Thursday, March 21, 2013
Death of an evangelist
It feels like part of me is dying. I am losing something that has been a part of me for nearly 20 years.
I bought in to the idea of electronic records in the early '90s and was enthusiastic enough to implement in my practice in 1996. My initial motivation was selfish: I am not an organized person by nature (distractible, in case you forgot), and computers do much of the heavy lifting in organization. I saw electronics as an excellent organization system for documents. Templates could make documentation quicker and I could keep better track of labs and X-rays. I could give better care, and that was a good enough reason to use it.
But the EMR product we bought, as it came out of the box, was sorely lacking. Instead of making it easier to document I had to use templates generated by someone else, someone who obviously was not a physician (engineers, I later discovered). So we made a compromise. Since it was easier to format printed data, we took that data and made a printed template. We would then write in the vitals, dictate our history, circle options on the review of systems and physical exam, and dictate our plan. That written record would then be put into the EMR as a finished note by the transcriptionist. It was a strange way to do things, but it was far more efficient. At the first user group meeting (after 9 months of use), we were using the product better than anyone else.
For us, the bottom line was not computers, it was patient care. Our record system was a tool to let us eliminate inefficiency and focus more on care quality. We were spending less time and doing a better job. Within two years I was elected president of the national user group for our EMR and became an evangelist for the benefits of computerized records. I was proof that doctors could adopt technology and not just survive, but thrive. My peers thought I was eccentric (shocking) and I made few converts.
There is one moment during those first years I will never forget: one of the "aha" moments in my life, a time when things snapped into focus. I was trying to figure out how to milk more efficiency out of our system and was thinking about using the data for more than just documentation. My zeal for process improvement earned me the right to be one of the first to have access to the content customization tool for the EMR and I quickly produced content that was very popular (our vendor wisely gave the tool only if we were willing to share our creations).
While I was thinking about ways to improve efficiency, I thought about all of the data at my disposal. I had years of structured data on thousands of patients: vitals, lab results, medications, problem lists, and other pertinent patient information. Whoa! What if I could put all that data together and really coordinate care? What if I could, instead of using the EMR as a fancy word processing program, I used the data I collected to improve care? It was like moving from two to three dimensions. Nobody was talking about this at all; the focus was entirely on documentation, not data. I remember the room I was in when the thought hit me.
Armed with my new vision of EMR, I called my vendor (I was, after all, the president of the user group) and made a pitch to the engineers and company executives. I was clearly one of the top users of their product, but I felt like I was only using a fraction of the product's potential. Yet I was in private practice and so had no access to the resources to tap that potential.
I proposed that the vendor fund my effort to make the product work on all cylinders, to really show what it could do if its full potential was harnessed. The investment wouldn't be much, since we were still a small practice. In exchange for their support, they could use what I made to show the world what really good care looked like. I expected astonished gasps from the other end of the line, but was met by silence. Eventually one of the executives told me that the product was already being used to its full potential. They did, after all, have an E/M coding advisor.
Frustrated at their blindness to my insight, I set out to prove them wrong, spending countless hours wrestling with the system to make it do what I want: improve the care I was giving without taking extra time. The systems I developed helped us offer better care (double the national average on colonoscopy, pneumococcal vaccine, A1c monitoring), and still be in the top 10% of income for primary care. This accomplishment earned us the Davies Award from HIMSS, and earned me a permanent spot on the EMR speaking circuit. Still, I was never really satisfied with the care I gave, and always looked for ways to do it better.
Unfortunately, the increasing popularity of EMR caused increased focus from the government. PQRI, NCQA, HIPAA, and CCHIT all took focus of our vendor from clinical development, instead focusing on regulatory requirements. When the HITECH act passed I was still (delusionally) optimistic that the focus would eventually turn to patient care. But the last update I saw on the product I bought in 1996 showed the truth: The product was certified for "meaningful use," but it was bad. Really bad. We even nicknamed it "Vista." Previously simple tasks were difficult, and data was harder to use, and was not moving at all toward better patient care.
My inability to accept mediocre care (and my obnoxious obsession with improving it, from my partners' perspective) eventually drove me from the world of meaningful use and E/M coding to my current home: a practice that accepts only monthly payments between $30 and $60 a month in exchange for an undiluted attention to patient care. Without the overhead caused by the ridiculous complexity of our payment system, I can finally realize my dream of showing the world what good care actually looks like.
But here's the hitch: EMR has never left the world of note generation. Yes, it does submit data so the doctor can get the check for (ironically) achieving "meaningful use," but that data is still very hard to actually use to improve care. My attempts at using other EMR products to accomplish my goal have proven to me once and for all that to truly give good care I'd have to abandon EMR as I knew it. I've got to look beyond EMR to something better, more focused on the patient and less on the payment. But it's really been a hard search. I know what I want to do, but the road to that goal is not yet evident.
So what do I think really good electronic records should look like? I'm up to 1,144 words now, so that will have to wait for a future post. Instead, let me take this moment to throw a flower on the grave of the EMR enthusiast. It's been quite a ride. I don't join those who look back to the "good old days" of paper records (It's like longing for the "good old days" before indoor plumbing). No, I still look to use technology to make my care better; it just won't include EMRs in the form they are now. In truth, it's never been about computers; it's about the person sitting across from me: the one who is putting their life in my hands. Perhaps the death of this evangelist can prevent other deaths, the real ones.
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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