I am an EMR geek who isn’t so thrilled with the direction of EMR.  So what, I have been asked, would make EMR something that is really meaningful?  What would be the things that would truly help, and not just make more hoops for me to jump through?  A lot of this is not in the hands of the gods of MU, but in the realm of the demons of reimbursement, but I will give it a try anyhow. Here’s my list:

  1. Require all visits to have a simple summary.
    One of the biggest problems I have with EMR is the “data diarrhea” it creates, throwing piles of words into notes that is not useful for anything but assuring compliance with billing codes.  I waste a huge amount of time trying to figure out what specialists, colleagues, and even my own assessment and plan was for any given visit.  Each note should have an easily accessible visit summary (but not at the bottom of 5 pages of droll historical data I already know because I sent them the patient in the first place!).
  2. Allow coding gibberish to be hidden.
    Related to #1 would be the ability to hide as much “fluff” in notes as possible.  I only care about the review of systems and a repetition of past histories 1 out of 100 times.  Most of the time I am only interested in the history of the present illness, pertinent physical findings, and the plan generated from any given encounter.  The rest of the note (which is about 75% of the words used) should be hidden, accessed only if needed.  It is only input into the note for billing purposes. 

  3. Require all ancillary reports to be available to the patient.
    Patients are already the information interface between providers, so why not use them as our interface?  Why not have them able to give the ER doc permission to see recent labs, or give the specialists access to their x-ray reports?  Why do I have to get permission from them to get the information sent to me from the lab or the radiologist?  The patient is there in the room, so why can’t they just say, “Here are my results.  You can look at them.”  While they are showing me them I can explain how I interpret them.
  4. Require integration with a comprehensive and unified patient calendar.
    We have the technology to give each patient a comprehensive care calendar to look toward the future and into the past as to what tests are due and what was done.  When I order a test and get the results back (thyroid tests for example) I should be able to queue up the next test on a calendar that the patient can see and use.  This is the “GPS” idea I’ve had in the past, and  would be simple to even share between providers.
  5. Put most of the chart in the hands of the patient.
    Patient information, such as family history, medication list, social history (where they work, are they married, etc), and even a list of past surgeries should be managed by the person who knows it best: the patient.  Keeping track of this is next to impossible in a busy practice (especially for pediatrics), and is re-transcribed for every visit the patient makes to a new provider.  This is burdensome on everyone and leads to significant inaccuracies that would be easily fixed if a unified patient record centered on one managed by the one with the most to gain from its accuracy.
  6. Pay for e-visits and make them simple for all involved.
    One of the worst parts of my practice is that I must force patients to come to see me so I can be paid for the care I give.  This is especially unfortunate because the Internet allows easy communication, making many (if not most) of these visits unnecessary.   It is a waste of my time, it wastes lots of patient time, and it greatly increases absenteeism from work.  Yet I need to be paid for my services, as I am taking significant risk and using my training for their benefit.  The technology would make this easy, but the reimbursement model stands in the way.  CMS would have to do the changes to make this happen, but doing so would give a huge yield to doctors, patients, and employers.
  7. Allow e-prescription of all controlled drugs.
    This falls under the “duh” category.  Why is it safer to hand a physical copy of a controlled drug prescription to a patient than to send it electronically?  Is it safer to hand a person a check and have them bring it to the bank, or to send it electronically for deposit?  Come on, folks, this is just so obvious.
  8. Require patients’ records to be easily searchable.
    I spend huge amounts of time searching for answers to questions like: “were they ever on drug x,” or “when was their last y procedure?”  I would love to be able to do a ctrl-f (or cmd-f) search on patients charts to get that information.  It should be standard in all EMR’s to allow this, as we all spend way too much time searching, and probably order unnecessary tests because it’s just too dang hard to search.
  9. Standardize database nomenclature and decentralize it.
    Let’s stop the proprietary nonsense.  EMR products should be able to interact well with each other, retrieving information about the patient at various settings.  I personally don’t think the centralized database is the best approach, as it is far more risky to have all data in one location.  Just have each EMR able to go (with patient permission) and get information wherever it is.  I shouldn’t have to store the CBC results in my record; I should just have easy access to the lab’s records.  This has actually been done to a smaller extent with e-prescribing, which can give a unified view into the patient’s prescription history (which is often useful, although it is still quite slow).  Having data in proprietary silos is a foolish and inefficient storage method.
  10. Outlaw faxing.
    I hate faxes, and with the Internet enabled communication (like you reading this), faxes should not be needed.  They are difficult to transcribe to digital format, usually ending up as PDF files instead of searchable data.   Most faxed medical information (ironically) starts in digital format (word documents, etc), and then is converted to paper or PDF, only to be re-imported as non-searchable image files.  This is stupid, but it is so easy that the only way to prevent it is to not allow it.

So there’s my dream “meaningful use” list.  I would be interested to hear what other ideas you all have.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind)where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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27 Responses for “10 Ways to Make the EMR Meaningful and Useful”

  1. BobbyG says:

    Nice. Very nice. I will have to quote you.

    #10 faxing, yeah. lol.

  2. Mark Martin says:

    Well said Dr. Lamberts. While most software vendors are focused on regulatory requirements, they miss the opportunity to make their application useful to the physician, and the patient. My physician is trying to meaningfully use his system which resulted in a close-to-useless visit summary being mailed to me a week after the visit. He may have met the letter of the regulation, but it was not helpful for either him or me and will do nothing to enhance the next visit. The one benefit I see in meaningful use is that we are inching towards some standard terminology and systematic flow which are vital for future solutions. If software vendors can’t create real usefulness quickly, we will be drowning providers in meaningless overhead and that is not sustainable.

  3. Rob says:

    This is the difference between a clinician making guidelines and a guideline-writer making guidelines. I want to:
    1. Stop wasting my time
    2. Stop wasting my patients’ time
    3. Stop wasting money
    4. Give better care.

    Computers SHOULD allow this. Used properly, they will. Used incorrectly, it’s like using a watering hose to dig a hole in the ground.

  4. Rich Berning, MD says:

    Totally agree. 100%. I get EMR notes by fax from the PCP about the referred patient that are nearly or totally useless. 15 pages of notes created by the PCP checking boxes, and it takes me 10 minutes to read to try to glean any useful information. I also use an EMR but hate the output so I dictate my note into Word (using Dragon), then FAX my consultation report back to the PCP! It’s all so frustrating, and has extended my workday 1-2 hours daily. Getting tired…

  5. Dr. Mike says:

    I’m getting tired too. The EHR and meaningless use are one of the reasons I am in the process of leaving primary care even though I am only 50. I like Rob’s list although I do feel that somewhere in the cloud lies the answer to most electronic health care communications problems. But until the “coding gibberish” is no longer needed for payment it won’t really matter for me as the third party payment system is an insurmountable problem for us solo docs.

  6. Janie Williams, RN says:

    I am shocked, literally shocked, that this failure of nationwide medical care infrastructure has been ignored by this blog and its bloggers:

    http://articles.latimes.com/2012/aug/03/business/la-fi-hospital-data-outage-20120803

    It matters not how these devices satisfy meaningfully useless guidelines when thousands of patients are put at risk at once.

  7. southern doc says:

    I am shocked, literally shocked, that people don’t understand that a blog is not a primary news source.

    I am also shocked, literally shocked, that people don’t understand how to use the word “literally.”

  8. Rob says:

    I was literally sweating bullets about people being shocked.

    I also would think that people would understand that, despite the risks, computers do provide ample benefit to justify their use in health care as it is in banking. People want to suggest that just because their is risk, it is not justified. Driving a car can literally tear you limb from limb, yet we take that risk because of the benefit. That doesn’t mean one shouldn’t try to be careful while driving.

    Bad use of a tool does not condemn all use of that tool.

  9. southern doc says:

    “Bad use of a tool does not condemn all use of that tool.”

    Dr. Lamberts’ point is that docs are being forced to use this tool in a bad manner, i.e., in a way that hinders their ability to deliver excellent care.

  10. Nick says:

    Very good write up, being in the health field myself, it’s great to read such good content

  11. This is what happens when casual readers of Popular Mechanics are empowered to write the specs and instructions for pneumatic torque wrenches.
    Where are your professional societies?

    • Rob says:

      The problem is actually similar to that mentioned in the previous post (on political posturing). Societies could have solved this problem long ago and taken the lead, but (especially groups like the AMA) were too focused on status quo and not in leading substantial change. It is quite frustrating for me that our societies have been followers, not leaders.

      On the good side of things, these posts I have written have not gone unnoticed by ONC, the ones in charge of MU. I do believe that there are people there who understand the reality of the doctor’s office. I am definitely encouraged by my interactions with the people at ONC I’ve communicated with.

      I am not, however, literally beside myself.

  12. southern doc says:

    “Where are your professional societies?”

    In bed with CMS and the large insurers, enjoying a post-coital smoke.

  13. tim says:

    Doctors telling everyone else how to do their work would be funny if it were one exponent less ironic. I know: if doctors only managed the hospitals, then hospitals would be better. If doctors only designed software, then software would be better. You also tell your accountants how to account, and your lawyers why they’re wrong. We get it. I say this with love in my heart: you have a serious blindspot in your profession, which is why your profession is being taken away from you. (Not a good thing.) Try fixing the fragmentation of care and lack of communication among yourselves (which kills people, and existed before computers), then set to work on everybody else.

    The truth is more prosaic: doctors refuse to learn how to use software, then blame the programmers for the result.

    Where are the professional societies? Are you kidding? Have you ever sat in a room with a dozen surgeons and listened to them try to come to a consensus on the color of the carpet? I have, and it’s the most painful 8 hours you’ll ever spend. Doctors in groups are dysfunctional; they self-select for that feature in the med school admission process. The professional societies have no use but to lobby Congress.

    Take some accountability for the note you produce. Every EHR I’ve ever worked with offers complete control over the content of the note that leaves the office. It’s not the computer that fills the note with garbage; it’s the laziness of the office staff and the doctors.

    The leading EHR vendors have physicians employed, and as consultants, and are constantly taking in ideas from physicians. The leading products are all designed with direct comment from physicians. I’ve had doctors draw screens on the back of napkins and the programmers produce them as drawn. (Then the doctors don;t use them of course.)

    There is an amazing lack of consensus on the part of physicians on almost everything. You say you want your note to have x and y — but your partner wants x and z, but only on Thursdays. So the product does both, then you both complain about the complexity.

    No, I do not work for an EHR vendor. I manage physicians. I’m in the middle of my second large EHR implementation. We’ll design the consult notes to look exactly how we want or they won’t leave the office. And we did that 10 years ago.

    You want a search function in an EHR? Seriously? A search function to find out of the patient was ever on drug x? Your software is obsolete. I know of a dozen products where you would see my entire drug history on my face sheet.

    Sigh.

    • Rob says:

      Gosh, I wonder why you have trouble getting along with physicians…. If you use this kind of charm, it would seem you would be irresistible.

      I have worked with EMR for the past 16 years, having shaped it in my clinical practice, becoming one of the most successful implementations, recognized by HIMSS and others for my practical approach to use. I’ve been a featured speaker for the CDC on the subject as well.

      The reality is that a combination of physicians, engineers, and office administrators (considering the clinical, technical, and business sides of the formula) working together is the ideal. Leave any of these out of the equation at your peril. The problem is that physicians (and other health providers) are usually the last on the list, yet the ones with the most at stake. All of this is built for one end: the interaction between patient and provider.

      Regarding the search capability, simply having a list of all medications is not adequate. We have that function (please try to avoid the condescension), yet searching through 12 years of prescriptions or looking through a flowsheet is not reasonable. CTRL-F is far easier and would significantly cut the time sitting in front of patients searching the chart. This fact is obvious to anyone who sits in my chair.

  14. CurtW, MD says:

    Nice list and great discussion. ‘am waiting for CPOE to be half as good as ordering something at Amazon. But, I digress… Yes, the doc, software engineer, and ‘bean counter’ triad is essential to assembling a useable product; but, the end user (doc) has too little time to invest in harnessing the knowledge and abilities of the other two and be the leader(s) of the software design project. For the impassioned, let me offer the following resources:

    1. The American Medical Informatics Association: http://www.amia.org – interested docs can take one of the 10 x 10 courses to see if a second career in medical informatics piques their intellectual curiosity

    2. About Face by Alan Cooper, IDG Books Worlwide, 1995

    3. Rocket Surgery Made Easy by Steve Krug, New Riders (Peachpit), 2010

  15. Lindsay says:

    I am an EMR implementor and have worked with a number of clinicians feeling the same way you do. Your list makes some great points!

    I can tell you that there are good products out there that accomplish many of your requests. The product I support happens to solve #s 1, 2 and 8, and integrates with a Patient Portal that accomplishes #s 3 and 5. I love suggestion 4, and think it would be a great way to manage patients!
    The system I support it webbased so the ctrl+F funciton does work, I utilize it a lot to wade through some of my system admin lists, but I am not sure it is necessary for clinical purposes given the way the information is organized and presented, having a number of reporting and search capabilities built in – for example, I can easily search for all patients system wide that have been prescribed a certain medication, or presented with a certain diagnosis.

    As an industry, changes are being made to work toward #9, and many systems can already exchange information using standardized messages. I am excited to see these capabilities increase!

  16. southern doc says:

    It doesn’t matter how good the system (designed by physician, engineer, and administrator) is if government and insurance bureaucrats require that it be used for meaningless chores.

  17. Syed Hussain, MD says:

    Well then but, there is differences of opinion but let me weight in: These devices called EMR are terribly and meaningfully useless when it comes to patient care that the patient needs. They are meaningful to the Feds who have no ideas about patient care.

  18. Sean says:

    I also implement EHR systems and I am currently working on a major project within New York City.

    I think one of the largest issues right now is the sheer number of EMR vendors on the market. Each one of these vendors differs in structure, features, documentation methods, templates/defaults, and methods of communication.

    Beyond the above issues, there is the far more significant problem as to how the data is stored within these different systems. It’s all well and good that an EMR may meet HL7 and CCHIT requirements, but data transmission depends upon whether it is “structured” or “non-structured” information. Without getting into too much detail, structured elements have a specific location within the database where the information can easily be found and transmitted. Non-structured information is usually free-text, meaning someone is literally typing the data, and it is extremely difficult to find. The reason that I know this is because I have worked on a project that was connecting different EMRs to web-based portal in order to track such priorities as Meaningful Use and PCMH.

    So, how does my technical rant come into play? Sharing information between EMRs is going to be EXTREMELY difficult if an effort is not made to not only ensure that all systems have the same basic skeletons, but also to mandate that all essential information can be transmitted. I am not saying that there should be one sole enterprise vendor but the backend requirements should be scrutinized a bit more closely.

    Nonetheless, I do not agree with southern doc or Dr. Hussain’s assessment of EMR technology. I understand the frustration, it is the opinion that is voiced to me on a daily basis. Perhaps it is a lack of forward thinking or belief on the part of a physician who has literally moved from short scribbles on a piece of paper to documenting in paragraphs. You will not be able to see 60 patients per day and you will be forced to spend more time with the patient obtaining history. Yes, this means more time in front of a computer when care could be performed, but you would be absolutely shocked what information comes out during these assessments that a physician did not know prior to the implementation of an EMR.

    I could write forever and I am sure any one of you could write an equally lengthy rebuttal, but I will say this; EMR will change health care and there is no getting around it anymore. There are many issues with the way things are now, but hopefully lessons will be learned and improvements will be made. It will be many years before we see the “perfect” system, if that ever happens, but the potential for information sharing and improvement of health outcomes is substantial.

  19. Jon Kotila says:

    I feel that patients suffer while doctors are busy at their computers. There is little eye contact and the patient is left feeling that they are treating the computer rather than the patient. While I”m sure EMRs and EHRs have their value, I just wish doctors, and others, would spend more time making eye contact so that they might see what the patient’s body language happens to be. I also feel that EMRs cause a very impersonal relationship between patient and doctor.

  20. Rose McClean says:

    Great analysis! I especially appreciate how thoughtful you were about involving the patient in the EMR conversation. This conversation is very critical for EMR success and should be further explored. You incorporated excellent ideas for other professionals to follow in order to enhance the benefits of EMR for patients as well as physicians. This article provides a great foundation in creating meaningful EMR programs and its powerful impact it can serve in the Healthcare industry.

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