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Death of an Evangelist


It feels like part of me is dying.  I am losing something that has been a part of me for nearly 20 years.

I bought in to the idea of electronic records in the early 90's and was enthusiastic enough to implement in my practice in 1996.  My initial motivation was selfish: I am not an organized person by nature (distractible, in case you forgot), and computers do much of the heavy lifting in organization.  I saw electronics as an excellent organization system for documents.  Templates could make documentation quicker and I could keep better track of labs and x-rays.  I could give better care, and that was a good enough reason to use it.

But the EMR product we bought, as it came out of the box, was sorely lacking.  Instead of making it easier to document I had to use templates generated by someone else - someone who obviously was not a physician (engineers, I later discovered).  So we made a compromise: since it was easier to format printed data, we took that data and made a printed template.  We would then write in the vitals, dictate our history, circle options on the review of systems and physical exam, and dictate our plan.  That written record would then be put into the EMR as a finished note by the transcriptionist.  It was a strange way to do things, but it was far more efficient.  At the first user group meeting (after 9 months of use), we were using the product better than anyone else.

For us, the bottom line was not computers, it was patient care.  Our record system was a tool to let us eliminate inefficiency and focus more on care quality.  We were spending less time and doing a better job.  Within two years I was elected president of the national user group for our EMR and became an evangelist for the benefits of computerized records.  I was proof that doctors could adopt technology and not just survive, but thrive.  My peers thought I was eccentric (shocking) and I made few converts.

There is one moment during those first years I will never forget: one of the "aha" moments in my life, a time when things snapped into focus.  I was trying to figure out how to milk more efficiency out of our system and was thinking about using the data for more than just documentation.  My zeal for process improvement earned me the right to be one of the first to have access to the content customization tool for the EMR and I quickly produced content that was very popular (our vendor wisely gave the tool only if we were willing to share our creations).  While I was thinking about ways to improve efficiency, I thought about all of the data at my disposal.  I had years of structured data on thousands of patients: vitals, lab results, medications, problem lists, and other pertinent patient information.  Whoa!  What if I could put all that data together and really coordinate care?  What if I could, instead of using the EMR as a fancy word processing program, I used the data I collected to improve care?  It was like moving from two to three dimensions.  Nobody was talking about this at all; the focus was entirely on documentation, not data.  I remember the room I was in when the thought it me.

Armed with my new vision of EMR, I called my vendor (I was, after all, the president of the user group) and made a pitch to the engineers and company executives. I was clearly one of the top users of their product, but I felt like I was only using a fraction of the product's potential.  Yet I was in private practice and so had no access to the resources to tap that potential.  I proposed that the vendor fund my effort to make the product work on all cylinders, to really show what it could do if its full potential was harnessed. The investment wouldn't be much, since we were still a small practice.  In exchange for their support, they could use what I made to show the world what really good care looked like.  I expected astonished gasps from the other end of the line, but was met by silence.  Eventually one of the executives told me that the product was already being used to its full potential.  They did, after all, have an E/M coding advisor.

Frustrated at their blindness to my insight, I set out to prove them wrong, spending countless hours wrestling with the system to make it do what I want: improve the care I was giving without taking extra time.  The systems I developed helped us offer better care (double the national average on colonoscopy, pneumococcal vaccine, A1c monitoring), and still be in the top 10% of income for primary care.  This accomplishment earned us the Davies Award from HIMSS, and earned me a permanent spot on the EMR speaking circuit.  Still, I was never really satisfied with the care I gave, and always looked for ways to do it better.

Unfortunately, the increasing popularity of EMR caused increased focus from the government.  PQRI, NCQA, HIPAA, and CCHIT all took focus of our vendor from clinical development, instead focusing on regulatory requirements.  When the HITECH act passed I was still (delusionally) optimistic that the focus would eventually turn to patient care.  But the last update I saw on the product I bought in 1996 showed the truth: the product was certified for "meaningful use," but it was bad. Really bad.  We even nicknamed it "Vista."  Previously simple tasks were difficult, and data was harder to use, and was not moving at all toward better patient care.

My inability to accept mediocre care (and my obnoxious obsession with improving it, from my partners' perspective) eventually drove me from the world of meaningful use and E/M coding to my current home: a practice that accepts only monthly payments between $30 and $60 a month in exchange for an undiluted attention to patient care.  Without the overhead caused by the ridiculous complexity of our payment system, I can finally realize my dream of showing the world what good care actually looks like.

But here's the hitch: EMR has never left the world of note generation.  Yes, it does submit data so the doctor can get the check for (ironically) achieving "meaningful use," but that data is still very hard to actually use to improve care.  My attempts at using other EMR products to accomplish my goal have proven to me once and for all that to truly give good care I'd have to abandon EMR as I knew it.  I've got to look beyond EMR to something better, more focused on the patient and less on the payment.  But it's really been a hard search.  I know what I want to do, but the road to that goal is not yet evident.

So what do I think really good electronic records should look like?  I'm up to 1144 words now, so that will have to wait for a future post.  Instead, let me take this moment to throw a flower on the grave of the EMR enthusiast.  It's been quite a ride.  I don't join those who look back to the "good old days" of paper records (It's like longing for the "good old days" before indoor plumbing).  No, I still look to use technology to make my care better; it just won't include EMR's in the form they are now.  In truth, it's never been about computers; it's about the person sitting across from me: the one who is putting their life in my hands.  Perhaps the death of this evangelist can prevent other deaths, the real ones.



Learning a New Language | An Insight into EMR

OK, I'll admit it: I had no idea.  I thought that the whining and griping by other doctors about EMR was just petulance by a group of people who like to be in charge and who resist change.  I thought that they were struggling because of their lack of insight into the real benefits of digital records, instead focusing on their insignificant immediate needs.  I thought they were a bunch of dopes. Yep.  I am a jerk.

My transition to a new practice gave me the opportunity to dump my old EMR (with all the deficiencies I've come to hate) and get a new, more current system.*  I figured that someone like me would be able to learn and master a new EMR with ease.  After all, I do understand about data schema, structured and unstructured data, I know about MEDCIN, SNOMED, and HL-7 interfaces.  Gosh darn it, I am a card-carrying member of the EMR elite!  A new product should be a piece of cake!   I'll put my credentials at the bottom of this post, in case you are interested.**

So, imagine my shock when I was confused and befuddled as I attempted to learn this new product.  How could someone who could claim a bunch of product enhancements as my personal suggestions have any problem with a different system?  The insight into the answer to this sheds light onto one of the basic problems with EMR systems.

Problem 1: Different Languages

As I struggled to figure out my new system, it occurred to me that I felt a lot like a person learning a new language.  Here I was: an expert in German linguistics and I was now having to learn Japanese.  Both are systems of written and spoken code that accomplish the same task: communication of data from one person to another.  Both do so using many of the same basic elements: subjects, objects, nouns, verbs.  Both are learned by children and spoken by millions of people.  But both are very, very different in many ways.

The reason for my feeling this way is that, at their core, EMR products are computer programs.  They are written by engineers with physicians (many of whom have left clinical practice to work for the EMR company) consulting to help shape the product.  The object of the program may be physician use, but their heart is that of an engineer.  So the storage of the data, the organization of the medical information, the location of where anything can be found, is based much more on the nature of the programmer than anything else.

Problem 2: Strengths vs. Weaknesses

The idea of an EMR is (reputedly) to simplify the task of health care providers in documenting care and retrieving the information quickly.  The reality is that some things are of higher priority to one EMR manufacturer than another.  Tasks that were simple in my old system (putting in labs, generating letters with structured data, getting a quick overview of a person's record) are difficult in the new system.  The new system, however, does other tasks much better (auto-completion of lab data, management of referrals, interfacing with patient portal, etc).

I am amazed at how many steps it takes to do tasks my old EMR vendor did quickly.  Why did they make it so hard?  It comes down to priorities, and for whatever reason (CCHIT, Meaningful Use, Moon Phase) some things get high priority, while others are consigned to the "later" pile.

Problem 3: The System

The fundamental reason EMR systems are so difficult is not the nature of the programmers making it or the doctors using it; it is that EMR's are grown in the hot-house of a chaotic and arbitrary health care system.  It makes no clinical sense that there are a gazillion ICD-9 codes, but there are, and any EMR system wanting success needs to devote lots of effort to ICD-9 (and soon to ICD-10 - yippee).  The structure of most office notes are not to give the best clinical information in the simplest format; notes are generated for the sake of proper billing, including a 10:1 ratio of useless to useful information.  Most notes are like a small gift contained in a large box of packing material, with the majority of information simply getting in the way of what is really wanted.  EMR systems are well-designed to generate lots and lots of packing material.

The system I chose does the E/M office visit very well, but does so at the cost of hiding useful information and de-emphasizing what is most clinically helpful for the sake of E/M codes, or what will qualify the practice for "meaningful use" money.  I don't fault the system for it, since we doctors spend far more of our time focused on E/M codes and "meaningful use" than on patient care.  That is one of the big reasons I left my old practice.

The reality is that EMR systems are designed to finesse the payment system more than they are for patient care.  That is because the thing we call "Health Care" refers to the payment system, not to actual patient care.  My frustration with my current EMR system is not that it doesn't do it's job well (it still is better than my old one...I think), it's that it is grown on a planet where the honor being a healer is being consumed by the curse of being a provider.  Patients don't matter as much as payment in our system, so EMR systems will follow those priorities.  Those who don't will not succeed.

So to those I have scorned in the past, I bow my head in shame.  I got good at using a complex tool that allowed me to manage the insanity of our system.  It turns out that my skill was a very narrow one.

It makes me feel like a piece of scheisse (たわごと).

*For those wondering, I was on Centricity by GE and am now using eClinicalWorks.
**My Geek Credentials:
  • I did my residency at Indiana University, the land where Clem McDonald, one of the pioneers of electronic records made our records electronic when personal computers were still new (I attended from 1990 to 1994).  It was there I became a believer in computerized records.
  • In practice, I installed MedicaLogic's EMR in 1996, as one of the first users of their Windows based product, Logician.
  • Within 2 years I was on the user group board, and was elected president in 1998.  I was a regular speaker at the conferences and known for my profuse production of clinical content (called "Encounter Forms")
  • In 2003, I applied for and won the HIMSS Davies Award for ambulatory care for our practice, recognizing our achievements with EMR in an ambulatory setting.
  • After that, I served on several committees for HIMSS, gave talks for multiple other groups (NHQA, National Governors Association), giving the keynote talks for the HIMSS series given around the country to convince docs to adopt EMR.
  • In 2011, I participated in a CDC Public Health Grand Rounds as a speaker from the physician perspective on the subject of Electronic Medical Records and "Meaningful Use."




What is a "portal?"

In it's broadest definition, a portal is a doorway from one place to another.  On the internet, a portal is a site that has links to other sites.  In health care IT, the term refers to a feature of an electronic medical record that gives patients the ability to see parts of their medical record.

In each of these definitions there are two important things that are consistent:

  • To access what's on the other side, a person must find the portal.
  • What is on the other side of the portal is not controlled by the person using it.

This is very important in the area of my concern: health care IT.  Our old friend "Meaningful Use" includes the requirement that the EMR system must "Provide patients the ability to view online, download, and transmit their health information."  In case you've forgotten (deliberately or not), "Meaningful Use" is a program to encourage use of EMR by doctors, paying them real cash money if they meet the prescribed requirements.  The main way EMR vendors accomplish this provision is through the use of a "patient portal."

So are portals the answer to patient engagement via online tools?  Are they the answer to e-Patient Dave's demand to "Gimme My Damn Data?" I don't think so.  They may be a step in the right direction, giving people some of the information they need, but there is still a wide gulf between giving someone a cup of water and ending a drought.

The Problem with Portals

The problem with portals is that they are too narrow.  First, the person must have access to the portal to get what's behind it.  Physicians need to give permission for patients to view the information they send to them.  But people often have more than one doctor, and not all doctors are on the same record system, which means that the patient has information available behind multiple portals (with the complications that implies).

The second problem is that what is behind the portal is determined by the clinician (or hospital) and the EMR system itself.  Patients have access to what they are "permitted" to access, not necessarily what they need. Some physicians (like me) send pretty much every test result I get on a patient, while others abide by the "no news is good news" rule, sending patients only "bad" results.  Some results are sent as summaries, like: "your chest x-ray was normal" (instead of the actual x-ray report with the typical radiologist's vague "can not rule out" litany), or "your labs all looked good" (sent this way to avoid having to explain to patients that their low BUN is not a bad thing).

Some of the limitations are put there by the EMR vendor.  I would love for my patients to see a flowsheet of their lab data over the years, but the EMR products I've used limit the view to the equivalent of an email document, not a flowsheet of discreet data points.

Why is this all important?  A more basic question must first be answered:

Why do patients need their data?

There is a wide range of answers people will give to this question, depending on the philosophy of "patient engagement."

  1. To meet requirements - The old-school of medicine says that doctors should be in charge of a person's care, and that information is there for our use in that care.  Giving patients information, such as lab results, is viewed as a "Pandora's box," resulting in more questions than answers.  "Just trust me with this information.  I'll let you know if there is anything bad" is the message sent off.  But that money from "meaningful use" is tied to patient communication, and many docs will communicate with patients only as much as is necessary to abide by the "rules."
  2. To make patients happy - This is the school of thought I once subscribed to (betraying much codependency on my part).  Did I think it improved care?  Not necessarily, but it seemed like what people wanted, and it did provide a safety net once people were used to getting results, as they would contact me if they didn't hear back from me.
  3. To improve care quality - The Annals of Internal Medicine recently released the results of the Open Notes study in which patients were given access to their entire medical record.  Going into the study, many participating physicians worried that patients would be confused and have increased anxiety over the results in the record, but the result was the opposite.  Not only were patients happier with access to their charts, they reported significantly better compliance with medical treatment.  Physicians were in agreement that this was a step forward in better care, with none of the doctors participating in the study choosing to stop offering chart access when the study finished.

The "Open Notes" study showed something we physicians are reluctant to accept: our patients think for themselves and want to participate in their own care.  What the study didn't address (mainly because it was done in large institutions with a single medical record) was whether or not access to the record reduced the overall cost of care through reduction of duplicate services.  If I have a chest x-ray in my PCP's office and then later in the week go to the ER for persistence of the symptoms, the chances are above average that the x-ray will be repeated.  If, however, I walk into the ER with a copy of the x-ray report, the chances drop significantly.  Furthermore, when patients go to the ER or to specialists for the first time, they are required to give their own medical history.  Having access to their records will free people from having to remember all of their past information, instead letting the new provider to get it (unfiltered) from the actual record.

The real reason patients should have access

This leads to the obvious conclusion which is now whacking us over the head mercilessly: Patients should have access to their records because they are their records.   The fallacy behind a "portal" which severely hampers its usefulness is that it assumes that the "official" medical record should be that of the doctor.  Why is this?  We use patients as our "interface" between different medical providers all of the time.  This happens because the other interfaces don't work.  I often have to ask patients "what did the cardiologist tell you?" or "what happened while you were in the hospital?" as I never got records of either.  I change what is in the "official" record based on these kinds of questions. "Are you still taking these medications?"  "What has your blood pressure been running?"  "Have you changed jobs recently?"  These are all things I ask patients, and then, as a good transcriptionist, I change the "official" record accordingly.

Why not put this in the hands of the one whose life depends on it: the patient?  Why rely on portals, or health information exchanges?  Why not just give all of this information to the patient in a secure patient record?  Yes, there could be hacking, and there will be some people who want nothing to do with this responsibility; but there will also be far more informed decisions made by clinicians who have access to the "official" record.  We do a huge amount of harm to people by "protecting" them from the information in their own charts.

My goal is to center my care on the patient, and perhaps the most important step in that process is to give them their own records.  It is a cornerstone of my new practice.  I will contribute to the PHR and can see it (as long as they give me permission), but in the end, the patients should have their own records.  Anything less than that, in my opinion, is acceptance of a lower standard of care, which would go against the central reason I left my old practice and am starting the new.



10 Ways to Make EMR Meaningful and Useful

OK, I am an EMR geek who isn't so thrilled with the direction of EMR.  So what, I have been asked, would make EMR something that is really meaningful?  What would be the things that would truly help, and not just make more hoops for me to jump through?  A lot of this is not in the hands of the gods of MU, but in the realm of the demons of reimbursement, but I will give it a try anyhow. Here's my list:

  1. Require all visits to have a simple summary.   One of the biggest problems I have with EMR is the "data diarrhea" it creates, throwing piles of words into notes that is not useful for anything but assuring compliance with billing codes.  I waste a huge amount of time trying to figure out what specialists, colleagues, and even my own assessment and plan was for any given visit.  Each note should have an easily accessible visit summary (but not at the bottom of 5 pages of droll historical data I already know because I sent them the patient in the first place!).
  2. Allow coding gibberish to be hidden. Related to #1 would be the ability to hide as much "fluff" in notes as possible.  I only care about the review of systems and a repetition of past histories 1 out of 100 times.  Most of the time I am only interested in the history of the present illness, pertinent physical findings, and the plan generated from any given encounter.  The rest of the note (which is about 75% of the words used) should be hidden, accessed only if needed.  It is only input into the note for billing purposes.
  3. Require all ancillary reports to be available to the patient. Patients are already the information interface between providers, so why not use them as our interface?  Why not have them able to give the ER doc permission to see recent labs, or give the specialists access to their x-ray reports?  Why do I have to get permission from them to get the information sent to me from the lab or the radiologist?  The patient is there in the room, so why can't they just say, "Here are my results.  You can look at them."  While they are showing me them I can explain how I interpret them.
  4. Require integration with a comprehensive and unified patient calendar. We have the technology to give each patient a comprehensive care calendar to look toward the future and into the past as to what tests are due and what was done.  When I order a test and get the results back (thyroid tests for example) I should be able to queue up the next test on a calendar that the patient can see and use.  This is the "GPS" idea I've had in the past, and  would be simple to even share between providers.
  5. Put most of the chart in the hands of the patient. Patient information, such as family history, medication list, social history (where they work, are they married, etc), and even a list of past surgeries should be managed by the person who knows it best: the patient.  Keeping track of this is next to impossible in a busy practice (especially for pediatrics), and is re-transcribed for every visit the patient makes to a new provider.  This is burdensome on everyone and leads to significant inaccuracies that would be easily fixed if a unified patient record centered on one managed by the one with the most to gain from its accuracy.
  6. Pay for e-visits and make them simple for all involved. One of the worst parts of my practice is that I must force patients to come to see me so I can be paid for the care I give.  This is especially unfortunate because the Internet allows easy communication, making many (if not most) of these visits unnecessary.   It is a waste of my time, it wastes lots of patient time, and it greatly increases absenteeism from work.  Yet I need to be paid for my services, as I am taking significant risk and using my training for their benefit.  The technology would make this easy, but the reimbursement model stands in the way.  CMS would have to do the changes to make this happen, but doing so would give a huge yield to doctors, patients, and employers.
  7. Allow e-prescription of all controlled drugs. This falls under the "duh" category.  Why is it safer to hand a physical copy of a controlled drug prescription to a patient than to send it electronically?  Is it safer to hand a person a check and have them bring it to the bank, or to send it electronically for deposit?  Come on, folks, this is just so obvious.
  8. Require patients' records to be easily searchable. I spend huge amounts of time searching for answers to questions like: "were they ever on drug x," or "when was their last y procedure?"  I would love to be able to do a ctrl-f (or cmd-f) search on patients charts to get that information.  It should be standard in all EMR's to allow this, as we all spend way too much time searching, and probably order unnecessary tests because it's just too dang hard to search.
  9. Standardize database nomenclature and decentralize it.  Let's stop the proprietary nonsense.  EMR products should be able to interact well with each other, retrieving information about the patient at various settings.  I personally don't think the centralized database is the best approach, as it is far more risky to have all data in one location.  Just have each EMR able to go (with patient permission) and get information wherever it is.  I shouldn't have to store the CBC results in my record; I should just have easy access to the lab's records.  This has actually been done to a smaller extent with e-prescribing, which can give a unified view into the patient's prescription history (which is often useful, although it is still quite slow).  Having data in proprietary silos is a foolish and inefficient storage method.
  10. Outlaw faxing. I hate faxes, and with the Internet enabled communication (like you reading this), faxes should not be needed.  They are difficult to transcribe to digital format, usually ending up as PDF files instead of searchable data.   Most faxed medical information (ironically) starts in digital format (word documents, etc), and then is converted to paper or PDF, only to be re-imported as non-searchable image files.  This is stupid, but it is so easy that the only way to prevent it is to not allow it.

So there's my dream "meaningful use" list.  I would be interested to hear what other ideas you all have.



A Funny thing Happened on the way to Meaningful Use

This July will mark the 16th anniversary of the installation of our electronic medical record. Yup.  I am that weird.

Over the first 10-14 years of my run as doctor uber-nerd, I believed that widespread adoption of EHR would be one of main things to drive efficiency in health care.  I told anyone I could corner about our drive to improve the quality of our care, while keeping our cash-flow out of the red.  I preached the fact that it is possible for a small, privately owned practice to successfully adopt EHR while increasing revenue.  I heard people say it was only possible within a large hospital system, but saw many of those installations decrease office efficiency and quality of care.  I heard people say primary care doctors couldn't afford EHR, while we had not only done well with our installation, but did so with one of the more expensive products at the time.  To me, it was just a matter of time before everyone finally saw that I was right.

The passage of the EHR incentive program (aka "meaningful use" criteria) was a huge validation for me: EHR was so good that the government would pay doctors to adopt it.  I figured that once docs finally could implement an EHR without threatening their financial solvency, they would all become believers like me.

But something funny happened on the way to meaningful use: I changed my mind.  No, I didn't stop thinking that EHR was a very powerful tool that could transform care.  I didn't pine for the days of paper charts (whatever they are).  I certainly didn't mind it when I got the check from the government for doing something I had already done without any incentive.  What changed was my belief that government incentives could make things better. They haven't.  In fact, they've made things much worse.

We first installed EHR in 1996, after we were scared by an abnormal Chest X-Ray that was missed due to our paper charting system.  We were afraid we were giving bad care for our patients, and saw computers as the solution.  Ironically, our success with our implementation hinged on our non-conformity with our EHR product's design.  We didn't care if we used every part of the product, instead focusing on only using things in a way that improved the care without hurting our office workflow.  Early on, we used a hybrid of paper and computers to give us the information in the proper format.  Then, once our vendor opened up the product to customization, I totally abandoned the hideous clinical content they had made, designing my own forms that maximized both quality and efficiency.

But last year, our first year in the "meaningful use" era, our focused changed in a very bad way.  We started talking more about our EHR complying to criteria than maximizing quality and efficiency.  Our vendor jumped on this bandwagon, ignoring the fact that they were stuck in a pre-internet, office-network design, and instead put all of their resources into letting their users meet "meaningful use."  In the past, the computers were a tool we used to help our patients; with "meaningful use" they became a distraction, taking us away from a clinical focus and driving us toward proper data-gathering.

This is sadly ironic.  We were once using our computers in a meaningful way for the benefit of our patients, but now we are being pressured to abandon the patients in order to qualify for "meaningful use."  This should come as no shock to anyone who has watched American health care over the past 20 years.  We have beaten doctors over the head with "clinical pathways," and "evidence-based medicine," all with a good intent: to make sure doctors gave good care.  The problem was, however, that these criteria become more important than the patients they were meant to serve.  The same is true with our payment system: designed with the initial intent of enabling patients to have access to care, but becoming a behemoth in the exam room, standing between the doctor and the patient.

So what can be done?  I don't really know.  I still do believe that universal acceptance of EHR, coupled with patient data flowing efficiently between points of care, could improve quality and save a bus-load of money.  But I am not so sure about where we are heading.  I want to use computers for the benefit of my patients, not for the sake of compliance to the guideline de jour, or the next great government incentive program.

To paraphrase a famous political campaign motto: it's about the patient, stupid.

So I am working to somehow comply with government guidelines (and get my incentive check so I can have a better shot at paying for four kids going through college in the next 10 years) but doing so while somehow not losing focus on the patient.  I have to say, it's a very hard thing to do.

My dream of universal acceptance of EHR has turned sour.  I am beginning to hate the words: "meaningful use."  I am starting to fantasize about a life without it, and maybe even a life without anybody else's definition of what the care I give should look like.  I want to be a doctor.  I want to take care of my patients.  I want them to be the most important thing, not the other people enticing me with their big checks.  Can I stay in our system while still giving care that is meaningful?



Clinical Summaries: Avoiding Gibberish Generators

I mentioned in my last post that I am growing to loathe "meaningful use" criteria.  I say that with a different perspective than most clinicians.  We went on EMR in 1996 with the belief  that it would improve our quality of care and make our workflow more efficient.  We succeeded, and are doing well with our EMR (despite the fact that it is not the cutting-edge software it once was [biting tongue]).  The goal was to make the visit as efficient as possible, making the clinician and patient end up with as much useful information as possible.  I had long planned on making some sort of visit summary that would give patients a written summary of their visit, giving them something tangible to go home with.  Most patients don't remember what was said in the office visit, so having a written record of things seemed like a good thing to do. Then came the "meaningful use" criteria, that allowed us to be paid for using our EMR "meaningfully."  We met most of the criteria automatically, with the exception of the inclusion of a "clinical summary" available for the patient at the end of every visit (given 50% of the time to meet the criteria).  Our first pass at a clinical summary met the criteria:

Clinical Summary – An after-visit summary that provides a patient with relevant and actionable information and instructions containing the patient name, provider’s office contact information, date and location of visit, an updated medication list, updated vitals, reason(s) for visit, procedures and other instructions based on clinical discussions that took place during the office visit, any updates to a problem list, immunizations or medications administered during visit, summary of topics covered/considered during visit, time and location of next appointment/testing if scheduled, or a recommended appointment time if not scheduled, list of other appointments and tests that the patient needs to schedule with contact information, recommended patient decision aids, laboratory and other diagnostic test orders, test/laboratory results (if received before 24 hours after visit), and symptoms.


It was easily printed out from the data we had from the visit and could be generated at the end of the visit by all providers.

There was a problem: it did nothing to help the patient understand what happened in the visit.  They gave me a confused expression after looking at it.  Why were these things on their problem list?  Why was generic advice about fever, etc. included?

So I went at it from the patient's perspective: what do they want and need to know at the end of each visit?

  • What do I have?
  • Did you rule out bad stuff?
  • What should I do about it?
  • What tests are you ordering?
  • What medications are you giving me?
  • What medications are you stopping?
  • What were the results of the tests done in the office?
  • How will I get the results of these?
  • Who are you referring me to?
  • How will this referral get done?
  • When do you want to see me back again?
  • When should I call if I have a problem?

While these didn't meet exactly with the criteria, they were a good jumping off point for the final product of my work (which was a lot of work).  Here's what I produced:

I do  admit that there is a lot of gibberish still on this, as the EMR is always a good generator of gibberish (cool aliteration!), but it gets the job done and answers the questions my patients want.  When they get this, they are happy with the information (and have often told me so).  They seem impressed I could generate this so quickly as well.

For those of you docs out there wondering how I did this, here are screen shots of my EMR forms (I use GE centricity) I made:


That is its "virgin" state, and below is the form after meds and tests are ordered.

Clicking "print handout" generated the handout I showed earlier.  Note that there is a "preventive care" box up top, which when checked produces a summary of preventive care (which is a work in progress):

This is "page 1."  I am trying to build information that will also give care management information for people regarding their specific medical problems, like diabetes, hypertension, or those based on their risk factors.  This is part of the "GPS" tool I mentioned in my last post.

So why am I growing to loathe "meaningful use?"  I was able to turn the criteria into motivation to produce something quite useful.  But several things make me, at best, nervous, and at worst, terrified:

  • Most EMR products produce the gibberish we first gave our patients.  It's far easier to produce gibberish than to produce meaningful (nice word) information for the patient.  It's far easier to meet the criteria than it is to do the right thing, and the majority of docs don't have the familiarity with their EMR that I do to create a good summary.
  • As the next set of criteria loom, it seems more time will be spent checking the boxes for "meaningful use," taking our focus away from the patient and on the government regulations.  It was my stubbornness that allowed us to get by with a form that is actually meaningful to patients, but it took a whole lot of time and effort.

We adopted EMR so we could use it in a meaningful way, and we were.  "Meaningful Use" is a promises us money with the price of changing our focus from the patient to the criteria.  Most docs will take the easy route.  I don't want to.  I don't want to be a gibberish generator



User Group

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I am in Orlando.  I am not here to bow to the god of Disney, opening the coffers of my wealth to the wonder of the mouse's greatness.  I am at a meeting of geeks.  I am at the user group meeting for my EMR product, Centricity.

These meetings have a lot of personal meaning to me.  I have been using the EMR for over 14 years, and have been attending these meetings for 13.  I served on the board for the EMR user group for four years, and even as its president for a year.  Before I started wasting...I mean spending all of my time blogging, I was throwing that same energy into EMR, and becoming a "power user" of their product.  These meetings were a time to see other geeks like me (some of whom became close friends), and share my knowledge and experience in our use of the EMR.

Things have changed, and now I am not at or near the center of attention like I once was; I am now attending to actually learn things.  The whole "meaningful use" requirements are breathing down doctors' necks, even doctors who have used EMR since it was done in morse code.  Despite the fact that our office has been meaningfully using EMR for over a decade, we want to be sure we qualify for the incentive money.  In truth, if we don't qualify for it, it will be a very strong sign that the system is terribly wrong.

Since I was once an "insider" in this user group, and since this meeting covers a topic that his hot on everyone's list for healthcare and healthcare reform, I will be reporting back to you from the meeting.  I will be "live tweeting" the meeting (my Twitter ID is @doc_rob) and I hope to record some video of people who know a lot more about this stuff than I do.  We shall see.

What about Fred?  Fred will show up later this weekend.  He's too busy to waste his time in Orlando.



EMR and Email in Action

If you don't know by now, I am an EMR evangelist.  A poorly implemented EMR is a nightmare - slowing people down and increasing frustration.  A well-implemented product, however, will give a huge improvement to workflow in the office, benefitting both doctor and patient. Here is our EMR in action (with HIPAA censorship present).  I am checking labs on a patient and evaluate their lipids using a Framingham risk calculator that takes the variables from the patient data.  I then generate an email and send it to the patient.  The whole process takes me about a minute (under 30 seconds if I am not recording).  The patients get an email stating that there are results waiting on our server and have to log on securely to view them.  We are notified when they view them and if they haven't viewed them after 30 days (or whatever interval we determine).

The quick jumps between screens are macros we put on our computers using free software.


My product is Centricity by GE, but the point is not to push their product, it is simply to show what is possible (and what I do every day with my EMR).

If you want more good information on choosing and EMR or making your current one work better, visit my EMR page.



My EMR Reality

OK, I am an EMR fan-boy, I will admit it.  I seem real “rah rah” in my approach to computers in the exam room, and to many I seem to have my head in the clouds; I seem to be out of touch with reality.  In response to posts I have written on the subject, comments have been thus:

“I couldn’t see as many patients if I had an EMR.  It would slow me down too much.”

“Using an EMR makes doctors ignore their patients and focus too much on the computer screen.”

“EMR is too expensive for the small practice or primary-care physician.  It will reduce their income in a time when it’s hard enough to function as a PCP.”

Yeah, yeah, yeah.  This is very familiar to me.  It’s also wrong.

True, there is a start-up period of getting used to the EMR in which you can’t see as many patients, but that goes away.  True, there is a time when you are uncomfortable with the computer in the exam room, but once you get used to it, it becomes as natural as having a paper chart.  True, EMR start-up expense is high enough to make doctors, especially PCP’s, wonder if they can afford the cost in this time of austerity.

I understand these things better than most people give me credit for, because I have lived through each of these troublesome sides of EMR personally.  Here is my EMR story:

I started thinking about using an EMR in 1995, when I saw how difficult it was for me to keep track of information in the record.  This came to a head in 1996 when the result of a test was missed, causing harm to a patient.  The problem wasn’t in the thought-process or in the intelligence of the doctor; the problem was from flaws inherent in a paper medical record.

I was practicing with another PCP at that time.  We were employed by a hospital, but were growing increasingly frustrated with their lack of interest in running our practice efficiently.  So we left them in 1996, bucking the trend at that time of hospital ownership of practices for the sake of personal control.  It put us under far more financial pressure, but the control made it worthwhile for both of us.

Feeling the sting of the missed test result, and feeling the empowerment that self-employment brought, my partner and I set about to look at EMR products.  My brother-in-law worked in a nearby practice that had already been on EMR for a few years and was functioning far more efficiently than we could ever hope with our paper record.  We both visited his practice and saw just how much we could gain from a computerized record.  Once we saw this, the question was not whether we were going up on an EMR, it was which EMR product we’d choose.

We narrowed our choice down to two products: one that was well-known and well respected, but more expensive; and one that was cheap, slick, but had a very small user-base.  We were sorely tempted by the slick sales presentation, but listened to our better judgement and went with the more established product.  After buying the product, the cost would end up being $1000 extra per month per physician (given the terms of the loan we could secure for an $80,000 installation).  We both winced at this, given our short time of independence, but then my partner boiled it down very simply:

  • How much do we earn on average per patient visit? We shot low, and said $50 per visit.
  • How many days do we work each month? Both of us worked 20 days per month at that time.
  • How many extra patients would we each have to see to pay the $1000 monthly loan payment? One extra patient per day would easily cover our expense.

One patient per day?  That’s all??  It made the decision quite easy, and it made the ROI quite easy to grasp.  Our goal was to use the EMR in such a way that it would improve efficiency (something we had seen in my brother-in-law’s practice) and focus on other benefits of EMR once we had it paying for itself.  We reached that goal easily within the first 6 months of using our EMR, and exceeded it soon thereafter. Neither of us saw ourselves as slaves to the EMR, we saw the EMR as a tool.  Consequently, we found our own means of accomplishing our goals, using the EMR in ways that other users hadn’t considered.

  • We didn’t care about being paperless, the goal was efficiency and quality of care, not saving trees.
  • We didn’t like the standard templates supplied by the EMR vendor, so we made our own.
  • Whenever I became frustrated with a process, I talked to my partner and then changed the template to fix the process.  I soon became an expert at template development, gaining prominence among users of our product.
  • When the process inefficiency was not template-driven, such as the use of nurses, the process of answering phone calls, or other common situations encountered in our office, we talked with our office manager and staff and came up with a solution.  Our EMR gave us a bunch of options for solutions we would have not had without computers.
  • We quickly realized that fixing too many things at once created trouble.  I adopted the philosophy: “a good idea at the wrong time is a bad idea.”  So we worked to prioritize problems in terms of their seriousness and how easy the solution was.
  • Once we had an efficient workflow, we realized there were incredible gains to be had from a care-quality standpoint.  We were not paid more for good quality, but our efficient workflow afforded us the opportunity to focus on it nonetheless.  That may seem backwards for non-clinicians, but it is the reality of private practice.  In truth, our quality had already gotten significantly better simply from the improved organization of our records and instant accessibility anywhere, any time.

Forward to 2010, and here is where we stand:

  • I see on average 25 patients per day, working 4 days per week.
  • We have 5 Physicians and 2 PA’s.  The efficiency of our office has increased with each additional provider, as we haven’t had to increase overhead much at all with each addition.
  • We no longer see patients in the hospital (except pediatrics, which is a small number), and we don’t do many in-office labs or other procedures.
  • Despite this, our income has been very good - well above the national average for PCP’s.
  • On quality measures, our practice has excelled every time we’ve been measured.  We easily qualified for NCQA diabetes certification, and our measures for prevention are impressive - with colon cancer screening, childhood immunizations, adult immunizations, and cholesterol screening far above national averages.
  • Most importantly, I give my patients the time they need.  I make a point to not rush my visits.  Each visit is given 15 minutes, no matter of the type, but visits that require 30 minutes are given that time (which is usually offset by the 5 minute sinus or ear infection visit).

That is why the arguments against EMR ring hollow to me.  I see it like the arguments people give against exercise:

“I don’t have enough time to devote to exercise.”

“I hurt after I exercise, and basically feel lousy.  I can’t afford to feel that bad.”

“I need my sleep in the mornings and am too tired at night to exercise.  I’m doing OK without it for now.”

Yes, I sympathize with these arguments.  I have made them all myself, and still struggle to exercise regularly.  But anyone who says people are better off not exercising are just plain wrong.



Meaningful Meaningful Use

Quiz:  What does the term "meaningful use" mean? a.  Using something in a way that gives life purpose and leads to carefree days of glee. b.  It depends on your definition of the word "term." c.  It is not mean.  It is really nice. d.  A large number of rules created by the government to assess a practice's use of electronic medical records so that they can spur adoption, give criteria for incentive rewards, and have physicians in a place where care can be measured. e.  Job security for those making money off of health IT.

The answer, of course is d and e.

Meaningful Use, in the eyes of many is seen as curse words, especially doctors. Here are the rules:

(Click on image to see enlarged version)

Under the plan, physicians will be paid cash dollars for meeting these criteria.  Here's the payment:

  • 2011 - $18,000 per physician, one-time payment
  • 2012 - $12,000
  • 2013 - $8,000
  • 2014 - $4,000
  • 2015 - $2,000
  • 2016 - $0
  • 2017 – 1% penalty in Medicare payments if you do not qualify.
  • 2018 and beyond  – 2% penalty.  More criteria to qualify?  More quality measures?  More penalties for not meeting criteria?  Stricter criteria for A1cs?  Other insurance companies using the same criteria or different criteria?  More government control is a definite.

So what's the big deal?  Why would doctors be against getting extra money?  Here are some of the main reasons:

  1. They don't want to use EMR and feel like the government is forcing them
  2. They think the rules are so onerous that it's hopeless to even try
  3. They only like yellow charts, and the blue ones make them feel depressed
  4. They see that eventually non-adoption of EMR will be penalized.  This makes many conclude that Meaningful Use is just a ploy for the government to cut reimbursement.

I too wish the chart was yellow, but overall I am not upset about all of this.  The reason I am not upset is entirely selfish: I have been on EMR for 14 years and use a high-end product, so I will very likely be awarded the full $$ and avoid penalties.  I also see this as an opportunity for physicians practicing good care to be seen as good doctors, and the bad ones to actually be penalized instead of rewarded.

You see, I have always seen EMR as much more than a computerized version of the paper chart.  The true value in EMR is not that you get to type, it is that all of the information is stored in a single place, organized, and easily retrieved when needed.  Using an EMR for documentation alone is like using a car to travel only as fast as you can walk.  If payment is not so much based on the quality of my coding and my note-taking, but instead based on the quality of the care I give, isn't that a good thing?  Isn't that what we should want?

No Patient Left Behind

The devil is in the details.  Or, to be more accurate, the devil is in DC.  The real problem with meaningful use is the fact that it is a mandate.  Mandates like this - the use of testing/criteria by the government to get people to act in a certain way - have a huge flaw.  This is best understood with another mandate of the government that has caused it's own trouble: the No Child Left Behind law of 2001.

The intent of the NCLB law was to improve the quality of education in the US.  It established standardized testing to:

  1. Set a minimum requirement for education - students cannot be passed-on to higher grades unless they pass the test.
  2. Held schools accountable for quality.  Schools performing in the lowest range on the standardized testing would be publicly identified and penalized.
  3. Teachers with low student scores would be penalized as well.

But the law of unintended consequences has caught up with NCLB, with schools/teachers "gaming" the system, undo focus on test-passage over comprehensive education, and squashing of teacher creativity with fear of low test-scores.  Talking to teachers and parents (as a pediatrician), there is very little love for the NCLB law.

And children pay the price of this legislation as well.  I saw a child recently who is a very hard worker, a very conscientious child, and who has been able to get mainly B's in his classes.  The problem for him is that he does not take standardized tests well.  Despite medication and even allowances made in the testing setting, he fails the test which covers information he has shown in the classroom that he knows.  The government calls his school and teacher as the cause of his failure, but he is the one who has to be held back until he's able to pass the test.

In the same way, making a bunch of criteria for EMR use is sure to have a slew of unintended consequences.  Doctors will select EMR systems based on meaningful use criteria, not on how well they work.  Doctors will select patients who can get the scores higher and discharge those who probably need the most help.

Sounds familiar.

Meaningful Meaningful Use

What should be done?  The real question should be: what can an EMR do to impact patient care that would be truly meaningful?  If an EMR improves the ability of the doctor to take care of the patient, that is meaningful.  But if the EMR makes the doctor pay more attention to qualifying for the cash payment than to the real care of the patient, it is more meaningless use.

I use an EMR every day.  I use it because it helps me give better care and makes our office run more efficiently.  If we have a new process that works better by using paper, we use paper.  We are not wed to the idea of using computers, we are committed to good process and excellent care.  The good news for us is that doing so has made us efficient enough to increase our revenue significantly at the same time that we improve our care quality.  That's what everyone wants.

It really worries me that the imposition of these criteria on EMR will dilute my focus on patients with a focus on achieving meaningful use.  This is similar to the experience of many good teachers who had to abandon more creative teaching methods to ensure better test performance.  If the criteria are not right, they will do this; there is no question.

So before imposing a set of criteria to be evaluated on doctors, we need to be sure that the criteria themselves are scrutinized.  For them to truly improve care and not add more burdens to medical offices, they should:

  • Improve doctor/patient communication
  • Make information more accessible to doctors and patients
  • Capture data automatically, not necessitating extra steps that could distract from care
  • Capture data so it can be used for reminders and clinical decision-making at the point of care
  • Improve doctor/doctor communication (primary care to specialists and hospitals)
  • Capture interventions, not just outcomes.  For example, the prescription of a blood pressure medication should be rewarded, not only if the patient takes it.  The ordering of a mammogram should be rewarded, not just if the patient gets it done.
  • Systems should be required to "close the loop" for interventions, meaning that ordering providers should be alerted to any test, procedure, or consult results that do not come back.  This is an enormous problem that frustrates many doctors and patients, increases medical liability, and causes harm.  Computers are good at this kind of thing.

I am sure there are more, but my word count is getting high.  The bottom line:  meaningful use has to be truly meaningful.