Learning a New Language | An Insight into EMR

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.

Problem 1: Different Languages

As I struggled to figure out my new system, it occurred to me that I felt a lot like a person learning a new language.  Here I was: an expert in German linguistics and I was now having to learn Japanese.  Both are systems of written and spoken code that accomplish the same task: communication of data from one person to another.  Both do so using many of the same basic elements: subjects, objects, nouns, verbs.  Both are learned by children and spoken by millions of people.  But both are very, very different in many ways.

The reason for my feeling this way is that, at their core, EMR products are computer programs.  They are written by engineers with physicians (many of whom have left clinical practice to work for the EMR company) consulting to help shape the product.  The object of the program may be physician use, but their heart is that of an engineer.  So the storage of the data, the organization of the medical information, the location of where anything can be found, is based much more on the nature of the programmer than anything else.

Problem 2: Strengths vs. Weaknesses

The idea of an EMR is (reputedly) to simplify the task of health care providers in documenting care and retrieving the information quickly.  The reality is that some things are of higher priority to one EMR manufacturer than another.  Tasks that were simple in my old system (putting in labs, generating letters with structured data, getting a quick overview of a person\’s record) are difficult in the new system.  The new system, however, does other tasks much better (auto-completion of lab data, management of referrals, interfacing with patient portal, etc).

I am amazed at how many steps it takes to do tasks my old EMR vendor did quickly.  Why did they make it so hard?  It comes down to priorities, and for whatever reason (CCHIT, Meaningful Use, Moon Phase) some things get high priority, while others are consigned to the \”later\” pile.

Problem 3: The System

The fundamental reason EMR systems are so difficult is not the nature of the programmers making it or the doctors using it; it is that EMR\’s are grown in the hot-house of a chaotic and arbitrary health care system.  It makes no clinical sense that there are a gazillion ICD-9 codes, but there are, and any EMR system wanting success needs to devote lots of effort to ICD-9 (and soon to ICD-10 – yippee).  The structure of most office notes are not to give the best clinical information in the simplest format; notes are generated for the sake of proper billing, including a 10:1 ratio of useless to useful information.  Most notes are like a small gift contained in a large box of packing material, with the majority of information simply getting in the way of what is really wanted.  EMR systems are well-designed to generate lots and lots of packing material.

The system I chose does the E/M office visit very well, but does so at the cost of hiding useful information and de-emphasizing what is most clinically helpful for the sake of E/M codes, or what will qualify the practice for \”meaningful use\” money.  I don\’t fault the system for it, since we doctors spend far more of our time focused on E/M codes and \”meaningful use\” than on patient care.  That is one of the big reasons I left my old practice.

The reality is that EMR systems are designed to finesse the payment system more than they are for patient care.  That is because the thing we call \”Health Care\” refers to the payment system, not to actual patient care.  My frustration with my current EMR system is not that it doesn\’t do it\’s job well (it still is better than my old one…I think), it\’s that it is grown on a planet where the honor being a healer is being consumed by the curse of being a provider.  Patients don\’t matter as much as payment in our system, so EMR systems will follow those priorities.  Those who don\’t will not succeed.

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.

It makes me feel like a piece of scheisse (たわごと).

*For those wondering, I was on Centricity by GE and am now using eClinicalWorks.
**My Geek Credentials:
  • 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.\”

14 thoughts on “Learning a New Language | An Insight into EMR”

  1. Wow. Both of those look like they were developed in 1995. I would love to talk to you about your specific issues/wishes with your new system.

  2. Interesting. As a software developer, I find that software is too often presented to the programmer as, “Here, make it do these ‘x number of things’, we don’t care how” and then are purchased by large organizations based on said same criteria, with little thought to the user workflow. Terrible systems are born that way.

  3. Do you think that EMRs will ever be standardized into one format or one program? I think that EMRs, like specific computer operating systems, will only be easy for those who “grow up” with them (i.e., the medical students going through school now or in the next few years). I was exposed to both Apple, Windows, and DOS computers in elementary school, so I was always able to figure out any computer with relative ease, but my best friend, who grew up only knowing about Windows, was overwhelmed by Apple computers when she had to switch. (And my mom, who scarcely saw computer until I went to elementary school, hardly knows how to turn my laptop on.) Do you think your source of frustration might be due to the fact that you used different EMR programs throughout your years of training/practice?

  4. I would have said “yes” to the first question before my recent experience, but now I am doubtful that there will be a unity of interface in the near future. Unfortunately, medical records reflect the dysfunctional nature of the rest of the system (embody it, in many ways). Their purpose has been entirely subverted from patient care to something else (I’m not sure what, though). The system is all about complexity, so these programs end up far too complex to come close to their potential as clinical tools able to simplify tasks. Perhaps (as one reader suggested) those of us who have left the complexity of the HC system will develop EMR systems that are truly about simplification and maximizing patient care. I don’t know about that, but I crave simplicity, and using a product designed to deal with the complex and chaotic system we’ve created doesn’t give me much chance to see that simplicity. It’s quite frustrating.

  5. I think there’s probably a huge opportunity for someone somewhere to do just what you said. Too often, software’s downfall is that even if it starts out simple, it tries to satisfy every quirk of numerous different users. Good software often forces a user to adapt to a new process. Unfortunately users are generally in the mindset of looking at software as a tool that must adapt to their own process, and in order to sell it, the developing company obliges and chaos eventually ensues. A good EMR system could be an enormously powerful tool by encouraging other doctors to adopt a proved process.

  6. Peggy Polaneczky, MD

    I started using EPIC in 2006. I think it’s only in the past year or so that I’ve become close to being fluent in it’s language, and only in the past 6 months that I am more rather than less efficient using it instead of paper.

  7. I have used several EMR systems, and none of them worked as well as the one I used in med school at Wishard. It gave me unrealistic expectations of future EMRs.

  8. As usual you are singing my song. I worked briefly with ECW (6 months) and determined it was programmed by a bunch of unmedicated schizophrenic monkeys! But it was no worse than my experiences with NextGen or Cerner for the reasons you mention; it’s not written by medical people who want to provide caring, compassionate care. The other caveat to my situation is that I live with a Cerner data guru/programmer/information systems analyst for a major regional children’s hospital. He, of course, believes as you once did that us providers are just a bunch of whiners and we should just suck it up and chart the way he thinks we should dammit (ok, he’s not THAT calloused but sometimes it feels like that…)Believe it or not I’m using Practice Fusion for my new practice and liking it. I accept that it is free and has limited features and support and get it to do what I need it to. Soon I will be sucked into Anasasi/Cerner’s primary care/mental health hybrid program and I suspect I will miss the simplicity of PrFu.
    What I find myself wondering is how (if we’re supposed to be moving toward a system where each pt’s health information is available in one format and one place) we will accomplish this with all these proprietary and widely divergent EMR systems. I still fax release of info forms multiple times a day (sometimes on people I have directly referred to the other provider) and struggle getting information in a useful, meaningful way on my pts.

  9. Rob- Fascinating to read about your transition to a new system. I stuck with “the devil you know” with my new group. Great to hear that you are pushing the envelope in the solo practice model. I will be very interested in how you use the simplicity model to deliver more personal care. Will also look forward to how you use the conceirage model to give better care. Keep in touch!Steve Clemenson, MD one of your followers from CHUG

  10. So I am curious, are you using eClinical in your ‘new’ practice? I mean… why you would switch it up as you venture out into a new practice model given your past success, and years of experience using GE’s EMR.

  11. To EMRSupport Guy
    We initially chose GE Centricity and worked with them for five months. They then pulled that product, and wanted us to upgrade to a version that was $300 more a month. They couldn’t understand why we were outraged.
    To the Rest of Us-
    Among things we have learned- ” meaningful use “isn’t very meaningful. I used to hand print an “action item list” to make it clear what was task list before the next visit. The visit summary coming out of the software wasn’t recognizable to most of my patients in the same way as a task list.
    EHR’s generate a lot of paper- by the time you give the patient a summary and health information- which is the same medication information that the pharmacy will also give- or some of the ACP literature , we have used more paper than a paper note used to generate.

    It took 5 months to connect to the hospital lab and radiology, Meanwhile, we either scanned- or the staff had to manually enter data, They have other useful things to do. Like check in patients and answer the phone. We still have data that has to be hand scanned- correctly, to the correct chart in the correct file. There is just as much potential for error,

    Questions generate a “ticket’ to speak to a programmer , Only in the last 2 months have we been given a call back number to speak to the same person for the same problem.

    My more computer wise associate thought I was exaggerating- until she got a new complicated medicare patient ( it’s 80% of my practice, 20% of hers) . It also took her 4 hours, by the time she reviewed old records and got them scanned into the system, entered immunizations, the depression screen, mental status testing, smoking status, etc. At least I felt less stupid.

    There is still no program for oversight billing in the form that Medicare requires. I have requested it since July,
    I only got a response after I pointed out that their billing service had to be losing significant money .

    My husband is an engineer working on detection for the big asteroid. Their project plan is complicated but clearly has better project managing. I agree that’s what the software feels like- components put together as tasks, but not with the vision for a unified whole seen in the detection system for that asteroid,

    Our patients’ lives are at least that important.

  12. Not atypical I would recommend a new breed of EHR, they are developed using newer technology, and understand usability. Top pick would be Kareo EHR http://www.kareo.com – it free too!

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