Non-Electronic Medical Records - Paper is just fine - Besides I am too sexy for EMR

[Tim2]

The boys with their toys are over there in the Electronic Medical Records (EMR) forum dreaming and scheming about gadget proliferation in medicine. I like the idea, but paper is working out pretty good and don't see many shoppers going out to gagetize their medical office.

I am curious why the gizmo guys haven't been able to convince you that they have something you need.

[pprescot]

They don't have to convince you. It will soon be required by the gov.

[Tim2]

Come-on P, I am trying to figure out what makes these folks tic. It's marketing research, I suppose. The gov. will have a difficult time getting this up to speed. They have no idea how great the magnitude of the resistance to adapt to tech is. I want to hear the gizmo-phobes story.

[Kursk]

The short story: them that has the money makes the rules. Do you like getting paid?
Look at all the humiliating funny things I can make you do if I hold your money and make you beg for it. How much of your overhead is hiring people that should be working for the insurer and not you!

So if payment is tied to quality and quality has to be demonstrated by chart review and you have to have someone come in and manually review charts and I don't ....

"coolness" is not the reasion I use EMR. Efficiency. Documentation. Improved adherence to screening recs, better office workflow, printed prescriptions with a record of meds given, etc etc.

I have 2 old AMD Duron machines 800 mgz, 3 years old, definitely not leading edge or "cool". I am absolutely convinced that computers help me deliver much improved healthcare.

[bshug4u]

i would love to computerize but it is time consuming and will cut down on the volume of patients that can be see. also it is costly. once the ins companies provide the software and the computer upgrades maybe i will try.

[Kursk]

EMR is often time neutral once the training period is over. Outpatient EMRs claim cost SAVINGS due to coding improvement and office efficiencies that let you reduce FTEs/physician or at least FTE expenses/physician. I suspect that this claim is probably true except for those "overly productive" practices that are in the top 5%. Often they prefer inadaquate documentation and patient outcomes to keep the money flowing. If you barely document anything and you see a million patients a day, EMR will probably slow you down. While I am logging in and finding a chart you will have seen 2-3 patients. Can't help you at all.

[Tim2]

Kursk, I know you have a better way. I don't see functional, plug and play, EMR coming in the 20 years I have left in my career. The reason is because there is no demand for functional EMR from the average doc who cannot write code or set up and maintain a system. I really don't care if the government demands it. The government demands many things that simply are not going to happen. The gamers out of medical school are looking for a similiar experience. A clunky gov. mandated EMR will go the way of the Wang.

For the work I do, I cannot chose what system I can use. I chart on what they have to chart on. I am not threatend by payment tied to electronic chart review. Outcome based medicine will create more fall through the crack patients than managed care did. I will probably be charting on paper for those patients and it is not by choice.

Now can I hear from the non-EMR devotees who may be brought around to EMR through undestanding their concerns?

[Kursk]

HD I see you point(s). Are you saying that there is nothing functional enough in the current product offerings? What are the sticking points as you see them? I too await the comments of the non-devoted.

But to expound a bit further, the chart is central to the care process and therefore is not your exclusive domain (although psych seems to have a better lock for now). The chart is slowly becoming a multi owner document and the needs of the other stakeholders will influence this decision.

[Tim2]

the chart is central to the care process

Absolutely, there must be transparencies. Though my process notes will never be seen, you must be able to see my progress notes on shared patient. A practical solution is the EMR, but we are not even close to the full meaning of the phrase. What are the common docs barriers?

[r2t2ellis]

... The government demands many things that simply are not going to happen. ....


So much for the free country we live in. The govt. demands too many things as it is all the while wasting much of the tax $ we pay them. If the govt. waste alone was channeled into Medicare/Health programs, we wouldn't have such a crisis for those that cannot get insurance.

I think that's what I said. :eek:

[hirschr]

i would love to computerize but it is time consuming and will cut down on the volume of patients that can be see. also it is costly. once the ins companies provide the software and the computer upgrades maybe i will try.

An EMR will pay for itself by allowing you to charge for the work you really do by counting bullets for you and telling you that it really was a level 4 not level 3. I can't tell you the last level 5 I billed or new patient level 4 or 5; I know I cannot write out a comprenhensive physical exam, but a computer will let me clcik off all the 19 things I examined. And they can threaten me and audit me, it's all documented. Rememberthe saying "If you didn't document it, you didn't ask it or do it"? Well with an EMR, it's "I documented it ALL, so show me the money!" And don't forget no manual charge entry- your charges are submitted the day you see the patient.

Most providers who are up and running will tell you they can see more patients, not less.

Cost is relative. Shop around, check out eClinicalWorks.

[Tim2]

i would love to computerize but it is time consuming and will cut down on the volume of patients that can be see. also it is costly. once the ins companies provide the software and the computer upgrades maybe i will try.

Thanks for indulging me bshug4u. I hear your concerns and think they can be overcome. Keep your thoughts flowing; don't buy anything yet. I'll promise disappointment, and wager on it to boot.

Just keep the ideas flowing to the barriers to EMR. Let's hear from some others. Any technophobes out there?

[jlively]

I'll throw out one reason why OUR practice has determined that an EMR is a necessity for us. It is the same reason that you give for not having an EMR. Paper is fine. Yes it is, and we generate mountains of it. We have grown over the last 20+ years to 12 facilities with over 220,000 patient visits per year. Each visit generates at least a note, a patient demographics/insurance sheet, sometimes a prescription, sometimes a physical form, sometimes a workers comp status report, sometimes a referral letter, etc. Our current costs for storage of these documents are close to $30,000 per year! Not to mention that the majority of the charts are stored at a wharehouse that is not even close to a clinic location. If a doc wants a patient chart then someone has to drive to the warehouse, find the documents in one of 15 different rooms and fax them to the clinic. How's that for a good reason? :rolleyes:

[Tim2]

[big yawn]

Geezus EMR fans, I am not anti-EMR. I am pro-EMR. Can you guys give it a rest? I know the pro-EMR mantra; been preaching it for more than ten years. I also know that you technophiles will go to any length to justify your techno existance. Ergo, the off topic crap each one of you has posted so far.

The question being asked, EMR-devotees, is for the folks that don't use EMR about their barriers to use of technology in their practice? Now go play with your toys and let us hear from those not trying to justify their existance through EMR.

Ah, I need a p & vinagar refill.

[abower]

Interesting, trying to find the "computer phobic" online.
Despite many trying to say that physicians are technically adverse, most of us do computer billing, do researches online and own at least one computer.
Personally I do not believe that computer systems save money. Hospitals and offices that have them have the same number of employees. In fact those employees tend to get more expensive. Even with a billing system you can generate letters to patients reminding them of needed exams or tests by the demographics and prior codes.
The problem is that the present EMRs will be replaced hopefully by systems that can talk with the hospital, the pharmacy, the lab and other physicians. So you will have to chuck the expensive one you have now and why waste the money? It may be an online system or not. Security will be the overriding concern. All the vendors who want to make the systems manditory will resist the change because it threatens their small business and they will blame the doctor.
:cool:

[Tim2]

Hey again abower.

My wife is one of a few Ivy-league trained Pediatrician hospitalists at a local hospital who regularly resusitate dead infants with out the back-up of a neonatologist and only a skeletal, level-two NICU. They don't use EMR. She has bought a Mac every couple of years since 1990. Plugs it in and it spins like a top. Slicker than hirschr's dog's snot.

I wouldn't categorize her or any of the docs she works with as computer phobic. They know how to lift from the knees and use the best of what is available. Damn smart people.

When I talk to her or any of tham about EMR, they compassionately smile and effectively say when you boys (and Mel) get it right we will use it. I assure you, they know that we can automate an office. They also know that they will use it in their own time, for their own reasons.

What I am attempting to discover is what those things are. There is not one thing stated thusfar that we have not known for more than a decade. When I am pushing up daisies, I sure as heck don't want a bunch of docs sitting around rehashing the same issues and never giving concern to what makes the potential consumer EMR doc tick. Perhaps knowing their mind and anticipating their needs will bring about a shared dream to fruition.

[r2t2ellis]

....When I talk to her or any of tham about EMR, they compassionately smile and effectively say when you boys (and Mel) get it right we will use it. I assure you, they know that we can automate an office. They also know that they will use it in their own time, for their own reasons.

What I am attempting to discover is what those things are. There is not one thing stated thusfar that we have not known for more than a decade. When I am pushing up daisies, I sure as heck don't want a bunch of docs sitting around rehashing the same issues and never giving concern to what makes the potential consumer EMR doc tick. Perhaps knowing their mind and anticipating their needs will bring about a shared dream to fruition.

"Feed the computer" :rolleyes: that is what I used to say that my residency when I was so busy that I didn't even have time to look up. I was in the military and we had CHCS. Most of us hated the computer, had (& made) little time to learn how to work it. We would get angry when we were told that "the order wasn't in the computer" or that "the note wasn't in the computer". When the computer was up we all complained. When the sysytem was down we all complained even more because we then had to run the steps eight or nine floors to the lab & radiology. (We were too macho & too busy to take the elevator.)

I had to do my research paper - couldn't get past the DOS and/or figure out how to navagate Windows 3.1 - make a file/save a file etc.

Attitude was one of my (our) problems. We were in a surgical residency, and there were other residencies in our hospital or complex that were not working near as hard as we thought we were working. Probably true & somewhat self inflicted. They had time to do computers, learn about computers play with computers etc., etc. Basically, we held them in great disdain. Those boys and girls of the cute little computers! Seems like all they were doing was just playing. We were just "too sexy for computers. (EMR)

Well, now that I'm over 10 years out of my residency in six years out of the military, I have learned that working all the time and doing my job to the exclusion of everything else including family is just not worth it.

I have found that using an EMR has helped us in so many ways. We don't wander around looking for charts.

1)We can find information from any room in our office that has a computer terminal.

2) Everybody can read my entries into the computer and are not complaining about my handwriting!

3) I put more data into each of one of my entries about my patients.

4)I'm less fearful of someone misinterpreting what I have put into the record, and certainly feel that my records are much more pristine and would stand up better in court.

So there was a time my life when I was too good for this computer thing, but I'm glad I learned a little bit of humility to allow me to find other instruments of the trade besides a scalpel or a hemostat.

[Tim2]

R2Unit, Enjoyed the war story. We all know the EMR benefit. Attitude may be some of it for the docs. Is that all the resistance amounts to?

Let's leave ignorance and sloth out for the sake of getting jinky with it.

Hear Velma say "Let's get jinky with it". http://promo.warnerbros.com/scoobydoo/thegang/velma_sounds.html

[r2t2ellis]

Is attitude all, probably not, but it played a big role for us. Ignorance of what EMR can do plays a role. Sloth...most physicians I have known were not sloths...some have been chumps, I mean chimps.

:eek: (Did I say that?)

[mel]

More barriers to EMR adoption (http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=264443) and how the Open Source movement can help

[Surgeon]

"I have found that using an EMR has helped us in so many ways. We don't wander around looking for charts. "
Too me, this is the single greates timesaver in the history of medicine. I can't imagine how many millions of non-productive hours we're talking about here. I long for the day when any film can be pulled up on any computer.

[mel]

Interesting, trying to find the "computer phobic" online.
Despite many trying to say that physicians are technically adverse, most of us do computer billing, do researches online and own at least one computer.
Personally I do not believe that computer systems save money. Hospitals and offices that have them have the same number of employees. In fact those employees tend to get more expensive. Even with a billing system you can generate letters to patients reminding them of needed exams or tests by the demographics and prior codes.

I know several docs that will never use computers, I think it has more to do with a combination of "intimidation" and being embarassed about learning something new. A few will admit in private they wish they had taken time to learn, and yes, you will not find computer-phobes online, the most they can do is check their AOL email, or get the front desk to do a Pubmed search for them.

[ozzie]

As much as open source can help its very limited you can't even give EMR's away . Until someone has the reproductive organs to stop the madness and say here is a definition of EMR , here is a scope of an EMR, its going to be tough to build..
National Alliance for Primary Care Informatics these folks right now do nothing but make the water cloudy.. full of theorem and serum but no do-um..lol
Its great to talk about informantics but if the systems doesn't talk to each other on any level what does it mean.???


Right now it's like building a car and everyone is talking about the hub caps and the vanity mirror and the color and how fast is MAY go and after all dont bother because the govt will give us a car in a few years anyhow.
I will steal a pfizer term " other influentials" to many folks that have influence over the doctor in assisting in EMR decisions and in the end it's their influence that has messed a lot of stuff up.
EMR is not billing and billing is not EMR.
Emr's should be built just like the internet all have core structure then tweaked from there. Any other way will just be a mess.


oz

[r2t2ellis]

My efforts in building an EMR have centered around the H&P & SOAP Note documentation process. It is what we do. I have taken this "core concept" & worked outward.

I wanted a speedy/effective documentation technque that allowed me to augment the note w/ things I usually left out in a note. Along w/ that note I wanted convenient retrieval. Aside from lab & x-ray retrieval & Rx writing other features are secondary in the EMR process.

[ozzie]

there you go start at the patient and finish at the patient

GMTA
oz

[Tim2]

Well, there you have it. I gave EMR talk up a few years back and should have stuck with my guns and continued on the course Bigdoc. If you want to continue to make a consensus statement BigDoc, I'll support it. Although, it seems like jousting with a butterknife.

[davidtm]

OK, I'll bite.

My agency is considering going to EMR. In fact, we've already invested $200K toward a product that will tie in to our existing MIS system. (It's called eCET for CMHC if anyone who knows it.) We started a "workgroup" to begin looking at/planning for implementation, but we got bogged down. That process died when another "urgent" project came up. We are now resurrectng the issue. (Notice the ambivalence?) Fortunately, our Admin person has said, "We need to articulate what we need, not just adapt to some product we already have." That discussion begins this Thursday.

The one advantage to EMR we already see is universal access throughout an agency with multiple sites. However, the technophobes are a factor, connectivity is a factor (though the same Admin person makes clear that is solvable given the $), security is a factor, and just plain usability by the end users is a factor. (Obviously, we will need to define what usability is ourselves, not just take some marketer's word for it.)

I welcome any advice.

DM

[Tim2]

Thanks for stepping forward, david®. I think the folks here will give you plenty of advice. I would like to use your comments as a springboard for others fledgling with ambivalence to sound off. I think those who would give you advice here need to better understand the real world and perceived concerns of community docs if EMR is to spread beyond hobbist to industry standard.

[mel]

If we don't do something soon, a solution we don't like will be forced upon us :eek:

[Tim2]

I keep hearing that, Mel. I cannot tell you how sadly unimpressed I am about it. I hope I am wrong. This administration doesn't even understand it's own foreign policy. How is it going to solve domestic issues? Remember, Bush put EMR on the ten-year plan. That is not acceptable, but it is real.

Sending out an alarm will force the ambivalent into hiding. I don’t think that is a position of strength. In an above post, Davidtm said, "OK, I'll bite." I don't want good docs thinking or feeling that way about something that is good.

[ozzie]

Vista is not true open source. its kinda like Microsoft making windows 95 open source. Vista for the most part was /is a huge government dev job contract. Vista has been around for a while no one used it because it not suited for small / medium practice. Just read one manual and try to make sense of it..

So much of the open source capability is limited as unless you run a VA its not much value . It has more value as an international product to give to the world.

I still think the push to Vista is smoke screen and a bull$hit way to sate the doctors. The doctors that really need EMR systems are not on 5th ave NYC but downtown Podunk with very limited resources and huge bloatathon like Vista is about us useful as udders on a bull to them. They need more simple solutions.
Vista is an answer but not the solution..
I could not even imagine trying to deal with the VA trying to agree to disagree on design LOL
So dont fall for the trap Vista will not solve anything.
Be a naysayer all you want but how many docs said they would never use electronic billing ??

How many docs said that they would never sign up with insurance companies?

I see it as pick your poison now or let the govt decide for you or hang up the shingle.
How many docs never were going to use that dang fangled fax , cell phoines , internet and it goes on and on.

[ozzie]

Also lets not even waste any more time on Vista and what the govt will do. These are the people that brought you the IRS / Lets move on stop crying on your paperwork and look down the road for solutions that will help assist patients medical needs..
oz

[Kursk]

Well, HD, chagrined I present evidence of the ineffectiveness of drug allergy alerting in CPOE systems from no less than the hallowed pages of JAMIA:

Results 6,182 (80%) of 7,761 total alerts were overridden in 1,150 patients. In this sample, only 10% of alerts were triggered by an exact match between the drug ordered and allergy listed. Physicians' most common reasons for overriding alerts were "Aware / Will monitor" (55%), "Patient does not have this allergy / Tolerates" (33%), and "Patient taking already" (10%). In a stratified random subset of 320 patients (28% of 1,150) on chart review, 19 (6%) experienced ADEs attributed to the overridden drug; of these, 9 (47%) were serious. None of the ADEs was considered preventable because the overrides were deemed clinically justifiable. The degree of completeness of patients' allergy lists was highly variable and generally low in both paper charts and the CPOE system.

Emphasis mine. Bad data = bad system. No doubt.

Overide 80% time? Talk about alert fatigue. No wonder docs don't want to use the damn thing!

However, to be fair, many other studies of excellent reduction in ADE with CPOE.

http://www.jamia.org/cgi/content/abstract/M1556v1

[Tim2]

Over 700 alerts were exact matches. I'd consider myself lucky to have a system alerting me.

Besides, look at the intermittent reward side of the coin. It is in your favor.

[Kursk]

I don't think you'd be happy having to dismiss 80/100 pop ups AND explain why. It is surely a major annoyance that gives one alert fatigue and results in "click through without reading". System clearly needs improvement if to be deployed to "unbelievers".

[Tim2]

I was trying to throw you a bone. Keep your chin up Kiddo, you are on the right track.

[Kursk]

Donk, ..... ouch. No more throwing of hard objects!

Speed and alerts were apparently key to the debacle at Cedars, the CPOE system that shall live in infamy. I think they are still on paper to this day. Poor Dr. Shabot.

[abower]

As a lowly paid FP it also seemed grossly unfair that my "speciality" requires a more complex system than a true specialty. That complexity would cost and overburden and already high overhead (avg = ~60%). With a true specialty, you are dealing with a limited number of diagnostic codes, office visits and procedures. Templates, voice dictation, everything seems to work better under these conditions. As primary care physicians, you see a volume of visits for a small reimbursement for each. Big hardware and big software :p

[Kursk]

AB, true words. More preventative care tracking, more things to get dinged, more risk, less respect, more likely to get replaced by paramedical personel. I live it every day.

But then the poor ortho guys simply must have digital radiology and miniPACS in their multiple office locations to have any efficiency, so its not THAT easy for the specialist types.

[abower]

Not just the visits, there are also the refills, phone messages and answers (50+) a day to go in the system, the nighttime calls, NH visits, Hospital visits and perhaps even home visits. How to get the input done without breaking the bank. I wouldn't worry about those specialists except pediatrics, general IM and psychiatry, they are managing to take home more.... the bottom line. :D