Sunday, July 1, 2007

Physicians Slow in Adopting Expensive and Inefficient EMRs

It seems to be fashionable to complain about doctors and present them as old fashioned and technophobic. Here we have Scott MacStravic wondering why on earth physicians seem to have difficulties transitioning to electronic medical records. Wise and heavy words are being used, concerns are expressed, motives speculated. Academic reasons are considered. Oh, my, oh my. We physicians are the same as everybody else. We are just a little more independent and demanding. We want things to be done quickly and easily. If you present us something that is easy, we'll do it. Scott MacStravic writes about "The hidden reasons"... Scott, you know what, do us all a favor, use those things for a few days and the reasons will no longer be "hidden".

Why are we not running to adopt EMRs? We all have seen the websites where doctors ask for help in deciding which EMR will be the least damaging to their practice and their pocket book! We are not rushing to buy them, because most EMRs today are clumsy, klutzy, slow and expensive systems. None of these software people has had the smarts to start with the consumer. Nobody has studied what physicians do in everyday practice, how exactly they do it, studied it down to the smallest detail, studied the exact work and documentation process. That is what they should do, and then, please take that process and take all, but all the routine work out of it, leave only the "presidential decider" part in, throw in a little help in the deciding department too, give the system some AI, make it adaptable, so that we can have it "our way" - like Burger King. Then make it smart, build in "favorites" everywhere, make the system able to learn our specific style, our specific preferences in diagnoses, billing codes etc. Make it able to link to literally everything and put it on a graphical surface, maybe one that you can also click on with your finger or your regular pen or with one of those fancy computer pens. And you will have a system would sell like the proverbial hot cakes.

Look at what we have in reality? We have overpriced systems that look more like Windows 3.1! Programmers, have you ever heard of MAC or have you seen Vista? Have you ever been to Have you thought about "ease of navigation"? I doubt it.

The system my health care system has presented me is a prime example of a clunker. The core was programmed 20 years ago, and you see it and feel it. History and tradition are a good thing, but not in software. It is so old fashioned, you see the Windows 3.1 still peeking through the creaks. It is crystal clear that it is a patchwork of not very well integrated components. It is embarrassing. Amount of work that has gone into investigating consumer needs and making it easier to use: Minimal. Price: Maximal.

And, talking about money. The clumsy Centricity that I am using has a completely separate billing component. The billing component knows nothing about what goes on in the EMR. This is the biggest stupidity I have ever seen. Billing should be done fully by the software based on the documentation. And should you fail to immediately understand this, you do not belong here in this discussion. We document what we do and we bill according towhat we do. Billing is 100% dependent on what we do, straightforward. So simple, a caveman could do it. And the famous software package Centricity of the famous American company GE should be able to do it too. It should be designed to do it in the first place. It should not even be separate from the documentation part, it should be a completely integrated part of documentation.

With all due respect, Scott is not a physician and has never used an EMR in daily life. I just finished implementing an EMR in my practice. As a hospital employed physician I did not have to buy the system, I just received the hardware and software and started using it.I am a computer enthusiast. And I was very, very disappointed by the EMR (Centricity from GE). It slows me down, it drains my productivity, it makes simple tasks complicated, every little thing takes clicks and click and clicks and more clicks and then some more clicks. It does not provide good access to data, it does not give me the same quick overview of a patient that I had in my paper chart. upon opening my paper chart I had the "summary", a kind of history of the patient with some personalizing remarks and notes and reminders - all on the left side. one glance and I remembered the patient and knew what was going on. My EMR does not allow that, it only gives me the stupid ICD 9 codes, uncoded comments, notes and remarks are "forbidden". When I protested about the lack in functionality I heard the sadistic comment "We try to keep the system standardized". Hey, that works in big corporations, not in private practice. Another one is "We have to do this for patient safety" of "it is a HIPPA requirement". Patient safety is such a fabulously chic buzzword at the moment. But it is a very bad excuse for a clumsy, klutzy system that makes you confirm and confirm and confirm again the most simple steps!

I drive a Volvo for security and it drives as well or better as any other car. Security happens behind the scene. My Volvo does not force me to stop every 100 feet to look around and it does not limit my speed to 25 mph in the name of safety, my car does not force me to stop before making a right turn and confirm that I really plan to make a right turn and so on.

Everybody out there, please understand. The sole idea of software is efficiency and ease of use.
The idea is the Three Click Visit. First click to confirm the history entered by the patient or the nurse, second confirming the template that the system chooses for you and third confirming the prescriptions that will be faxed to the pharmacy, the education leaflet printed for the patient and the automatic letter being faxed to the PCP.That would be a system everybody runs to adopt. Please do not try to find contorted far fetched theoretical reasons for "lack of adoption".

And that, my dear concerned observers, is the reason that physicians are slow in adopting EMRs! EMRs on the market today are complicated, user unfriendly, inflexible and expensive. What a winning combination! We can't wait to buy one of those systems. Did I mention that they drain productivity, but we get paid less instead of more? Physicians are just a tougher clientele. We are not employees in a big corporation where you can simply slap a computer on each desk and say: put up with it or leave. We actually (still) have the freedom to choose (still). We would love to have EMRs, but we are not going to put up with crappy ones. So, make some good ones, and keep the price down. Is that so hard to understand? If Yahoo was as difficult and clumsy to use as my EMR, it would already have vanished from the net.

Can someone please design a systems with a surface like Vista or Mac OS, a system that is built after careful user studies and user analysis, after studying what physicians do all the time, systems that physicians can adapt and mold exactly to the way they want.

And then make those systems cheaper. Forget the abusive purchase prices and the high maintenance costs. Doctors are not rich anymore!


Anonymous said...

Dr. Muenzer

I am not a physician, but have consulted with a number of them in their
practices, and have encountered resistance to EMRs and all computer-based
record systems from as simple a reason as their not being able to type,
therefore use a keyboard well. I agree that the systems are anything but
easy to use in many cases, but on the other hand, I lack the talent to
create a truly simple and convenient system. My aim was only to mention
two logical reasons for physician resistance or at least reluctance in
addition to many others. In any case, I hope your EMR eventually helps
rather than annoys you.


A Urologist said...

The reason for low EMR adoption among physicians is multi-faceted. Cost, technophobia, reluctance to change, "hidden agendas", poor usability, lack of ROI, decreased efficiency, lack of industry standard, etc., are just some of the issues. I think the fundamental resistance is often the need to change. Change is stressful to not only the physician, but also the support staff.

A physician should look at the long-term gains and realize the short term costs in dollars, time, and effort is well worth it. A fully functional and integrated PM/EMR will allow him/her to leverage the data amassed through his EMR / Practice Management software to effectively evaluate his/her performance, production (in terms of dollars/pts seen/RVUs), patient outcome management, and perhaps better negotiate with insurers. These data can also be used to market his efforts in starting or growing a practice.

One only needs to look at recent efforts by Google's Adam Bosworth to realize that some form of electronic patient records is coming, despite reluctance by physicians to adopt. Patients will very quickly be electronically empowered despite poor adoption by physicians. EMR or not, will a physician be liable when a patient comes in with his PHR (Personal Health Record) and the physician fails to diagnose and treat because he did not fully evaluate that PHR? I would rather have an electronic medium whereby that PHR can be organized and manipulated instead of swimming in more static sheets of paper.

Realizing that the cost of NON-adoption will be greater to me in the long run for the above and multiple other efficiency and safety reasons, I have acquired a fully-integrated system that allows me to import/export CCR (Continuity of Care Record), is CCHIT certified, and will keep me interoperable as I mature my practice. The ability to customize the EMR (including changing the incoherent ICD-9 language into something understandable and relevant clinically, yet still being able to send that code to billing without error) is the minimum criterion when anyone evaluates a system. True electronic prescriptions (NOT faxing or simply printing out a piece of paper), easily generating and faxing a referring provider note, and being able to keep "social notes" are also what I consider "minimum standards" for an EMR.

Acquisition of EMRs should not be based on price or the number of clicks alone to complete a task. Ultimately, the product must be compatible with and be tailored to the long-term goals of the practitioner and be able to ensure good patient care.

ObGynThoughts said...

Dear 'A urologist' (Dr. Lin):
we are looking at the same issue from different angles. I agree with you in every aspect, but ant to emphasize that you focus on the long term view. Yes, the EMR is the future, it will come to the vast majority of offices and it will bring great benefits - then ones you mention and maybe more. EMRs will in the not so distant future allow us to compare our diagnoses and treatments with those of the most advanced colleagues in our fields, it may present us with instant updates on the newest literature most relevant to the patient and her present problem. For universities hospital wide EMRs will be akin to "paper generators", since it will be very easy to mine tens of thousands of charts for any kind of data. We all will be better off for it. These are the issues you focus on.

But in the meantime I am sitting in front of a system that makes it tedious for me to even send a letter to the referring physician, where charting and billing is not integrated, where the software does not work well with the tablet I am carrying into the exam room and on and on. That is what I am focusing on. The bumps in the road need to be taken care of, then the road will be what it was emant to be: a highway that will allow us to travel far with ease.
Your Matthias Muenzer