Sunday, September 12, 2010

Electronic Medical Records, Surgery or a Grand Canyon Hike - Which Hurts More?

Two weeks ago, I did what had to be done. Months of procrastination had to end. Fears had to be put aside. Anxiety and misgivings had to be overcome. Second opinions always confirmed the need to proceed. So, when the excuses ran out, I jumped.
What decision did I make?

Did I…

(a) Finally have rotator cuff surgery?
(b) Begin electronic medical records (EMR) in the office?
(c) Retire from medicine to be a full time ‘Whistleblower’?
(d) Agree to a family vacation when we will hike up and down the Grand Canyon sans mules?
(e) Agree to become an expert witness for a medical malpractice plaintiff’s attorney?
(f) Apply an Obama 2012 bumper sticker on my car?

Two weeks ago, our office entered the paperless universe. The era of ink on paper was over. The manner that I had seen office patients for 20 years suddenly evaporated. And, I wasn’t happy about it. For our small group of gastroenterologists, even though we are aware of the potential advantages of computerized charts, we adopted EMR because we had to. For me, I was perfectly satisfied seeing patients in the office the old fashioned way, similar to how physicians have treated patients throughout history. Prior to 'point & click medicine', I had lots of time for eye contact and observing patients’ body language and facial expressions. I have previously expressed my concern about EMR adversely affecting the doctor-patient relationship. My written chart notes were in my own unique verbiage, code words and phrases that could convey my precise meaning when reviewed months or years later. True, I couldn’t access patient records from remote sites, but somehow we managed to get the job done without tragic consequences. EMR is a cure, but I wasn’t aware that my practice was diseased.

So, now I face patients with a laptop, loaded with software that I don’t fully understand. I am clicking, pasting, free typing and spending minutes searching for some common term like hemorrhoids to insert into the history of present illness. During the first week, I have sorely tested my patients’ patience, and my own.

Since, I don’t want to communicate to my patients my frustration, annoyance and trepidation, I try to make the experience seem like it's all jolly-good fun. I maintain a fixed smile of delight that must make patients think I administer an hourly Botox injection. Looking deliriously happy when I want to smash my laptop to shards is hard for someone with no acting skill or talent. Therefore, I \prepared some cue cards to assist me. Here’s a sample.

  • Do Not Say: I hate this system and so will you.
  • Say: Isn’t this wonderful? I can now search my whole practice for all of my porphyria patients.
  • Do Not Say: Remember how you used to wait a half hour in the waiting room for your appointment? Those were the ‘good old days’.
  • Say: My partners can view your medical history even at 3:00 a.m. Try it out this weekend when I am not on-call.
  • Do Not Say: I wonder who can hack into these records?
  • Say: Of course, this will really improve your medical care. I already clicked that you are feeling better.
  • Do Not Say: I can check my email during office visits and patients think I’m looking at their EMR charts!

Of course, it will deliver many improvements for patients and physicians, as pointed out by ├╝berblogger Musings of a Distractible Mind . I am excited to have access to my patients’ records from anywhere. It has been vexing to receive phone calls at night from my partner’s patients with stomach pain, when I do not know them, and have no access to their records.  E-prescribing will save time and screen for important drug interactions and allergies. Letters can be sent to referring physicians at the time of the office visit automatically, although the software writes them in a robotic fashion. Ultimately, all  EMR systems will communicate with each other, so that a patient seen in an emergency room can have medical records accessed from any EMR system. By then, patients should be carrying a flash key or a microchip containing all of their medical history, radiology images, EKGs, etc.

While on balance, EMR is a true reform that will improve medical quality, it won’t make everything better. It will take great effort by physicians to prevent EMR from dehumanizing our personal interactions with our patients. This is a formidable task, and many of us will not fully succeed. We should not simply consider the medical outcome, but also the path and the experience that precede it.
For example, we would sustain ourselves on Ensure or Meals Ready to Eat (MRE) for life. This would save us time and money. But would it be worth it? When we focus only on the medical outcome, then our humanity is at risk. While the nutritional analogy above isn’t a perfect fit for the EMR issue, I hope you will agree that there is a connection.

What do other physicians think about EMR? More importantly, I am interested in the views and experiences of real, live patients. For those who are dissatisfied, how can we physicians do better?

If I do end up at the bottom of the Grand Canyon, and the National Park Service adds WiFi service there, should I take my laptop with me?  While my feet are dangling in the Colorado River, I can refill prescriptions.

20 comments:

InTheWild said...

From my perspective as a patient in a large multispecialty practice, I had every reason to hate docs with laptops, and I don't. First, I am 55 y/o, on the cusp of the generation of folks who can be suspicious of technology and who pines for the "good old days." Second, I am more than unusually fearful of medical encounters in general (no need to go into the history; I am just a wuss). Third, the CEO of this large, local multispecialty practice went on record as saying something along the lines of "Marcus Welby is dead and he's not coming back; get over it, people" in a press interview. No, he didn't say that but that's how it was interpreted by many in the community.

My internist, whom I see monthly for ongoing issues, is a warm and wonderful person. Yes, he comes into the room pushing a cart with a laptop and spends the first few moments of the visit doing point and click etc. But invariably he pushes that cart aside, looks me in the eyes, and treats me like ME, not a computer file. The other docs in the practice whom I have seen do the same, more or less.

My point is that doctors with compassion and humanity will show that compassion and humanity whether or not there is a EMR to be tended to. Doctors who are jerks would have been jerks, with our without the electronic leash. It's not about the computer, it's about the person operating it.

Dr. Whistleblower, I see your compassion and humanity in your posts. You are in a transistion phase in getting used to this new process, give yourself some time. Oh, and you might try expressing some of your frustration to (some, selected) patients--we know you're human and we want to be there for you too, even if only to grouse along with you for a moment. Bottom line: your compassion and humanity are going to shine through, just like they do with my doc. We get used to the new normal. Who you are behind that computer does not have to change.

A. Bailey said...

If Obama gains the nomination of his own party, he would run for re-election in 2012.

Michael Kirsch, M.D. said...

@IntheWilds, thanks for your thoughtful comment. I will keep it in mind.
@ABailey, of course, I erred. Must have been some wishful thinking, on my part. I corrected the goof that you kindly pointed out.

#1 Dinosaur said...

You asked: answers here, here, and here. By the way, no one has ever shown that "EMRs improve quality", because no one bothers to start by defining "quality".

Anonymous said...

I am a patient in a mutiphysician practice that started using EMR a couple of years ago. This practice was just sold to a local hospital. It has been my experience that the challenge for the doctor in this scenario has become the computer rather than the patient. I watch as my dr. struggles to enter data into the computer, all the while performing a physcial exam that lasts less than 10 minutes total.

There is no effort to review prior information. There is no effort to have a conversation. Forgive my self-centeredness, but when I go to the doctor, I (as the patient) expect to be the center of focus, not the computer. I always leave feeling that it was a waste of time, both for me and the doctor and that there is no way the doctor could develop a sense of what is going on with me physically, emotionally or psychologically.

BTW, I work on computers for a living. I am in my mid-50's and find that I am often more computer literate than those half my age - they know how to surf, update their Facebook page, and play games, but know nothing about the workings of a computer on ANY level.

Anonymous said...

Kirsch and fellow doctors:

I just came across a blog put together by an MD/JD. According to his blog, he had a medical practice in Georgia until May of this year. Now he is a full time trial lawyer.

I do not know him, but hopefully he won't mind if I leave a link so you can read it and ask him any questions/ discuss your concerns with him.

http://publicprotectionlawyer.wordpress.com/

Greta said...

With the onslaught of computers in offices the patient should expect and should demand access and communication to a much greater degree. I would urge everyone to insist that on a frequent basis they view their chart and understand what is in it. This information can and will be shared and it is critical that it is correct. My doctor when on EMR and I sent a letter to him stating my expectation. Most EMR have the ability to send information and gaining this information is essential just as having access to your credit rating is important to your financial situation so to with your healthcare. I was also being charged an annual fee because of the high cost of administration and with paper I could see the issue. With the government funding a lot of the costs with our tax money for EMR, I do not see why this fee should continue and have advised them of this as well. The doctor if they do their job right in the office should also see a reduction in cost moving from paper. If they don't, I expect that it is because they are not doing a good job. I will watch for the loss of human contact and if this happens, will ask that the doctor put down his computer and talk to me as a human being and if they do not, find a new doctor.

Michael Kirsch, M.D. said...

Thanks to 'Dino' for the links to her irreverent blog posts. Good points, Greta. So far, EMR is extremely inefficient during the learning phase. I'm sure this will improve, but I doubt it will ever be as efficient as pen and paper. Will office costs decrease? We'll see. So far, despite the government financial assistance that has been promised, it has been an enormous expense of $ and time. Getting money from the government will probably be a tough slog. We tried to do it with the PQRI (a government endorsed quality program), but we could never even get a person to pick up the phone.

Lisa K. said...

As patient I completely approve of the move to adopt EMRs. I am sure the transition will be traumatic for many doctors and I doubt that the benefits will be as immediate as promised but I think it will ultimately make tracking medical information much easier. Once doctors can send over a patient's chart with the click of a button it should help with the inherent communication problems of modern medicine. And the only way to get to that point is to first get a large number of doctors to adopt EMRs.

Anonymous said...

Dr. Scot Silverstein, of the Healthcare Renewal blogsite, has followed the "growth" and the (as yet unfulfilled) "promises" of EMR cost-savings and efficiency. While he is a proponent of healthcare IT, he endorses it when it is DONE WELL. Since what software writers think is important trumps what many doctors see as important, I think there are many, many kinks to be worked out (first, and foremost, accreditation standards for the industry) before either doctors or patients will see the cost-benefit we all envision.

--Melody

Regina Holliday said...

Hi, you wanted to hear the patient voice. Thank you for talking about your frustrations. It is always hard to be confident in a system you are not familiar with. This will improve in time.

Do not despair. We want you to succeed.

Remember with practice everyone gets better. Think of how important POS systems have been in retail. Remember back in the early '80's when grocery stores were first adopting these systems. It was really hard to do. There were a lot of complaints, but would you go back to the world of hand ringing every item and hand pricing every product? I think not.

And now those retail cashiers can ring an order and keep eye contact during the transaction. It gets better. Technology gets better and so do you.

-Regina

Nicholas Fogelson, MD said...

Mike -

I feel completely backwards from you. I have always worked with an EMR, and when I am in situations where I have a paper chart I feel like I am half a doctor.

When I get handed a massive chart and am expected to do a GYN consult, as far as I am concerned that chart is near useless. It has 20 pages of useful information in 980 pages of crap, and I can't quickly sort out which pages are which. On an EMR I go right to what I want.

Now I'm not saying that EMRs are well designed. They have issues, and many are complete trash. But I would never go back to paper.

Part of the problem you are facing is due to bad design. EMRs designed by engineers are full of clicky boxes and pull downs, under the idea that these are efficient. They are not. What one really needs is an electronic chart, not a new way to document medical care. For the most part, what goes into EMR progress notes should be prose, just like we have with paper charts. Some things can be automated, like adding the labs into the note, but as much as possible it should end up looking like what you may have written. When EMRs get too far away from that model they are bad.

The best EMR I ever used was actually not so far from being a word processor with a bunch of macros in it. It was primitive, but it did what was needed. Labs, path reports, imaging, and consults were all available, and I could still write my notes the way I wanted.

Hang in there. Six months from now you would not go back to paper for million bucks.

Nicholas Fogelson, MD said...

I am a huge supporter of a movement to create an interoperable standard for representing all medical information, so that each EMR company could interoperate with other companies. Right now the entire industry is so balkanized that it is very difficult to integrate different products.

Michael Kirsch, M.D. said...

Thanks, Nick, for your encouragement. I may post your comment on the wall, highlighting the comment that "Six months from now you would not go back to paper for million bucks." We are making the system better, which is costing our practice lots of time and money. In my view, the work we are doing should have been done by the vendor in close consultation with real, live practicing physicians. (Bascially, we are doing a lot of this work for them for free.) Fortunately for me, I type well, so I can free type into the HPI. I'm sure that soon I will also come to appreciate the advantages, but I loved my 'paper charts' which have served me and patients will for over 2 decades. As far as the 'crap' in the chart, a term that we GIs are familiar with, we try to 'flush' all of this out.

SeaSpray said...

Loved this post too! And linked and used excerpt in new post. Thank you. :)

Anonymous said...

I have a company that can do the notes for you in the emr/ehr all you have to do is dictate. They will do your notes, billing everything then you can keep that personal relationship with your patients. It's a life saver for the less computer savvy doctor. If you are interested email me I'll give you their info. If you try it you will love it. They are located in Georgia but can do anywhere. Let me know if you are interested actually their email for info is lisad@streamlinedbilling.com. Hope this helps.

Anonymous said...

Dr Kirsch, I worked for years as a nurse in a multi-specialty clinic. At one time or the other I did everything from surgery to unstopping toilets, when our beloved maintenance man couldn’t be found. 15 years ago I was yanked into the systems department as “clinical support” for developing templates and work flows for the new EMR. I ended up being not just clinical support, but building the templates as well as the workflows to the specifications of the providers using them. (As well as having to structure the documents to generate real office notes, that was a real PITA) I will be the first to say that EMR’s are indeed a great advancement, but they also have the ability to be the perfect tool (when used incorrectly) to game the system.

Many systems are what they are, but others can be completely customized in ways that are not always …kosher, so to speak. Triggers can be put in place to generate (with one click) all normal statements on ROS’s and PE’s, with the ability to go back and click off any minor significant findings. As well as single clicks that indicate that all past medical, family, and social histories were reviewed, (whether you actually look or not). The bottom line being here is that in many cases a significant amount of what is clicked off on those normal and history statements is not actually done, but it allows the provider to bill many level 4 and 5 office visits when the visit actually would have only qualified for a level 3.

Fraud? Yep! But I know for a fact that it takes place. I was also responsible for training all new medical personnel, and my primary task was to train them on how they could use the EMR to optimize their coding. Nurses had to be trained on exactly how many points they had to click off when documenting HPI’s, and we had all the coding points visible (if you scrolled far enough over to see them) so they could check and make sure they had enough things documented.

It was the same for providers, which is why we ended up with buttons to click off all those normal and history reviewed statements. (Docs didn’t have time to be clicknitions, they needed to keep moving)

Most EMR’s also have a designated time limit for visits to automatically “lock”, allowing time for any testing to come back and be entered before that event occurred. The idea here being that once locked, that visit can no longer be changed or amended, without adding a dated amendment. Wrong, that visit can be unlocked and changed at any time by any one with the right access. (Yes, I’ve seen it happen)

So, are your notes safe from tampering? Well, depending on the type of system you have, potentially not. If tampering does occur, can it be traced and proven? Not if someone does it on your laptop, or with your logon when you’re not looking. Documentation will show that you did it.

Prescriptions? OMG, you have no idea of the multitude of fudging that can take place there. Especially on systems that can fax the RX’s directly to the pharmacy through the server. (Have you ever picked up a prescription for a family member? Did they ask for ID or just say, “ Sign here”?)

This is but the tip of the iceberg. EMR’s are a wonderful advancement. IMO the greatest thing is that you never have to go looking for another lost paper chart. (God knows how many hours have been spent doing that!)But they also open many different doors to massive fraud, and potential liabilities that could cost you your license to practice medicine.

Are these things that need have a few whistles blown on? Yep!

Anonymous said...

As a physician myself, working at the VA - which has one of the oldest (or maybe the oldest) EMR's in the country - I can say that it took me at least 6 months to get used to using an EMR. However, unlike what you are describing, the VA's EMR gives the provider the option of using prose and/or templates when writing notes; most people choose a reasonable combination. In the end, I can say that EMR's have different pro's and con's than paper charts, but are probably overall better. I do worry about the liability issue of having access to all the records from every VA and much of the DoD. It would take me hours to review one patient's entire record; so of course, it doesn't happen. I definitely have a hard time maintaining eye contact with patients the way I used to with paper charts. But I've also gotten better at that than I was at the beginning...and I have seen some physicians who have the typing/eye contact thing down to a science. I think they do it well without sacrificing the doctor/patient relationship. So...maybe there's hope.

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n.darsana said...

Nice post. Thank you for sharing opinions. keep on posting .
Regards
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