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.