to blame him though since they are all over the place and it’s hard to find the good ones amidst the 300 other EMR vendors.]

The coming EHR era…may have different implications than anticipated by those wise folks at ONC and the HiTECH Policy and Standards committees. Only if the EHR is designed from the ground up to help the providers do their job better and more efficiently…without losing the volume of patients they need to see…can it all work and do what has always been expected of it: Improve Healthcare…and start to reduce costs.

John’s Moral of the Story: This is the story you want to avoid in your EMR implementation. Choose your EMR wisely. It’s worth spending the time and energy up front to get the right one for your practice. Be trained well on the system so you can feel comfortable using it in the room while still providing excellent patient care. Minimize the effects government initiatives have on your patient care.

Side note: If you don’t read my other site EMR and EHR, go check out this post I just did about EMR training. I think you’ll really enjoy it. While you’re at it, go and like the EMR and HIPAA Facebook page. There’s got to be more than 142 of my readers on Facebook.

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.

15 Comments

  • It’s alway train more, make a better selection etc. Why is it always about what doctors need to do to use EMRs? Why dont we focus on bringing EMRs in line with doctor’s requirements? Why can’t IT people just face the truth: the software is lousy. Our tasks are too complex and nuanced and provider-dependent to be captured electronically. Somebody make an EMR that is as flexible, as subtle, and as efficient as paper and I will sign up. We love technology. We hate lousy software. Windows Visual Basic enterprise garbage is just not up to the task.

  • Very nice post and very important story. I am sure that their software, at least the way they customized it, left something to be desired. I also agree, as I have written in the past, that EMR products have a ways to go.

    But in this story I blame the doc the most. He clearly resents the EMR and is using passive-aggressive behavior to take it out on his patient. He is probably an employee of his practice rather than a partner. I don’t care if you’re paper or EMR, you never walk into an exam room without knowing enough about your patient to start the conversation.

    I’ll also bet that some blame rests with the practice of “100+ ENT group.” They probably used a large institution, arm twisting “my way or the highway” approach to EMR implementation. Although they talk about a “phased approach” now, they probably started with a single global Go Live date and fell flat on their face.

  • I’m inclined to agree with Brian rather than Mike. Without market competition, HIT stakeholders are destined by gravity to produce lousy products based on profit rather than utility. In the giddy, grand plans of HIPAA and slippery interoperability, why didn’t anyone in the nation recognize that when free-market influences are removed from the bargaining table by “mandates” plus stimulus money, it removes accountability to the principals who must depend on the cheaply-manufactured garbage? That naturally creates an atmosphere where stakeholders are quick to blame doctors and patients. Why not?

    Today’s eHRs are like US automobiles in the late 1970s when steep tariffs protected US automakers from foreign competition – clunky, unimaginative, unreliable and expensive. Except the Pinto was safer in a crash.

  • Brian,
    It’s what the doctors need to do since they’re the ones that want a good EMR and not one that will make their life miserable. Of course, there’s always the other option of ignoring the EMR software and continuing on paper. There are just consequences to this course of action too.

    There are a lot of doctors that can’t imagine practicing medicine without their EMR. I’m sure there are many more doctors who could enjoy those same benefits. They just won’t if they don’t spend the time or work with the right people who can point them to the efficient and effective EMR software.

    Mike,
    I agree with your perspective. Whether it’s true in this case or not isn’t particularly important. I’ve seen exactly what you describe in other situations. Certainly much of that falls on the organization that forced the EMR on the doctor. The best approaches involve buy-in from the doctors.

    D. Kellus Pruitt,
    You think that 300+ EMR vendors isn’t enough market competition? I’d say there’s plenty of market competition. The challenge now is actually sifting through all the competition.

  • John,
    It’s not the EMR but the remote, affortable, portable, secure PHR that will be the solution for the routine office visit along with a “smart” assertive and empowered consumer. Hope your wife is feeling better!
    jerry

  • Good point, Jerry. But there’s the rub. Will PHRs catch on with protective parents strong enough to cause doctors to have no choice but to adopt interoperable EHRs? The Ponemon Institute’s latest studies show that data breaches from healthcare facilities is still increasing in frequency as well as severity. It’s just common sense that if the secret gets out and patients come to mistrust the security of their paperless health records, EHRs will be neither interoperable nor safe. Did you hear last week that Wikileaks founder Julian Assange threatened to release Rupert Murdock’s proprietary business information if something should happen to him or his organization? You can bet that strategic gambit wasn’t lost on those who would use patients’ sensitive PHI for extortion. The desperate international whistleblower probably doubled the street price of stolen EHRs and doesn’t even realize it.

    Please bear with me, John. There is no doubt the herd of vendors needs to be culled, but it needs to be thinned out by natural selection or only the fat ones with one foot on Wall Street and another on Pennsylvania Avenue – like Allscripts CEO Glen Tullman – will survive to serve providers rigid, unimaginative CCHIT-certified EHRs with the compassion and speed of Ma Bell, and she’s been dead for decades.
    .
    While most physicians are too busy quickly examining too many patients per day to pay attention to the drivers behind HIT, the 300+ EMR vendors you mention are competing with each other in an artificial market based on arbitrary “meaningful use” criteria and 20 billion “free” dollars in stimulus funding. I think the absence of even basic interoperability that was promised years ago by politicians and stakeholders hints that even tens of thousands of dollars in subsidies cannot jump-start consumer-driven EHR sales. As for patients as market-driving EMR consumers, that’s just nonsense.

    One thing against the adoption of EHRs other than the price and the industry’s miserable de-installation rate is the embarrassing history of stakeholder data-mining of digital claims records. Some providers might happen to recall NY Attorney General Andrew Cuomo’s 2008 spanking of Ingenix for unfair business practices. He caught the UnitedHealth’s for-profit subsidiary catering to the insurance industry’s need for excuses to underpay doctors. Their most popular product line was a service that mislabeled out-of-network doctors according to “cost control,” calling it “quality control” in literature distributed to trusting patients. Cuomo didn’t buy it, got pissed and shut down the scam… for what looks like a limited time.

    It’s not hard for attentive providers to see new HITECH signs of micro-management through HIT “for the common good.” Don’t expect busy physicians to be receptive to insurance employees having back door access to their computers in order to judge their quality in real time according to ever pickier “meaningful use” criteria. There are lots of novice consultants attending informatics schools across the nation funded by stimulus money who would love to be given the opportunity to judge physicians’ abilities. And to bring home a federal check for a few hours on the keyboard makes the HIT job all the more appealing I imagine. At least until the expensive informatics work is outsourced to India.

  • Dr. Pruit,

    As a trainer for an up and coming EMR vendor I agree with what you are saying. There is not a “free market” when vendors are forced develop products to fit the needs of bureaucrats (certification) rather than what their customers actually want to practice better medicine more efficiently.

    I have worked for a few different EMR vendors, and a biggest issue I see is that 99% of the systems out there are based on templates. Templates are rigid! And medicine is an art. Trying to combine the art of medicine with the rigidness of templates is like trying to insert a round peg into a square hole. Templates work well for practice management systems, billing applications, and in some cases clinical charting for nurses and medical assistants. But physicians are a different story. All of the template based systems I have seen either A.) force the doctor to act more like a “technician” than a doctor or B.) chart so inefficiently that they are a case of carpal tunnel syndrome waiting to happen.

    For the majority of vendors the model seems to be to take a system that is already not user-friendly and pile on more and more “features” making the system even less usable. Meaningful use only adds to this phenomenon.

    I am convinced that templates not working well for providers is the “dirty little secret” of the EMR industry. A secret that will get out sooner rather than later as more and more doctors attempt to implement EMRs over the coming years.

  • Hmmm….lots to chew on in these comments.

    I still see the EMR market as a free market. Certainly meaningful use has an impact on development, but I expect most EMR vendors will overcome it and move forward. It’s not a real differentiator, so the market will still have to differentiate in some way.

    Certainly, many are concerned about what the data for getting the stimulus money is going to do. Are people watching? Right now the answer is no. CMS doesn’t even know what to do with the data if you started sending it, but they’ll do something eventually.

    Templates were one iteration and work well for certain situations. Many EMR vendors are moving well beyond templates.

    I’m still not seeing the huge consumer-driven successful PHR companies. However, there are going to be dozens and dozens of EMR companies that sell for many millions.

  • John, Once the employer groups promote the PHR like Dossia, they will begin to penetrate the market. PHR will be a neligible medical expense slotted in an HSA and incentives will drive their utilization. Of course, I can’t predict the future but heck… why not I’m “in the game.”

  • John, which vendors have moved well beyond templates? The only template-free EMR I am aware of is Praxis which is based on an artificial intelligence “concept processor” engine that “learns” the way the doctor thinks.

  • Steve,
    There are a bunch of them that do all sorts of hybrid approaches similar to the “concept processor” that Praxis uses (which I’d still say is just a different approach to templates).

    Some use an interesting combination with voice recognition. Others are using the benefits of a touch screen like the iPad. Others learn from your previous charting so you can chart similar things in the future. Plus, even amongst “template based systems” not all are created equal. Many have created some pretty innovative ways to overcome the million click issue of many template systems.

  • John,

    I’ve trained doctors on both types of setups you describe.

    For example one EMR I worked with is specifically designed for out-patient wound care centers and they get around the doctor time killing templates by off-loading the heavy template charting work (wound descriptions) to MAs and RNs. The system has a slick setup where the staff’s charting auto-populates the doctor’s soap-note so the doctor charting is minimal for “routine” cases. These types of workarounds are a little easier for specialized EMRs targeting highly specialized markets (such as wound care), but much more difficult for the majority of doctors who see different things in their practices.

    If doctor’s are trained correctly and put the effort in, voice recognition can also make templates somewhat more bearable. I see this a lot with many of the “big name” EMR companies. This never makes the charting “fast”, but at least it provides some doctor’s the opportunity to escape a lot of the heavy typing work that many template based systems require.

    Praxis is NOT template based. It’s based on free text and every installation of Praxis starts out with a 100% “clean slate”. No templates whatsoever. All of the content is provided by each individual doctor and the system gets progressively faster and faster the more the doctor uses it. It continuously learns and “maps” the doctor’s mind, patient population, and charting style. It truly learns the way each individual doctor thinks. No template based system can do this. At least not one that I have ever seen.

  • Along with voice recognition, I’ve seen a number of EMR vendors that leverage the benefits of transcription as well.

    There’s a lot of ways out there to document a patient visit. A hands on test drive of an EMR system usually is pretty telling for a user interested in seeing how many clicks/swipes/steps it takes to document.

    We can agree to disagree on whether Praxis is template based or not. Certainly it’s not a standard large template file of click boxes. Although, it’s still using essentially user generated templates that it creates on the fly as it learns how to document. It is great branding for an EMR vendor to say they aren’t template based though.

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