Why EMRs Are Moving In The Wrong Direction
- Nicholas A Campitelli DPM FACFAS
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As many hospitals and institutions work at transitioning to electronic medical records (EMR), the ability to obtain information on a patient has become more difficult than ever. In my opinion, electronic medical records as we know them today are probably the largest setback to the advancement of medicine that we have seen. It's frustrating for me, someone who loves technology and even contemplated a career in it, to watch medicine and technology collide instead of seeing the advancements of computers and accessibility of information complement medical records. Before giving my opinion as to why this has happened, I will share with you my personal example that occurs routinely when I am at any of my three hospitals.
I was performing an I&D of a diabetic foot abscess and began the process by seeing my patient in the holding area in pre-op. Before talking to the patients, I wanted to see the laboratory results as well as the reports of other physicians who were seeing the patients. This particular institution was in the process (which has lasted well over two years now) of transitioning from paper charts to electronic records so the information is in two places. The laboratory reports were not yet on the paper chart, and there were no computers in the holding area to pull up the patient’s chart.
The patient then went back to the OR and I began the dreaded process of logging into the electronic records, which of course are protected by countless screens with passwords. I find this somewhat amusing as there were no barriers to finding a patient’s Social Security number on a paper chart. Instead of making the process easier with electronic records, it has become more time consuming as we see with the password issues. That is a debatable area as well, which I will not go into.
So I finally get through the log in process and now it’s time to recall all the steps presented to me in the two-hour crash course on using this system. Mind you, I’m on staff at three institutions, all using different electronic records. So, we have to find the patient in the system. You would think the patient would be under a list of patients I’m treating but of course I was not “tagged” or “attached” to the patient. Luckily there is a paper chart in the room with the patient’s birthdate and medical record number on it (not protected with log in screens) and I can use this to look up the patient in the EMR and find the patient in the system.
Now it’s time to cursor over the 50 or so icons on the screen that are almost too small to read even if there were letters under them describing the icon. I can’t remember which one brings me to the laboratory section so I have to ask a nurse. She responds, “Oh, our screen is different from the doctors’ but I can try to help you.” She is able to get me to the results section, which shows the results of every complete blood cell count (CBC) and other test ever done on this patient at the hospital. Of course, today’s is not visible. Why, you ask? Because I didn’t select the range to display “to date.” Why that would not be automatically selected when the software installs is beyond me, but the fact is I had to select it.
Then we found the labs. It took roughly 10 minutes if you add in the time I couldn’t find a computer in the holding area and had to walk back to the OR with the patient and get logged into one in the OR. I then ask anesthesia if the patient received a dose of antibiotics in pre-op. The anesthesiologist informs me that he will call pre-op and see if anyone gave any antibiotics because it’s much faster than trying to see if it was “entered in the computer.” There is also the fact that sometimes doctors give antibiotics and the nurse hasn’t had time to enter the medication in the electronic chart yet so you’re better off calling.
One who has any basic background of understanding computers could spend a few days and create a process to take notes that far surpasses the current EMRs implemented in healthcare practices. The problem is that process would not be Medicare approved. I watched an internist do this and take pride in his ability to simplify his practice through self-created templates that streamlined his ability to take notes. It was eventually sidelined as a result of not being Medicare compliant.
Consider that there is no one EMR that physicians are longing to have. It’s an untapped industry that is awaiting an overhaul. This means people are not lining up or waiting to get their hands on a new electronic record system that will streamline their office and make their job easier. On the contrary, the same physicians are all in love with their iPhones or Android smart phones, which have revolutionized the way we all communicate and access information.
Things have progressed from the philosophy of “It wasn't in the note” and “It wasn't done for malpractice purposes” to “If you want it done, put it in your note.” This is not from a malpractice standpoint but from a standpoint of billing purposes. This is across the board with all aspects of medicine, not just podiatry or any subspecialty. We create templates from a standpoint of reaching billing points, not covering aspects that look at patient care. It’s pretty clear when you look at a consultation note sent from a family physician that is six pages long, full of all normal findings. However, if this physician were to have covered every aspect in the note, he probably could only see 10 patients a day and never survive from a financial standpoint. This is also probably a topic for another discussion, but without a doubt medical notes are being designed to hit points for billing purposes, and then secondarily to cover all aspects of necessary physical exams and tests.
Working Toward Streamlined EMR
In my opinion the problem lies within those who are creating the EMR programs. They clearly do not have any idea of what the needs of the physician are. You have to step back and look at this from a simplistic standpoint and ask: what are we trying to accomplish? Then, work backwards from there. The number one goal that you need to accomplish is recording information from the patient and making it very easily accessible so you can spend time with the patient either to explain the problem or search for more problems.
The devices are in existence: a tablet, a phone, a laptop, etc. The challenge is creating the software for them. What’s amusing to me is these devices have been around for years, and we have yet to see them assist the physicians in record keeping. They help us everyday in obtaining information from periodicals and electronic textbooks. I’m sure most of you reading this have either Googled a topic today or looked up something else online today that relates to medicine. On the contrary, if you’re in a hospital and you’re trying to find someone’s vitals signs or a CBC, it can be challenging.
Think of a book, which includes the title on the cover, a table of contents in the front, and an index in the back. Then think of completely rearranging this and have someone try to find a piece of information. I see it as needing to use the devices we have at our disposal to keep records and information that pertain to the patient. There is no need to make the software so complex that you have to take hours and hours of classes to understand how to use it. I’m sure many of you reading this have the ability to use Google, PubMed and other educational software and applications on a computer without having any training. You are using the software or app to accomplish one simple task: Obtain information.
The same can be said for an EMR, which you are using to obtain information. When handed an EMR that you may have never used before, it could take hours to find a CBC or someone’s vitals if you don’t have instructions for how to do so. Would you not agree there is a problem here? I use one of the most popular EMRs in my office that is in use in many hospitals throughout the country and for me to snap a picture of a wound or foot and incorporate it into the chart would take multiple complex tasks and more than one office staff member to accomplish this. On the contrary, I can snap a photo with my iPad and securely send it across the world in seconds. Again, it is very clear that the industry is in need of serious innovation.
Even if one governing body created a monopoly and we all had to use this software or application for record keeping we would be further ahead than we are now. The industry for electronic medical records has no innovation or leader that is creating competition so what we currently have now is doomed for failure. If you look at operating systems for computers, we basically have two: Windows and MacOS X. Anyone who uses a computer is without a doubt familiar with one of these two enough that they can navigate and obtain information from the computer.
Will a day come when we can use the EMR to help physicians? We need a lot to change for that to happen. It is very unfortunate because other industries have simpler systems that have made users’ lives easier, yet keeping records in medicine has become one of the most difficult tasks I perform daily. This is despite the fact that I’m pretty computer savvy, having grown up in the generation that used them daily since elementary school as well as programming and using them as a hobby.
In order for technology to work toward our advantage in the healthcare industry, we will need to have a complete overhaul in the system. There are too many barriers that are now government regulated to meet the “healthcare compliant” standards, which are too far beyond my knowledge to even understand. Thankfully I’m part of a multispecialty group that has a complete division of employees assigned to making sure our notes are set up to hit the points that are needed.
Can we meet halfway and still fulfill these compliance issues with a simple electronic record? Possibly, but I don’t see this on the horizon. In my opinion it will happen first with the concierge medicine model in which the physicians have patients pay into or subscribe to the practice for unlimited care over a given timeframe, which is typically one year. The doctors in these models are already streamlining their notes to be more simplistic, easy to follow and patient pertinent.
Eventually someone from the technology sector will merge with someone in the healthcare industry and use technology to assist in note taking. Until then, we will probably see our current record taking process become more complex with more and more useless information clouding the chart, making it time consuming and difficult for the physicians and nurses to do their job.