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.

8 thoughts on “My EMR Reality”

  1. My doc's practice has a computer in each exam room now, and I *love it*. It's got my prescriptions and my history right there, and the prescriptions get reviewed every time I go in, as well as the status of anything I've brought up as issues in previous visits. And new/refill prescriptions get printed out legibly or are sent electronically. Same office, same doc – slightly better experience as a patient.

  2. This comment is from my brand new 'EMR-ready' laptop/tablet. I'm not young enough to welcome the adventure and I'm not old enough to slip out of the profession before jumping into the quicksand. Our training begins in about a month. In GI terms (my field) I regard it as undergoing a colonoscopy without sedation – I'll get through it, but it will not be fun.

    I am concerned that this 'advance' will be a force that separates me from patients, as has been related to me by other EMR practitioners. Sure, the benefits are clear, and I hope they will overtime far outweight the drawbacks.

  3. It totally depends on the focus of this “advance.” The problem working in a bigger system is that you are forced into the priorities of those above you. Your priority may be patient interaction, but if your “superiors” are simply trying to get HITECH money, then they may detract from patient care quality. What I can tell you is that it certainly is possible to live on the other side. This is the activation energy – you need to get over the big hump of adjustment of learning a system and integrating it into your practice. Hopefully the folks who chose your system were wise enough to pick one that actually will help you and will give you a better patient experience than you could ever have had on paper. That's my experience, and the experience of any doctor/nurse/support staff that works in our office.

  4. “Your priority may be patient interaction, but if your “superiors”… In our case, the superiors are us. I hope we have chosen wisely. The various vendors promise everything. I hope the company we hired has a strong follow through. They are great pitchmen. I think it will work out and we will get through the obstacle course that leads to a minefield that leads…

  5. That's what I hoped for when my mid-sized PHO bought one of the two popular products. My career before medicine was computer programming, but it has meant I type the HPI section of all my notes, along with the assessment and patient instructions. We have voice rec but it effective range begins with baritone. I use it because I must but it misses about 30% of the words. YES I practice , I have had it for > 3 years.

    Prior to EMR I had 24 “slots” per day. Because there are some longer appts- I saw about 20 patients a day–remember all my patients are either elderly or have a chronic illness
    like type 1 diabetes or stage 5 kidney disease that requires a lot of fiddling after they leave the room. I see maybe one ear infection per quarter and one or maybe two URI's per week. Now I have 20 slots , 17 or 18 patients per day , I refuse to work > 12 hours regularly even though it means I spend a large portion of my weekend doing charts , a larger portion by far than when I dictated.

    Now we go to the heart of it, underfunding We have two wonderful IT support staff for about 200 PCP's ( I got that count by looking at our web site it could be only 160 or 170 if a lot of people show up in two specialties) , and two clinical folks who have privileges and no IT training . These are the only 4 people allowed to alter the shared templates or clinic-wide med lists . There is one “abbreviated” list of meds for each clinic that has > 5-6 providers . Is it because my employer is evil? No, its because in Oregon the Medicare rates are low enough my jaw dropped when I read $50 a visit. As I understand it 60% of the kids in Oregon are on the health plan, I am an internist and I learn all this from my colleagues who are home right now. That pays less yet, and they see many more patients than we do . Its not like the big company lowered our purchase price because we get less per visit.

    I am still a believer , because I can see the chart when I work in hospital even on weekends, even for out of area docs. I am a believer because there is at least the possibility of an accurate med list. I am especially a believer because I can hand the patient instructions at the end of the visit, with an extra copy for the caregiver if there is a caregiver. It has raised the floor for care, we have a diabetes registry , we can track missing mamms and immunizations, finally after 3 years . It has lowered the ceiling- I used to have in my charts FRAX risk of hip fracture, Gail model risk of breast cancer, NHLBI risk of vascular disease on the bottom of the problem list . There is no variable name for these , I can type them into a note but I have no way to ever retrieve them.

    I raised a query and IT went to the vendor to get a “name” for Tissue transglutimase, which is supposed to be checked in type 1 diabetes patients, according to the ADA guidelines. It took > 1 year to get the name assigned.

    An arcane example for internists only. I can't complete my PIM for the ABIM boards because there is no way to document the “improvable” items from the initial survey. I chose that subject (osteoporosis) because I did not think I was doing very well. I many ways I wasn't , but the areas that are easy to find in EMR –doing screening, checking vitamin D and so on I was doing > 85% .
    The areas where I was doing poorly had no “space ” in the EMR I had worked on a letter to explain low but not osteoporotic results, tell the patient what was the next step, giving a hip fracture risk point out there are several different prediction models, discuss calcium and vitamin D supplementation , mention smoking and drinking, where the “balance classes” were held , and thinking I could use this. Its easy enough medicate (those who benefit), its hard to educate . I am only allowed to use 140 characters –maybe I could tweet this to patients as they retire. I will have to find a PIM where I am not doing well , which shouldn't be difficult and where I can document improvement, which will be lots harder.

    Its the way its all going , but if you can't pay the bill, or your employer refuses to spend money on low-profit areas, you will still not have a functional records system.

  6. My doc's practice also has a computer in each exam room but I'm less impressed than you are. When I go into the exam room, the nurse/med. asst/blood pressure taker logs into the computer and reads off a list of questions, occasionally glancing at me. When the doc comes in, she logs in and asks me the same questions, also glancing at me now and again. Afterward she's busy doing the exam so I never really feel like I have her attention – it's like she's always distracted by something. Last time I was there, I saw her sign a sheet on the door, then ask the blood pressure taker if she'd happened to notice what time she came in the room because she'd forgotten to write it on the sheet. I assume someone higher up is pressuring them time wise so I don't blame her – I think she's very good. Taking home a sheet of paper is nice, I guess, and we can check the info online, too, but I'd rather feel like the dr was listening to and seeing me, not just filling in a checklist.

  7. The first time I saw the computer, I was worried it would be like that, but my doc (I don't know about the others in her practice) is really good about talking to me about why I'm there, then looking at the computer to see if there's anything relevant to my immediate problem, then going through my history.

  8. Hi Rob,

    You have correctly grasped that you are just another person like the rest of us.

    You have not grasped the absurd arrogance that is characteristic of most doctors, including yourself.

    You are stating and implictly endorsing that a patient has to tip toe around the reality of their condition with you, in order to avoid offending your ego and desire for control.

    This is a disgusting and indefensible attitude, and it is self evidently a condemnation your profession.

    If you truly held a desire to help people, you would be honest with yourself regarding your capabilities, and check your ego at the door.

    Your profession holds a high degree of institutionalised incompetence in this regard.

    One day you will face your own health problems, and you will appreciate how self-indulgent you are.

    It is extremely common amongst doctors. A bad tradesmen blames his tools, and a bad doctor blames his patients.

    Looks like you’re shit at your job in that regard.

    Regards,

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