So, the question has been raised: why am I doing this? Why re-invent the EMR wheel? What is so different about what I am doing that makes it necessary to go through such a painful venture? I ask myself this same question, actually. Here's my answer to that question:
What medical record systems offer
What I need
High focus on capturing billing codes so physicians can be paid maximum for the minimum amount of work.
No focus on billing codes, instead a focus on work-flow and organization.
Complex documentation to satisfy the E/M coding rules put forth by CMS. This assures physicians are not at risk of fraud allegation should there be an audit. It results in massive over-documentation and obfuscation of pertinent information
Documentation should only be for the sake of patient care. I need to know what went on and what the patient’s story is at any given time.
Focus on acute care and reminders centered around the patient in the office (which is the place where the majority of the care happens, since that is the only place it is reimbursed)
Focus on chronic care, communication tools, and patient reminders for all patients, regardless of whether they are in the office or not. My goal is to keep them out of the office because they are healthy.
Patient access to information is fully at the physician’s discretion through the use of a “portal,” where patients are given access to limited to what the doctor actively sends them.
A collaborative record, sharing most/all information with patients so they can use it in other settings for their care. Also, I want patients to have edit privileges for things they better suited to maintain, like medication lists, demographics, insurance information, and past history items.
Organization of information is not a high priority, as physicians are not reimbursed for organized records. The main focus is instead on meeting the “meaningful use” criteria, which gives financial incentive to physicians who use a qualified record system.
Since the goal is to share the record and to maximize care quality to make communication more efficient, organization of the record is crucial. The goal is to put the most important information up front and to give easy access to the details sought. I am the “curator” of the record, organizing it and prioritizing information in a way that is useful to both me and my patients.
Top priority is paid to billing workflow, with second billing given to in-office patient management (not apparent to most patients). The least attention is given to clinical workflows for patients outside of the office.
My priorities are 180 degrees from this. My top priority is keeping people outside of the office healthy and happy (which will keep them paying their monthly payments), so maximizing organization and communication need to be the focus of my records. Certainly in-office care needs to be efficient, but not in the same way as the rest of the healthcare system (efficient documentation for payment); it must focus on getting the most accurate information into the system and making it easiest to get information out. Billing is almost a non-issue, as it is very simple in my system.
Task management is again a low priority, as it increases potential non-reimbursed work for physicians (and staff) in the typical office. For example, there is not much emphasis put on phone office follow-up or making sure the plan is communicated to the patient. This is not strictly avoided, as most medical professionals do want to give good care, but the high-stress overworked atmosphere in most offices makes most medical personnel reject any tool that gives “extra work.”
Task management is near to the top. I am focused on coming up with a care plan for each patient and making sure the patient understands that plan. The goal is to reduce the chance of misunderstanding, as it increases my work and decreases the patient’s chance for health. So an integrated task-management tool is very important, as is education resources which can be accessed directly from the patient record and given to the patient to keep (ideally) in an online “folder.”
Mobile communication is becoming more available, but it is very much system-centric, meaning that it is built by the EMR vendor to only be used by patients of physicians who use that EMR and to only be for viewing information from the physician, not as a patient-centered tool.
My goal is to give patient access to accurate medical information and access to me in a way that is easy and efficient. Mobile technology is the most obvious means to this end. I want patients to be able to access their entire record, not just what I generate, from a mobile application (or at least a web application). I want any place they get information to also be the communications hub, as it allows them to communicate with as much information as possible. In short, I am looking to have a “one stop shop” for all patients’ needs, not a “walled-garden” that only gives them access as long as they see a doctor that uses the system.
Payment for health services generally depends on two things: a problem being treated and a procedure code. These are both, therefore the focus of the record system. Problem lists are in the record, not primarily because they help with care, but to allow billing for services.
I believe we should focus far more on reducing risk factors than on treating “problems.” My goal is to avoid problems and do fewer procedures when and where at all possible. Problem lists should not be focused on code, but instead to give the most accurate information to lead to the best decisions, and to help understand the risks the patient faces so problems can be avoided. If this happens, I will have less procedures, a fact that will make both me and my patients happy.
Optimistically, the ultimate goal of the typical EMR is to allow a physician to practice the best medicine possible while not going out of business. It allows physicians to give good care despite the system that rewards them for bad care.
The goal of my record system is to promote the success of a new business model: pay doctors more to keep people well and to keep people out of the rest of the health care system. The ultimate goal of this record system is not to make money for me as software I can sell, but to make it so I can extend the model efficiently to a larger population, ultimately making this new system of care an attractive enough alternative to physicians, employers, and patients to make the switch. Perhaps in doing so the “do more, spend more” system can be replaced by a welcome alternative.
So here is the goal:
- Create a prototype of a system that allows me to give my system of care efficiently to a large population.
- Use that prototype to “prove concept” - that the care I give is better for patients, better for me, and saves money.
- Create enough interest in the model that people are willing to develop the system. I think this is best done through making it open source and setting up a foundation to fund the program (and let me gladly hand it off to people who are better at this than I am).
- This will ultimately lead to more adoption of the practice model (by making it easier to make the transition), which will in turn lead to more interest and funding in the software.
I don’t believe we can retro-fit a standard EMR product to do this job; I think their focus is too different from the goals of this practice model. I may be wrong, but I looked at numerous systems and found that they fought against my goals instead of enabling them. I turned to this idea not out of ambition, but out of a desire to survive and see my practice model succeed.