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The EMR Language

Posted on February 4, 2013 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

If you haven’t read this insightfully candid post by Rob Lamberts, MD, you should go check it out now. Here’s the opening which should get you intrigued:

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.

Since he said it, I had to take a look at his “credentials” to provide some perspective on the post as well:

  • 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.”

Finally, he ends with the money quote, “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.

There are so many fascinating things about this post. Many of which we’ve discussed many times before here at EMR and HIPAA. The first one that I want to highlight is the idea that EMRs were developed around our insane payment system as opposed to around amazing patient care. Long time readers might remember my starry eyed dreaming about what an EMR would look like if it didn’t have to worry about billing. Sadly this isn’t the state of EMR software and likely won’t be in the near future. However, it is the biggest challenge that an EMR vendor faces.

Dr. Lamberts is right that there are good and bad parts of every EMR system. No EMR system is perfect. Instead, each one does certain things really well and certain things subpar. This is a feature of pretty much every software. When an EMR system doesn’t do something well it could be because they just haven’t had time to optimize it. Although, more often, their are subtle development issues which make changing an EMR workflow very difficult. Not to mention the impact of a subtle workflow change to your existing EHR users.

Thinking back to Dr. Lamberts post, he talks about how he’d become an expert on the intricacies of his EMR software. If his EMR vendor were to change that workflow to a more optimized one, he would have revolted. Maybe the new workflow is better, but the fact that he knew the old workflow has value as well and changing it has its own costs. Thus the challenge to updating any EMR software.

No EMR is perfect. Choose the EMR whose challenges you don’t mind dealing with on a daily basis.

Another message I get from Dr. Lamberts post is not to give too much value to awards, groups, and industry committees. Not that I really did before anyway. I’ve always been a take it with a grain of salt kind of guy.

Doctors and Patients as Customers

Posted on May 11, 2011 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’m not sure where I came up with the following idea. I had stored it in my list of future posts and I didn’t have any reference for it. So, if I forgot to acknowledge who provided me the comment I’m sorry.

This is the comment that I received from someone, “EMR provides benefits to the patient (better patient care) and payers (cost savings).”

Of course, we could argue these two points until we’re blue in the face. In fact, feel free to argue either point in the comments below. That will be interesting. I’ll just say that there’s the potential for better patient care and the potential for cost savings to the payers. Whether the potential will become a reality will be a fun discussion in the comments.

When I saw the above statement I started to consider the impact of “better patient care” from a doctor’s perspective. Better patient care seems like something that should benefit the doctor. Pretty sad to consider that the customer (patients) getting better service has little effect on a doctor’s business. Certainly there are some hyper competitive markets where this isn’t true. However, I believe that most patients (myself included) aren’t very good (shall I say knowledgeable) enough to be able to distinguish between good patient care and great patient care. Sure, there are outlier cases, but what measures do patient use to distinguish the quality of care their doctor provides?

If you assume the above statement of EMR software providing better patient care (Clinical Decision Support, Drug to Drug and Drug to Allergy interaction checking, etc etc etc), then why as patients (customers) aren’t we asking future doctors if they use these features? Maybe a few people are, but there’s far from an outcry of patients leaving doctors who are refusing to use an EMR.

For some reason this isn’t working:
EMR Use -> Better Patient Care -> Happy Patients -> Better Business for Doctors

I’m sure that some will come and say that it’s just not clear that the EMR benefits to patient care are tangible enough for this “customer demand” to occur. I remember about 5 years ago when on the EMR Update forum someone suggested a “Got EMR?” (similar to Got Milk) ad campaign for doctors to advertise the fact that they had an EMR. So, of course this topic isn’t new. Although, it’s still very relevant.

Although, even beyond EMR, I wonder what a company or website could do to help consumers/customers (patients if you prefer) to better evaluate the quality of healthcare that’s being provided. I don’t have any ideas on this regard. I’m as bad as the next person at figuring it out. However, whenever there’s a lack of good information I think there’s an opportunity. As you’ve probably figured out, I’m all about good information and accountability.

Revealing Visit to EMR Using Doctor’s Office

Posted on January 14, 2011 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I must admit that I’m a little reticent to post the following story that I was sent to by a regular reader of EMR and HIPAA. I’m not afraid for the story to be told (I’m sure you’ve read and/or experienced it already), but I’m concerned that stories like this ignore what could be done to avoid the situations described. There are often solutions to the issues you’ll read in this story. Let me provide a few of them up front, and then I’ll include some other commentary in the story in [italicized brackets].

1. Selecting an EMR that will maintain your efficiency is key. Certainly there’s some drop in efficiency during the beginnings of any EMR implementation, but 4 months after you shouldn’t still be at 50%. Selecting the right EMR can help avoid this.
2. Doctors need to be deliberate about how they use the computer in the exam room. Communication is the key here. Only chart what’s necessary and efficient in the exam room. Save the rest of that time for the patient. The problem is that most first time EMR users are overwhelmed by the EMR and the patient can see it. Get enough training up front so you can avoid feeling so overwhelmed by it.
3. Offload as much meaningful use items to your other staff (ie. seems like the nursing staff can ask the smoking question right?)

Ok, now for the story I was recently emailed. Also, this wasn’t probably intended to be published, so be generous with the writing style.

Had an interesting….well, maybe more REVEALING visit at a doctors office last week. Had to take my wife to an ENT for sinus and hearing issues. The office was part of 100+ ENT group and was fully electronic…no charts or stacks anywhere. But it took her 20 minutes to do “the clipboard” when we got there (my wife was aggravated by the time she was done. do you know how many times she had to put Name, Address, Phone Number, SSN, etc)…and when taken back to the exam room, the MA spent about 10 minutes on the terminal there, asking more questions (HPI, allergies, vitals, etc), plus entering some things from the clipboard. [Why aren’t more EMR software implementing patient kiosks for their paper work? I implemented it in a clinic and it was great! Walmart like signature pads and all.] I could see from my chair they used one of the “big names” for EMR, one I’m very familiar with. Very detailed, busy screens…and very data-hungry. Forget to fill in a box or try to move on without closing a box…”BEEP”.

Anyway the ENT comes in and went straight to the terminal, which was mounted on a cantilever arm on the wall. Pretty expensive set up, but took up no footprint on a counter or moving cart. He said “Hi”, introduced himself and rummaged on the screen for the Chief Complaint and medical history. I asked him if he liked using the EHR and his immediate response was “I hate it”. When he saw I was involved in the industry—even if with another product—he opened up. He had been using it for four months or so, and was clumsily navigating his way around. He said his patient load was down just about 50%. [This is a real travesty. 4 months later and still at 50%. Either this was implemented wrong or you need a new EMR software.] He said the financial impact was palpable..and that’s why they were “phasing” the implementation in his large group.

The first question he asked my poor wife whose head is exploding and she can’t hear much, is “What kind of smoker are you?”. I laughed out loud and he turned and looked at me…he smiled and said, “You know I HAVE to ask that question now, right?” Your meaningful use and up-coding dollars at work. [Of course, this was probably asked on the intake paperwork as well.]

He eventually got to the exam…and needed to order a hearing test…and went back to the terminal, where it took him more than 5 minutes to document his exam…and order a hearing test (which was done on site and immediately). He kept saying, “just a couple more things to enter….”. After the hearing test, he came back in with the results…and spent more than 5 minutes again, typing his results and impressions into the terminal, then spent a lot of clicks entering a prescription for steroids (prednisone) to knock out the infection. My wife told him she was already on a daily dose of the drug for other issues and was carefully managed by her Endocrinologist to deal with her thyroid issues. This information was “on the clipboard”, sitting on the counter. While distracted with typing in more data, he said, “…then get approval from your Endocrinologist before doing this”…and kept typing.

There is a big problem in there. No cross checking…pre-occupation with typing, clipboard data sitting there, and not really hearing some dangers…what if she can’t take the extra prednisone…no discussion of that. And a whole bunch of other things we don’t have to get into here.

This doctor was a very reputable doctor, in practice specialty for more than 25 years. Seemed very personable and professional. But what impact did the technology he had been using for about four months have on him? Loss of focus? Does pre-occupation with data, government requirements (smoking?) and documenting live during a patient visit distract more than it helps? Not only is he losing 50% of his patient volume, is he really losing more contact with the remaining 50%? What kind of “healthcare improvement” is that?

Your discussion this week about the daughter who was lobbying for her dad to use an EMR [here’s the post in case you missed it] may suggest why adoption rates have been so low for ten years…and NOW need government incentives to be used broadly in the market: THEY JUST DON’T ADAPT WELL TO THE USER’S ENVIRONMENT. That’s the way technology gets traction…it adapts to the user’s way of doing his/her job…and makes it easier and more accurate. Maybe the daughter doesn’t understand that quite as well as dear old Dad does. [Or maybe dad has only seen these “Jabba the Hutt” EMR vendors who as you describe don’t adapt well to the user environment. Hard to blame him though since they are all over the place and it’s hard to find the good ones amidst the 300 other EMR vendors.]

The coming EHR era…may have different implications than anticipated by those wise folks at ONC and the HiTECH Policy and Standards committees. Only if the EHR is designed from the ground up to help the providers do their job better and more efficiently…without losing the volume of patients they need to see…can it all work and do what has always been expected of it: Improve Healthcare…and start to reduce costs.

John’s Moral of the Story: This is the story you want to avoid in your EMR implementation. Choose your EMR wisely. It’s worth spending the time and energy up front to get the right one for your practice. Be trained well on the system so you can feel comfortable using it in the room while still providing excellent patient care. Minimize the effects government initiatives have on your patient care.

Side note: If you don’t read my other site EMR and EHR, go check out this post I just did about EMR training. I think you’ll really enjoy it. While you’re at it, go and like the EMR and HIPAA Facebook page. There’s got to be more than 142 of my readers on Facebook.