American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, September 24, 2012

EHR installation redux

Well, here I go again. I'm about to install an electronic medical record for the second time. I installed the first exactly 10 years ago this week. Boy am I nervous (and boy is my right index finger tired).

I am nervous about what I know is to come, from prior experience, and about what I don't know is to come, because every electronic record is different, and because I now have not one but two partners looking to me to have configured it perfectly. (Remember the known unknowns and unknown unknowns our old friend Donald Rumsfeld spoke of? I have to grant he was right about that, if not much else.)

After having put in about 50 hours, I can tell the new system won't be even close to perfection. The last one cost me 200 man-hours. But the vendor tells me it is unrealistic to expect to get it right the first time; every practice they work with spends the first 6 months polishing and refining. I know that better than anyone.

But this will not be a rant about electronic medical record software in general or about its influence on medical care. I already did that one a year ago. Instead, I want to share a response I gave at another website to the blogger whose commentary I found interesting, valid and provocative, as well as to the substantial commentary that followed ranging from cynical to outraged. That part I disagreed with. So here is my take on the original topic.

I wrote: "I'm sympathetic with all that has been said by the commenters but I think there is a level of hyperbole and hysteria in their reactions to EMRs. I have used one for our three-man practice for 10 years, and because it does not qualify for meaningful use we have had to replace it.

After a few months of searching and three site visits we selected one that is set to go live in 4 days. Naturally, I am quite apprehensive. The first time around we were slowed substantially for several weeks. I put in over 200 hours configuring it, and I don't see that the new one will cost me fewer than that. The old one had no order-tracking, such as the ability to follow-up on orders to see if they were done and what the results were. The new one does that, and I have worried for 10 years about the lost blood test, or more likely, the one the patient failed to go for.

The new EMR still generates a note that looks robotic in authorship, just like the old one, but it does look a bit neater and prettier, if such can be said about a medical report. And although the interface is seemingly more complex, it is more powerful and customizable. The old system and its replacement both force us to think about the list of possible diagnoses and lab tests that might not have otherwise entered my mind.

They both allow me to edit my note at the end of the day, unlike ones that I simply dictated before 2002. They both allow me to use Dragon Speech, and I have been using this voice-to-text application fairly happily these 10 years (although I have to watch it diligently as it does commit grievous mis-transcriptions every few lines). One of my partners, who prizes speed over completeness, is worried greatly he will have to slow down, and he will for a while. But he has been clicking on "non-contributory" or "ROS essentially negative for 14 systems" for the past 10 years and I doubt he will change.

I am not worrying about the questions I have to ask my patient for my new system to qualify for meaningful use as specified by the new health care law, the way everyone among the commenters who are already using one of the new EMRs seemed to be. Maybe I have not yet experienced it for myself, but I am planning to have staff enter most of the past history, review of systems, and other important data.

Of course the use of an EHR will not offer the kind of efficiencies we are hoping for yet. We will need new generations that allow me to view the blood count that is in my referring doctor's EMR so I don't have to order redundant studies or have my staff nag his staff to fax the reports. We need better prescribing abilities that don't set off alarms about drug interactions for every pair of medications prescribe, to the point that frustrated physicians disable that feature. We need computer-aided diagnostics.

Of course we have a long way to go. And I know I will want to throw the tablet through the window at least once next week, as I did for the first 6 months the last time around. But overall, I am still hopeful.

And stop blaming the government for everything that's wrong in medicine. Without government, we would have no Medicare, and no clean air and water, for that matter. So to all the incensed commenters, stop all the grousing and make some constructive suggestions!

The problem is not that we have the wrong incentives, but that we need new and better incentives for my colleagues to remain in primary care and for new trainees to enter it. Forgive me, but as someone who can hope to see his internist retiring before I expire, I would prefer not to see a physician "extender" when he goes. But that's a whole 'nother rant.

And thus endeth this one.

David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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