Doctor Code: Learning EMR Language

OK, I’ll admit it: I had no idea.  I thought that the whining and griping by other doctors about EMR 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 EMR’s 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 it’s 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.”

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.

20 replies »

  1. EMR can be of great help to doctors, hospitals as well as patients for multiple specialties including if used in a right manner. Nice, informative post, thanks!

  2. I appreciate that you brought up a very important topic regarding EHR usability and challenges between different systems. I was a former micropractice family physician for 9 years before I threw in the towel due to declining reimbursement rates and other factors which I explained at my blog aboutfamulyhealth.blogspot.com. I had significant challenges with my EHR options after 2009 due to the Meaningful Use requirements and the one I was using (Amazing Charts) became significantly unaffordable after the changes took place. I then decided to create my own EHR from open source and I’ve been trying to promote it as an open source project for smaller, independent practices. I used it for my own practice, knowing the intricacies of running a small primary care practice, so the design was very critical for me. In my experience, I’ve learned a lot about the EHR industry and the impact it has on smaller practices which I blog about at noshemr.wordpress.com. Good luck and I hope things go well for you as you use eCW for your practice.

  3. I think I posted my reply against the wrong post. I thank the smart phone for it. Here is my reply to your reply 🙂

    Of course Rob. The offers stands. Like I said I won’t talk good or bad about our competitors but you will see the difference. I hope all works out for you

  4. A very generous offer, Moiz. Thank you. One of the other folks to comment on this post was the CEO of eClinicalWorks, who is not deaf to this criticism. Going live with my office in 2 weeks, this wouldn’t be the best of times to change. I also want to see how eCW responds to this. Can I hold on to your offer pending how things transpire?

  5. Rob – I am not going to say how good or bad the EHR INDUSTRY is. I do know that the software industry has been treating the healthcare industry unjustly. Why – because they can definitely do a MUCH MUCH better job. I’m the president/founder of TECNEX Systems, LLC. Again I will not talk about how good or bad our software is – BUT I will offer you our EHR for free. $0.00 cost. Pay only when you think it’s worth it or keep it for free forever. But be honest and do write what you think about it. I know I’m taking a chance but I’m confident and want to let you know we are honest and work hard for our customers. We have been in the market for almost 6 years now and NOW launching the first ever physician Clinic Business Management solution on Feb 2nd. The first system with HR, Clinically Integrated inventory and business finance management including employee clock in/out, employee payroll management, along with of course ONC-ATCB complete certified EHR and PM. I offer you this with just 4 hours of training. If you cannot see the ease of use – keep using the software and never pay for it. Let me know. I can’t give my personal email due to spamming etc. but email customers@tecnex.net and put “Free EHR offer to Rob” on top of the email. It will get to me. No demo, no binding contracts.

  6. Hola! I’ve been reading your website for a long time now and finally got the courage to go ahead and give you a shout out from Houston Texas! Just wanted to mention keep up the great job!|

  7. Very insightful blog post.. We will want to learn from you.. If you find time write me an email.

    “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”

    …. Insightful

    Girish Kumar

  8. Rob–

    Totally “spot on” –usability

    I thought you were talking about EPIC until I read the end of the Blog

    ONC is driving everyone into Big Vendors — they do not care about usability

  9. Nice informative post! Rightly said EMR can deliver unmatched advantages for doctors, hospitals as well as patients if used in a right manner.

  10. Bro’, it’s eClinicalWorks. Get just a TAD of a clue. A mature, proven product, one of the better ones. Stable, fully featured. (It’s ambulatory setting btw)

    eCW comprises about 30% of my REC book of business. There workflow are things I don’t like about it. But, then, there are things I don’t like about my Adobe CS6 Suite, the Lexus of digital pre-press (I pay by monthly subscription).

    One way or another, it all boils down to $2-$4 / yr / chart (paper OR digital, inclusive for small outpt primary care shops). Unless you’re a total chump (in which case I have no sympathy for you).

  11. Has it crashed yet? How much did it cost and what are the maintenance costs? Inform us on the errors you have made while using it, how much longer your day is? Does it auto fill fields, does it have a search function, does it enable you to enter orders on your hospitalized patients?

    And tell us of the number of misidentifications, the number of interface dysfunctions, the number of communication failures, and the efficiency of the help desk. Thanks

  12. “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.”

    You nailed it there, Doc. Great post (as always).

  13. Peter: It’s hard to “try” an EMR, as many of my complaints revolve around customizability issues (or lack of them). Demos don’t help, as they scoot by real usability issues. I did my best to do my homework, but apparently that’s not enough. Perhaps overconfidence was part of it as well.

    Southern Doc: I think at the time I was able to transform my care using an EMR, so I was OK with it. The problem is that EMR has been transformed by the system far more than it has transformed it. That was a huge missed opportunity. Regarding making my own: I’ve considered it, but don’t want to become a programmer. The point of my new practice is to get back to just being a doctor. I’ve not settled with a single answer yet.

  14. Apology accepted!

    To be blunt, you were used by HIMSS, NHQA, CDC, etc. It would be great to hear what some of those you worked with have to say about your epiphany.

    More and more docs are realizing that the emperor has no, or very few, clothes. An EMR designed to work well in a totally dysfunctional system is going to be dysfunctional by any objective standards.

    Since you’re outside the insurance/CPT/MU realm now, wouldn’t it be better to just build your own EMR?

    Enjoy your posts tremendously.