“… a fundamental barrier [to successful EMR implementation] that has not received due attention is the disconnect between health IT developers and users.” (1)
I was a solid advocate of electronic medical records (EMRs). Now I am a skeptic.
Primary care physicians are currently paying a big price, in terms of both time and money for the elusive promises of EMRs. As a quality reviewer of hospital medical records, an experienced office-based pediatrician, and a medical director working with an excellent medical staff, I believed that EMRs would really help us to improve the delivery of quality care. I happily jumped on the “evidenced-based medicine” bandwagon and believed that EMR data would help us. After three years of working with two different EMRs in a primary care practice, I have now “gone over to the dark side.” I have slowly realized that EMR “data” does not equate with “useful information” for primary care providers.
I have never belonged to the AMA, for me a “too-conservative” medical organization that I considered primarily a bastion of physician resistance to positive change. A definite sign of my conversion from EMR advocate to EMR skeptic is my agreement with a recent AMA statement by the Executive Vice-President and CEO of the AMA:
“Harnessing the power of health data is an enormous and important challenge, and one that should be led by physicians. The solution must be useful for physicians, and it must allow us to spend more time with our patients and deliver better care.”
Of course, there are all kinds of physicians in all kinds of practice settings, and “one size fits all” does not seem to be working for primary care EMR.
Use of EMR in our office is slowing us down, is decreasing the time we spend with patients and their families, is increasing the chances of provider communication gaps or slips, and has increased the frequency of “work arounds” for the delivery of quality care. “Work arounds” is a traditional quality improvement term that describes the methods that workers in any setting develop to skirt the system problems that hinder them from doing their best job. The presence of “work arounds” is one of the cardinal signs of a dysfunctional system. “Work arounds” often serve as the first target of any effort to analyze quality performance.
So why have I “gone over to the dark side”.
EMR has become way too complicated – There are too many screens requiring too many clicks, too many switches from scrolling wheel to cursor pointer, too many inconsistent navigation routes using tiny icons or miniscule, barely-noticed arrows. To see the basic clinical information I need before entering an exam room with our EMR , I need to review 2 or 3 computer screens, make 4 or 5 clicks with the mouse, and both scroll and/or drag with a cursor for the information that I use to be able to read quickly on two facing pages in the paper record.
In the quest for the versatility that is necessary to serve thousands of different physicians in hundreds of different settings, the award-winning EMR we use is awkward and time-consuming for us in primary care. It is driven by the need for reimbursement documentation in specialized (expensive) care settings. Workaround? – I read the paper encounter forms completed by my patients and my staff before I start the patient encounter. It is faster, sometimes more reliable (because there is no absent entry), and is more focussed on today’s encounter than those multiple computer screens which are trying so hard not to “miss” any data, no matter how irrelevant to today’s tasks.
EMRs have too many ways to record information from multiple sources – Valuable patient encounter information from nurses, social workers, and medical assistants can be hard to find in the mass of data. It usually requires purposeful clicking on tiny icons or miniscule arrows (again) on multiple screens. Boiler plate checklists tend to make every patient’s chart read the same. Workaround? – I know how to type. The actual, and helpful, differentiation between my patient encounters is almost always found in my “free text” note. But, not all providers in my office know how to or like to type. When I have to track down another provider to find out the information I need, there are now two of us not seeing patients.
Safeguarding patient privacy in an EMR is more complex. Sensitive results or comments are sometomes consciously avoided in the EMR or are deeply buried underneath a number of more clicks, scrolls, and screens. Workaround? – See above about physically tracking down another provider or more likely, that valuable information is not available in the medical record at the time that you need it. The route(s) of clinical information coming in from outside our office like lab results, X-ray readings, and specialists’ consultations are multiple, varied , and often obscure in our EMR. The vigilance required to NOT miss such reports is INCREASED, not decreased, in EMR. Workaround? – I ask the nurse, medical assistant, or front desk staff to track down the information by telephone or fax just like “in the old days.”
Correction of recorded errors like dates, or names, or even diagnosis can be tedious in the EMR. A simple single line cross-out and rewrite did it in the paper record. The EMR requires multiple cursor clicks and several screens to do the same. The timing of the clicks, or more nearly correct, the sequence of clicks can be important for success. Workaround? – Sometimes I will delete a whole section of generic computer-speak in an EMR section because I can’t easily change one or two lines (2 screen colors, at least 3 clicks, and a small check box way down at the bottom of the screen are often involvedin making an EMR correction).
The EMR has reduced the delegation of accepted clinical tasks. Renewing or initially writing common prescriptions ordered by me is not permitted to be done by the nurse practitioners or nurses on our EMR. Instead of a verbal request to a trusted professional, my time and attention is required on at least three computer screens, up to half a dozen clicks, and my entry of my unique password to do that. True, the prescription is sent electronically to the correct (usually) pharmacy, but the nurse or office staff used to do that quite quickly via fax, and it took less of my time. Work around? – Perhaps patient safety clearly trumps convenience here, so I have not spent much time thinking about a work around for this, but it does continue to disrupt a previously smooth work flow.
My computer keyboard is in one room, and I use three other rooms as exam rooms, To complete a note, look up a growth chart, check results, answer an unexpected question from a parent, or order a medication I often do a far amount of time-consuming walking back and forth between rooms. Workaround? – Why not just get a tablet?, you ask. Well for some mysterious reasons neither of our EMRs support that functionality in our office. After several frustration attempts we know that the tablet works beautifully at IT headquarters, but not in our office.
What benefits most from EMR in the office setting?
Reimbursement and research.
Clinically the only useful information to know about an ear infection is whether it is “left” or “right”. Our EMR requires a half dozen more adjectives before the diagnosis is “recorded”. It has no effect on reimbursement now (what we are paid for that office visit) ,as far as I know, and I can only hope that such minutiae won’t affect reimbursement in the future.
There are also half a dozen adjectives required to record the diagnosis of “nose bleed”, and I can only imagine that somewhere out there exists a researcher just waiting to write the definitive article on “recurrent, non-injury, chronic, episodic nosebleed” which happen more often on the “right” than the “left”.
Both these R&R benefits of EMRs are quite removed from improving actual clinical care. That is another reason for my move to “the dark side”, and this current blog that deviates from my founding pledge to NOT publish personal rants.
If you chose to dismiss this particular rant as “just another doctor complaining about his poor lot in life”, you should read a more scholarly short treatise on the same subject: “Accelerating Innovation in Health IT”, New England Journal O f Medicine, 375:9, September 1, 2016, 815-7 (1).