It’s been a long time since I wrote a post.  My life, you see, is incredibly dull and boring.  There has been so little to write about that I’ve been at a loss.

No, actually that’s a load of crap.  It’s become a fantasy of mine to have such boredom.  In reality, my life is as un-boring as it could be.  It’s like the part of a story where everything is in flux, where little decisions have huge consequences, and where the inflection point between a comedy and tragedy is located.

So how’s my new practice going?  In some ways things are going about as well as they could.  My patients are amazed when I answer their emails or (even more surprisingly) answer the phone.  ”Hello, this is Dr. Lamberts,” I say.  This usually results in a long pause, followed by a confused and timid voice saying something like, “well…uh…I was expecting to get Jamie.”  Yet I am often able to deal with their problems quickly and efficiently, forgoing the usual message from Jamie to get to the root of their problem.  It’s amazingly efficient to answer the phone.

Financially, the practice has been in the black since the first month, and continues to grow, albeit slowly.  The reason for the slow growth is not, as many would predict, the lack of a market for a practice like mine.  It’s also not that I am so busy at 250 patients that growth is difficult.  In truth, when we aren’t rapidly adding new patients, the work load is nowhere near overwhelming for just me and my nurse.  In that sense I’ve proved concept: that it’s not unreasonable to think I can handle 500, and even 1000 patients with the proper support staff and system in place.

Which brings us to the area of conflict, the crisis point of this story: the system I have in place.  The hard part for me has been that I have not been able to find tools to help me organize my business so it can run efficiently.

I have well-documented my realization that the EMR systems I’ve tried have not met my approval…To those who are students of writing, I just used a literary device called irony, specifically the irony of a ridiculous understatement.  I was able to use the term EMR without descriptions like “sucks at high decibel levels” or “crappier than a Carnival Cruise ship.”  Other example of this type of understatement include calling the Korean war a “Police Action,” and referring to congress as “a bunch of mindless fools.”…I’ve tried multiple solutions to this problem, only to have found little to improve my efficiency.  Sure, I can handle the current load of patients with the (non) system I have, but what happens when I grow?  I’m trying to build something that can grow, and something that others can emulate.  It’s obvious that I need a better system than I’ve found up to now.

So what do I need?  Surely the freedom from both E/M coding and the utterly ironic “meaningful use” criteria have made documentation of care much simpler, which they actually have.  The thing that most EMR systems devote 90% of their energy, documentation of office visits, is one of the smaller problems I face.  This has caused some readers (not on my blog, thank goodness) to conclude that I don’t need computers at all!  I can go real “old school” and return to the days of paper and illegible handwriting.  These folks are morons (and they get me very irritated) because they aren’t willing to think about what health care could look like if it weren’t corrupted by our pitiful system.  But, I ask, would they ask their bank to stop using computers and keep their financial records on paper?  Would they go to a travel agent instead of booking their flight online?  My suggestion that they write their comments to my posts on paper and mail them to me has not been met with any understanding or aplomb.  Sad.

Perhaps the problem is that I still use the term “medical record,” or (worse) “EMR” to describe what I am looking for.  While computers have been an important part in the corruption of the system, they have not been the cause of the screwing up, they have simply made the screwing happen at a much faster rate.

So what am I looking for?  The same thing I look for in a good story.  The best stories excel in three areas:

     

  • Back Story – what happens before the crisis?  How did the person get to the crisis?  What are the motivations?  What are the inner conflicts?  What is at stake?
  • Narrative – How well does the story-teller communicate what’s happening during the crisis?  How well do they describe the setting, the action, the dialog?  Do you feel what they feel?  Do you believe what they say?
  • Resolution – How does the crisis get resolved?  Does it make sense?  Does it satisfy the listener?

These are also important parts of good medical care for any given patient at any given time:

     

  • Back story – What has happened to the patient in the past?  Do they have diabetes?  Do they smoke?  Did their father have a heart attack at age 45?
  • Narrative – What is going on now?  What are the symptoms?
  • Resolution – What is the plan to get their problem resolved? Does it make sense?  Does it satisfy the patient?

So what system am I looking for to help this?

  • Back story – Organization of data is key here. The information needs to be complete, but it also needs to be well-organized.  It needs to prioritize important things (like the father with a heart attack at 45), and allow me to get a quick, accurate idea of who I am dealing with. Real world examples: Evernote, Wikipedia, Google.
  • Narrative – Communication tools are key here. While a typical EMR product stands in the way of communication, focusing instead on obfuscation by documentation, a good system would improve communication.  This has been the easiest to attain, using online communication tools and simply being free to answer the phone.  Real life examples: email, Twitter, Facebook, iPhones.
  • Resolution – This is perhaps the hardest part (as it is in story-telling), and the worst done in our current system. I am looking for a robust task-management system that can organize what needs to be done to get to where I need to go.  Examples: Wunderlist, online calendars.
  •  

This is a simplification of what really goes on, but it gives some idea of where I am heading.  My goal is not software, it is good medical care.  I am financially motivated to keep patients well, to efficiently answer their questions, and to handle their problems early, as it means I have more time and can handle more patients. Keeping patients well and at home was bad business for me in my former life (good riddance to that), but it is what patients want.  The more efficient I can be at meeting that desire of my patient, the better off both me and my patients will be.

They still will call, though.  I think they get a kick out of me answering the phone.

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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15 Responses for “The Electronic Medical Record and the Patient Narrative”

  1. This would be the money shot:

    To those who are students of writing, I just used a literary device called irony, specifically the irony of a ridiculous understatement. I was able to use the term EMR without descriptions like “sucks at high decibel levels” or “crappier than a Carnival Cruise ship.” Other example of this type of understatement include calling the Korean war a “Police Action,” and referring to congress as “a bunch of mindless fools.”…I’ve tried multiple solutions to this problem, only to have found little to improve my efficiency. Sure, I can handle the current load of patients with the (non) system I have, but what happens when I grow

  2. Rob says:

    I’d vote for Bubba.

  3. hi Rob,
    I’ve been having a similar experience, trying to better set myself up to provide good outpatient geriatric care. In particular, I’ve been struggling to keep the backstory organized (and for these patients, they really need a personal health record to keep their backstory organized, so that they can easily bring it to a new doctor). And I’ve been struggling to find a way to keep track of what they tell me, and what I’m doing for them, and what we together have decided to do, and following up on that.

    We certainly need a collaborative task management system to keep patients, caregivers, and providers on track.

  4. Jim Salwitz says:

    I think the contrast presented here of the simplicity of getting your doctor easily on the phone (or I suppose directly by email), verses the overwhelming data crunch that most EMRs still produce is the key. While our practice has been EMR based for 13 yrs, it continues to be a struggle to produce, in real time, a clean universal concise final product that could easily be exported to other systems (which must happen if we are ever to be as universal as the banking industry Rob sites) or which can be read by any doctor quickly and with critical data in focus. I dread the core dump data printouts we see when an EMR based hospital transfers us a pt and provides the chart by simply hitting “print.” Slowly, however, we are developing an EMR note which will provide a current HPI (even in a very complex pt) by rotating out old information into achieval PMH sections, a tight Assesment identifying only current or relevant issues and a Plan which discusses today’s issues, not irrelevant yesterday decisions. None the less, the data in and data out problems of EMRs remain a massive hurdle and Rob is correct to look for solutions in social media platforms which have handled these problems far more effectively. None the less turning back to paper would be a ridiculous as getting rid of cars and turning to horses, because MVAs are such a problem. We need to fix the technology.

    jcs

  5. Everything that causes the frustration is real. And the current solutions are indeed not helping. But you are missing the actual point of the EMR, which is to be used as a clinical tool to aid decision making and remembering and information sifting and decision suggesting in a way that the human mind simply cannot.

    Very frustrating to be alive in a world where the health system is so incredibly broken, but your description of a search for organization, communication and task management and the simple tools you use as examples greatly misstate the reality of the need. Well meaning doctors kill patients every day with treatment that is not state of the art. As William Mayo said in 1907, paraphrasing, “Only a fool would think he holds any small part of medical knowledge in his head.”

    What is needed is not doctors retreating from the system into an isolated cocoon with a few hundred patients and an internet lifeline. What is needed is comprehensive destruction of the entire system, starting with specialty definitions (why are orthopedic surgeons even going to medical school) and extending deep into the medical education process and on into the world of artificial intelligence and patient engagement.

    The current path of trying to assemble chunks of feces into a workable system is as flawed as you feel it is, and part of me is envious of your decision to retract into your shell, and I think that for you and your patients the short term reality will be all upside.

    Long term, the system is doomed and maybe your choice to choose to walk away from that doom is wise since I feel like the nutball on the corner preaching armageddon most of the time.

    Sorry, I’m all over the map here.

    • Rob says:

      I agree that clinical decision support is the ultimate goal of EMR, but the data need to be organized and complete before it is of use for decision support. Decision support based on incomplete data is prone to bad consequences.

      This is why I talked about this not being a complete picture. I think the idea of a care plan (looking ahead in the story, or the resolution) would definitely involve using the data. The problem is, most EMR systems I’ve seen don’t tell me easily what a person’s last lipid profile was and when their next is due. They don’t organize preventive care data so I can decide who needs what done. They do, however, meet the “meaningful use” criteria so the docs get their $42,000 checks.

      My hope is that I am not walking away from the system, but rather doing what I can to disrupt. That’s why I write. That’s why I am doing this in public.

    • Nathanael says:

      “As William Mayo said in 1907, paraphrasing, “Only a fool would think he holds any small part of medical knowledge in his head.” ”

      Mostly, what’s needed is a searchable book for diagnosis which is equivalent in function to the PDR’s function for drugs. This isn’t actually a hard problem, just one involving an absurd amount of work to collect and organize the known information on each disease in a standard form.

  6. I have been following your reports on your practice changes with interest. I love love love that you answer your own phone. I bet you don’t get paid for it.

    Part of our frustration with EMR stems from the same physician behavior that took cost considerations out of our hands and into bureaucracy. We are reacting to, or NOT reacting too, or reacting too late to, the prevailing winds. EMR has been imposed upon us while we sat around clinging to our pens hoping the tech guys would go away. Now we have a fragmented, market-driven system that is subject to so many federal regulations as to make most of what we chart meaningless. I count myself as one of these luddites.

    Just as doctors don’t learn anything about cost or business practices in Med school, they don’t learn code either. Nor do most of us want to. But we better be willing to jump in to the sea and swim with the dolphins (or the tech guys) if we want to see changes in our lifetime.

    One other thing, in response to Craig Bradley: In an ideal world EMR would function as a useful decision-making tool and patient safety mechanism. I think Rob would agree that it functions much more as a funnel for Big Data, helping the government and insurance companies track trends and claims. It’s use as a tool for physicians is still largely theoretical.

    • Rob says:

      I do get paid for the phone calls. It’s part of my monthly fee that patients gladly pay for the ability to call, email, etc.

  7. It would certainly shock the heck out of me to call a doctor’s office and hear the doctor answer the phone, very cool!!!!

  8. Darius says:

    Go open source, get 2 good coders and one good design person (the design person needs to understand basic medical terms and be able to talk to a computer person, they don’t need to be able to build a computer out of an NES , research what they have accompished to make sure they can handle larger projects. Pay minimum wage to work on a functional health record, Offer a sizable bonus for reaching the goal. kinda X prize style. There are folks out there who can do in small teams what Microsoft does, gotta be some folks who could pull a smart database off…

  9. Colin says:

    The unfulfilled promise but there’s progress, albeit slow. When you were paper charting you might have had even less access to the calculation of when the next lipid profile was do. Too many people, like yourself, are involved in QI for the digitization of medicine not to continue to improve. By the time I’m out and independent EMRs will facilitate communication and tasks.

    We’re training a whole generation of physicians who know nothing else in terms of medical records. My particular program has multiple training sites and all but two of them have full EMRs – outpatient clinics for the academic practice, a county hospital, two private non-academic hospitals, an academic children’s hospital, a va hospital. I don’t think this exposure is going to make my generation complacent with current systems. I think it’s likely to make them more active in innovation.

    Also, I appreciate the writing references a lot :)

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