Electronic Medical Records, Workflows, and Meaningful Use

As I've been trolling the blogs on KevinMD, and this one by Margalit Gur Arie, there are questions about whether electronic health records are the "panacea" to the problems with health care and whether they improve the quality of care of patients in the real world.

Although my own experince is just an n=1 of this question, here is my two-cents worth.

From the very beginning of my medical career, I had no illusions that electronic medical records could fix all the problems with our health care system.  But just like I envisioned the computer as the next tool that could spark further advancements in communication, the electronic medical record was an extension of that future.  Nothing more, nothing less.

I also was not going to wait for definitive studies to prove that electronic medical records could improve patient care or improve medical decision making.  For me, electronic medical records were a tool to simplify my tasks as a doctor, to automate certain tasks that humans are more prone to produce errors.  Also, all these studies are predicated on the assumption that all EMRs are equal...which are not.  It's also assumed that these EMRs are easy to use...which universally, are not.  So these studies, in my mind, are moot.

I mean, look at all the world around you...Google, Yahoo, Facebook, Macbooks, laptops, iPhones.  We are now in an electronic world.  The electronic world took off nearly 50 years ago.  There were no studies convincing people that using the iPhone could be beneficial for you.  People can see the potential without these studies.  The reason why iPhones, iPads, and Android phones are so successful is because the user interface is intuitive and the device is able to combine several tasks and simplify what were separate tasks on separate devices into one.

It pains me to see the medical world falling so behind on this.  It pains me to see doctors office still using paper charts while in the very same room, medical staff were using computers to check their e-mail, buy something from Amazon, and update their Facebook accounts.

Financial entities, insurance companies, computer software companies, internet companies, high technology companies, shipping companies, even libraries and restaurants use computers to document and track their work efficiently and without significant redundancy.  Even WalMart has this supercomputer that minutely keeps track of all their purchases and goods and it even can predict buyer trends, to help their bottom line...because they all realize that there are certain things that computers can be really, really good at doing better than humans.  And there are certain things that humans are much, much better at doing than computers.

And if they did not use the computers to their advantage, they'll be left in the dust.

It's just that the physician's office and hospitals are still at the starting gate and stalled in the first leg of the race, running around in circles about what these contraptions called electronic health records can do for them.  The insurance companies all know they have the upper hand in this because they use computers day in and day out in their industry and now they are trying to dictate to the doctors what kind of data they need, even if it doesn't neccesarily improve patient care or respect patient autonomy.

This kind of dictation to the doctors is what all this meaningful use jargon is all about.  On paper, it seems like a good idea; to set a series of guidelines and features that an EMR must have so that it is certified as a good product.

I'm a car guy, so I'm going to use this analogy for people.

Let's say you are a "certifier" and you are trying to make a list of cars that you want to "certify" that have a certain list of specifications.  The specifications include a car that makes at least 300 horsepower, has a navigation system, 2 cup holders, 4 wheels, a steering wheel, front disc brakes, and a fold down rear seat.  You compile a list of cars, but because you're looking for a car that needs more than 300 hp, you're really picking maybe 10 cars that can qualify.  And they all cost a lot!  But none of these 10 cars are easy to drive because with all that horsepower, the car has a tendency to swerve to the right or left when you press the accelerator pedal and you have to hold on to that steering wheel tight to keep from getting into an accident.  But you left out a pretty big list of cars that actually drives well and safely and still gets the job done...just not with 300 horsepower.

This is what has happend with meaningful use and EMR certification.  Some "certifier" has deemed a list of specifications that doesn't necessarily define real "meaningful use".  And this "certifier" has said that for EMR companies to be certified, they have to pony up $30,000 a year just to get a stamp of approval.  Back to the car analogy, Ford would have to go to their "certifier" to prove that their car makes at least 300 horsepower just to be on this list and Ford then passes on the cost to the buyer of the car.  Why would anyone in their right mind do that in the real world?  I certainly wouldn't want to buy a car like that, and certainly not for that amount of money!

Even worse, this list of EMRs is the only one that the government will recognize so that the buyer of the EMR may get some reimbursement of their purchase.

What is the alternate view of EMR use?

For me, I needed to have an EMR that would fit my work flow, how a doctor thinks and how we document encounters intuitively so that we don't need to spend a lot of time figuring out how to use it.  I only managed to pick a few EMRs, and most I nixed because I could not afford it as a small, solo doctor.  The one I picked initially worked "OK" but the there were things I needed to automate but could not use without adding a whole bunch of "macros" that I programmed for myself to interface with the EMR so I can order labs, send bills, send faxes, and scan documents.  It worked for a while but with any macro, any change to the system "broke" the macro and I had to start over from scratch.  Every EMR I continued to look for, was constructed in a way that looked like the billing was the central part of the system and documenting encounters took a back seat.  I understand we have to make money through billing, but it should not be how a doctor sees a patient during an appointment.  It made no sense to me and I did not see how it would help my workflow to be efficient with that kind of framework for an EMR, which was the norm; not the exception.  In an act of desparation, I gave up looking for one and I decided to make my own since I spent a lot of time making macros anyways.  Crazy, I know.  I was that desparate!

And how I made it was all based on what made sense for a doctor's work flow when I see a patient.  I was a doctor, I know my own workflows and it was based on how I was taught in medical school.  I want ready access to all patient parameters, not through multiple clicks, screens, or special terminologies that only exist in IT world.  I want automated tasks and scheduling features, reminders of important alerts, and not have these clinical decision making tools that impede my ability to document my encounter.  I created this system all on my own and I used it for myself and with my patients for the past 1 1/2 years.  And it worked really well for me and I was much more efficient that I could ever be with my practice.  Ironically, the landscape of medicine had changed so much by the time I was using it (see my previous posts) that it didn't matter how efficient I was.  The odds were against me.  That is where the limitations of EMRs can go, at least in primary care.  But I still believe that a good, user-friendly EMR is what doctors need, not to fix health care or even prevent a patient from dying, but that good communication and efficiency from using an EMR allows a doctor to focus and do what computers can never replicate...practice the art of medicine.

And that was what I did with my practice; spending quality time with my patients and the computers were way, way in the background (even though the computers were doing lots of things for me...but out of the way of the patient).  That is what improves patient care; that is what reduces health care costs.

Here's the link to my new project...NOSH EMR, coming soon for public consumption!