Blog | 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.