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 90′s 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 it 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 1144 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 EMR’s 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.

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.


37 replies »

  1. Right here is the right webpage for everyone who would like to find out about this topic.

    You understand so much its almost hard to argue with you (not that I
    really will need to…HaHa). You certainly put a fresh spin on a subject that has been written about for years.
    Excellent stuff, just wonderful!

  2. The innovation, I feel, is not in the EMR business itself, but driven instead by the payment system. The biggest innovation I’ve made is abandoning fee-for-service and going to a model where I can focus on disruptive ideas (like connecting with patients via email and other modalities). I don’t think EMR vendors can innovate because the payment system restricts it too much.

  3. Technology is changing the landscape in many ways. You can expect EHR/EMR systems to be incorporating big changes. A tablet with a stylus will replace a computer screen. A mobile/phone app. will allow you to create/read/update on the go. Multi-tenant (several physicians using the same app) installations in the cloud enables sharing analytics on their collective (private) data. Adverse events can be discovered, analyzed and tracked by web crawlers surfing the Internet. In Colorado ACOs are working with hospitals, primary care physicians and specialists to create a collective shared database designed to improve patient outcomes. Both Case Management and physician activities are evaluated. Engagement with them increases awareness and targets areas for improvement.

    The makers of EHR/EMR systems, who understand these ideas are not capable of making quick changes. In most cases it means an entire redesign of the system. These changes are coming, you can count on it. The market leaders will drive the changes. It will be on their timeline, which is driven by … you got it, wealth creation.

  4. I wonder if the problem is in the design. Most EHRs are designed for documentation, when we really need data for documentation, communication and analysis. By using database architecture, perhaps we’re boxing systems into too tight of an application and need to create a system where the data is separated from the apps. Then apps can use the data for a variety of purposes, and apps can be more “user-friendly” for whoever is the user because each user has a different app. That’s what we’re working on – I think this is going to become even more critical as we have many useful apps being developed that end up in a different universe than most EHRs (or need to get an expensive interface to each system, and who knows how that will work out), and patients and providers are starting to demand access to a larger set of patient data than what’s available in each provider’s EHR. I think that’s what Blue Button Plus (formerly Automate Blue Button Initiative) is all about. Personally, I think we’re far from having the right data to analyze for ANY ACOs to be able to determine what impacts patient outcomes. You need information about what a patient is doing outside the healthcare system, and that information is hard to integrate into EHR data right now. Claims data just won’t do it – not even when it’s integrated into what’s available at this point.

  5. As a PA with experience in the good o’ paper world, the military-based EHR system (which is quite good) and my present day frustration with a civilian-based EHR…I totally agree with the frustrations of your posting. When one lives in a “meaningful use’ world dictated by bean counters who have no clue what it is like to actually “see” a patient, there is absolutely no comparison to being able to sit down with a patient without the ubiquitous computer screen between you. In these days of administrative types dictating pretty much how many people one “needs ” to see to insure profitability for the generic system, I fear that in several generations we will have created a medical paradigm where the notion of compassion and direct eye-to-eye communication of health care will fall victim to the needs of the corporation and we, as practitioners, will become advisors of evidence based medicine only…and, to ensure that we can maintain the obligatory 15 minute visits that seem to dictate the future of medicine.

  6. Ya. add me to the list of ‘confused’ individuals by your posts. So you don’t want to go off the grid to the days before indoor plumbing, but EMR is dead to you? But you aren’t going back to paper?

    I agree with comments that the EMR is designed with the status quo in mind. That means the business end of medicine. Its made to accurately document your encounters such that you can collect a pay check. (and government incentives more recently)

    Patient care… I am looking forward to what a ‘good’ EMR looks like. I am currenly of the opininion that patient care is your job as a Doctor, and I am interested in what suggestions you have for how your software might help you with that task.

  7. The need would be filled I think for Doc Lambert’s EMR if his market size were big enough. But that was the (albeit flip) crux of my comment about him wanting (and establishing) a more patient centered practice before he accused me of being a troll.

    Look, if you want off the grid you’ll have to improvise. Maybe his evangelical fervor for EMR is not quite dead. If it were he may realize he can use paper.

  8. You alluded to this, but I think the problem is healthcare wide and isn’t just limited to EMRs. All new revenue cycle / care management technology that comes in healthcare necessarily leads to more complexity because the technology is immediately viewed by various stakeholders to get something that they always wanted but couldn’t get before. Those stakeholders are regulators, academics, payers, and even providers from time to time.

    DRGs, MS-DRGs, ICD 10, HIPAA transaction sets, i.e. 837 claims, 835 remittance, EMR, the list goes on and on of things that were supposed to automate, simplify, etc., but all it did was provide an infrastructure to support more complexity and the industry immediately saw the “vacuum” and filled it with that complexity. We have so much more data than we did 20 or 30 years ago but the process to accumulate and support that data is making companies like mine (a software vendor in the Hospital Revenue Cycle space) rich while little actually improves.

  9. Hi,

    Not being a physician and being an Enterprise Architect gives me some insights, which others may not have. EHR/EMR systems reflect our health care priorities. In our current system patient care is secondary to wealth creation. The regulatory system is designed to protect Health Care Providers from legal recourse. Compliance is designed to protect wealth and secondarily help patient outcomes. Non-compliance creates exposure to legal/financial recourse from patients and regulators.

    The Affordable Health Care Act (AHCA) has changed the motivation for regulations. It has shot holes in the ironclad armor of wealth protection. Instead it has focused regulation on improving patient outcomes, which requires providers to step-up and deliver performance, not just compliance.

    Pioneer Accountable Care Organizations (PACO), will be a key force in improving patient outcomes (and oh by the way they can make money too).

    The payment system is still a mess. Until we can get rid of fee-for-service, the primary business driver will be wealth creation, not patient care. Kudos to you Rob for eliminating fee-for-service in your practice.

  10. Ed:
    Yep, we do go way back. My personal hope is that I can build my current practice into something that is actually viable when generalized. This was always my objection to retainer-based practices, yet what I am trying to build is not some comfortable existence for docs that want to get away from the system, I am trying to build a viable alternative – a proof of concept – when compared to the system which clearly needs such an alternative. For me the key will be building the IT infrastructure that would focus on care and communication rather than documentation and compliance. I would not have left the other if I felt I was just running and hiding.

  11. Like a national (or state) not-for-profit, civil service, health service? Maybe?

  12. Rob, I was one of the early EMR “knowledgebank” contributors with you. I’m still slugging it out in the fee-for-service world using the same EMR system you started out using. Some things get better, most are stymied by the need to play within the system of rules to get paid, get care authorized, and still try to give good care. Having an EMR and jury-rigging it to give us the help needed to improve care has been exhausting and frustrating to be sure. Unfortunately if we all chose to drop out and provide the type of monthly retainer care you have chosen it simply would not work either. The whole payment system needs to be thrown out and something different implemented.

  13. Well, my teachers in residency explained that EMRs were in fact billing/scheduling software first, and medical record software second. That’s how they are developed. At first, I didn’t believe what I was being told. I had hoped that as things developed, more attention would be paid to the actual medical end of EMRs. Sadly, it is not looking that like that. I think that as long as we have fee-for-service and profit-motive medical care, we will not have decent EMRs.

    I continue to be VERY interested in your progress. Please keep us posted. Indeed, thank you for posting these updates. You are doing a very ballsy thing here, and I cannot help but be impressed.

  14. Great piece, Rob. As a premedical student, it’s eye-opening to read about the issues that EMR users have in private practice. What a delicious irony that many large hospitals that could most benefit from EMR are the same hospitals that lack the policy infrastructure to support EMR in the first place. At the risk of sounding like I’m a fan of similar relics of antiquity like outhouses and paying physicians with chickens, I daresay it’s worth looking into hiring physician scribes instead of EMR. If there’s one thing I know from my time as a student, it’s that there are hoards of us elbowing one another for the chance to work in hospitals. Perhaps having a student by your side instead of a computer screen would kill two birds with one stone.

  15. We need a Steve Jobs clone to put a mind to making an EHR that serves the user and the patient and, in the process, the billing task. It can be done, but the money for development has gone to the lobbyists with the most persuasive sales techniques regardless of how clunky their products. It’s been a process only a criminal could love.

  16. You are the true cynic in this, which I understand. Yet in the years I came up on EMR the view was on patient care, not billing. EMR and PM programs were separate, not conjoined. I am disillusioned because I adopted EMR as a tool for patient care and used it effectively as such.

  17. Dr. Lamberts,

    I am sorry for your disillusionment. But I confess I do not understand some points. I have been using EMRs (many) since I was a medical students. What I have learned over the years is that EMRs are billing programs with medical record front end slapped on top. They are not intended to help us take care of the patient better. They are intended to bill the patient more and report on us physicians to our overlords (CMS and insurers).

    EMRs are not about doctor/patient. They never have been and never will be. Do I hate them? Of course. On the other hand, they are working as intended. I do not understand your disillusionment.

  18. That makes perfect sense, Rob! It gives me hope that you’re talking about these issues so frankly – I consider it a very generous use of your time that many who feel the same way don’t do. Count me as a fan, and I look forward to reading what you write in the future!

  19. Your obvious intent is to aggravate me, as you ignore my message and misinterpret what I say. I’m pretty sure that’s what people call being a troll. Silly me to be sucked in.

  20. ” This is because they are devices which enable regulators to expand their requirements (as a doctor using paper records could never create enough data to satisfy regulators,”

    But I thought your new practice was off the grid? Going off the grid does mean more self reliance and sacrifice.

  21. I appreciate this fact, and it gives me some hope. Forgive my skepticism, however, given my jaded experience over time. The only reason I have a clear view of this problem is that I am no longer taking the complexity of our payment system as an assumption, having left it altogether. As long as EMR products have things like CCHIT, HITECH, and documentation-driven payment, the realization of this vision is severely (if not fatally) limited. Create an easy “work around” for E/M coding, and the requirements will go up. Fortunately for me, I don’t have to go there any more. My best course is to somehow prove what I’ve been saying for all of these years. This post is the pre-quil to the one I meant to write about what “Good” really looks like (IMO, obviously).

  22. “My options are: 1. Don’t use computers (as you seem to suggest).”

    Well Doc, you seem to want that touchy-feely, horse and buggy, take a chicken for payment type practice – you know, the good ol’ days.

    Carry a pad and paper, design your own check box questionnaire, put them in a file folder.

  23. We figured out that current technology was following a path that wasn’t sustainable a few years back and started developing new technology that is enabled by new technology not available 10 years ago (storing data in structured documents themselves in such a way that the data can be utilized by other products in ways not originally anticipated – like what Google uses for indexing web pages) and HL7 documents, with additional technology to use smaller parts of the documents for other uses as well. Bottom line – much more flexibility. HL7 is going down a very similar path with their FHIR initiative, which we are supporting as well. I think you were at the mHealth Summit in DC in December (I thought I saw your name on the program) – it is very similar to what Open mHealth (Ida Sim at UCSF is co-founder) is pursuing for smaller apps. You couldn’t create Facebook without this technology; we don’t think you can create the next generation of HIT without it as well. I think you’re right that the government created a “checklist” for current vendors to use in developing something that could be sold to clinics and hospitals without making it usable, and that’s a problem. But I think they’re trying to turn the corner, too, with their Blue Button Plus initiative. Let me know if you’d like to have a conversation about this – we’ve been singing this tune for the past few years, and I think physicians and other clinicians are finally starting to understand.

    Sandra Raup

  24. Thanks. That’s why I am writing about this. The monumental shift I’ve made from my belief in EMR to my disdain for most of the software on the market is hard to understate. There was not a stronger physician-proponent.

  25. The problem is that EMR is less user-friendly than it was 10 years ago. This is because they are devices which enable regulators to expand their requirements (as a doctor using paper records could never create enough data to satisfy regulators, it takes computers to produce reams of data). This is how EMR has become about increasing complexity, not simplifying care. This is the bitter pill I’ve had to swallow as a recovering EMR enthusiast. Things are not improving, and the system will continue to corrupt them because that’s what our system does.

  26. So, you really think I don’t need an EMR and should use paper? Really? There are no records systems out there at the present that aren’t corrupted by the payment system. My options are: 1. Don’t use computers (as you seem to suggest). I’ll get rid of my cell phone and microwave while I’m at it.
    2. Jury-rig something using one of the current EMR programs
    3. Build my own system. Ugh. I really don’t want to start down that road if at all possible.
    Perhaps my writing will spur someone to see the pent-up need for something that doesn’t suck. I can dream.

  27. “Computer software should never make the user bend to its needs – it should serve the user.”

    The “users” of EMRs are CMS and the large insurers. I think they’re pretty satisfied with what they’re getting.

  28. The problem isn’t the programmers and it isn’t the EMRs: it’s the CPT/ICD/MU/CYA medical system for which they are designed.

    If we want more usable EMRS, we have to revamp the non-EMR sources of the problems. Until we do that, we’re stuck. (Don’t hold your breath)

  29. This a great article. EMR had been designed to optimize billing not outcomes. I would like to take this discussion offline if you are interested to pursue the discussion.

  30. I think many EHRs were developed for complex hospital-type care; others were developed for episodic care where one visit didn’t relate to any other so just had to have basic information and a way to bill for it. The care most people need today addresses a longitudenal care plan – and may involve many providers and non-providers as well. New technologies are available that weren’t available 10 years ago. I hope clinicians are aware that this is the way all innovation occurs – remember how long it took for a practical design for cars to be developed. The Model T was not an overnight success, and I’m glad people didn’t give up after the Model N.

  31. Computer software should never make the user bend to its needs – it should serve the user. This is the fault of the programmer. Rob – you made a poor purchase decision.

    EMR isn’t necessary unless you want/need to share your health records with multiple non-communicating providers.

    EMR isn’t necessary unless you’re running out of record storage space.

    EMR isn’t necessary unless it’s tied to your billing system.

    Of course EMR requires data/text entry – what did you expect – for it to read your mind.

    Hire a data/record entry clerk to follow you around.

  32. Rob, following your story has compelled me to take a look at my own father’s practice in Macon, GA. Almost six years ago, I watched as my mother and father patiently made the transition to EMR. And I continue to listen to them as they muddle along, bringing the discussion home.

    Your story and journey are certainly being followed–>is the short version of this comment. My parents (and others like them) will certainly benefit from the insight you provide along the way.