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Monday, February 25, 2013

Learning a new language: an insight into EMRs

OK, I'll admit it: I had no idea. I thought that the whining and griping by other doctors about EMRs 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 EMRs 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 its 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."

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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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.

Auscultation
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 Richmond, Va., 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.

DrDialogue
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.

FutureDocs
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.

KevinMD
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).

Prescriptions
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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