The DIY Electronic Medical Record

There was a hole in the wall of our bathroom that was a painful reminder of a bad encounter with a plumber.  Yes, that hole has been there about a year, and it has been on my to-d0 list for the duration, daring me to show if I inherited any of the fix-it genes I got from my father.  Why not hire someone to come fix it?  I also got (as I mentioned in my last post) dutch genes, which scream at me whenever I reach for my wallet.  So this hole was giving me shame in surround-sound.

I attempted to fix it the hole last year, even going to the degree of asking for  a router table for my birthday.  Since there was previously no way to get to this all-important access to the shower fixture without cutting through the sheetrock, I decided I would take a board, cut it larger than the hole, then use the router to make a rabbet cut so the panel would fit snuggly.  Up until then, I thought a rabbet cut was a surgery to keep the family pet population under control, but my vocabulary was suddenly expanded to include words like rabbet, roundover, chamfer, dado and round nose. Unfortunately, my success only came in the realm of vocabulary, as I was not able to successfully master the rabbet cut without making the wood become a classic example of the early american gouge woodworking style.

I am not sure why, but something inside me told me today was the day to give this another shot, and to my shock (and that of my family), I was successful!

This home project is actually a late comer to the DIY party I’ve been holding for the past few months.

  • Don’t like your practice?  Build your own from scratch!
  • Don’t like the health care system, build a new one!

My latest DIY venture is in an area I swore I’d not go: I’m building my own record system.

There are several reasons I’ve avoided doing this DIY project:

  1. If I fail, I’ve wasted a bunch of time I should have been building my practice.
  2. If I succeed, I don’t just have a practice to manage, but a piece of software.
  3. I tend to get obsessed with details, losing hours coming up with elegant solutions to problems for which simple solutions are available.
  4. It requires that I spend far too much time thinking about HIPAA and security issues.  I hate that kind of thing.  It bores the socks off of me.  I fell asleep three times while writing this bullet point (and I have no socks).

Business is good; we are up to 250 patients and are managing the volume pretty well.  But I’ve had to keep a cap on growth while I figured out what system I would use to run the practice. Obviously, EMR systems designed to produce enough E/M vomit to scare away Medicare auditors don’t fit with my business plan. Other systems seem to have become so obsessed with “meaningful use” that they don’t do basic business functions.  Expecting a system designed to work with the Economics Through the Looking Glass of American healthcare to function in the real world is folly, and so I had to choose: do I stay with my current non-system and let the quality of my care suffer, do I keep growth of the practice to a minimum, ignoring the reality of 3 kids in college next fall, or do I give in to the belief that I know what I need and can build a computer system that will work with my type of practice?

I decided on what’s behind curtain number 3.  Unfortunately, this all happened just as I agreed to an interview with a local TV station – an interview that went viral and now has people as far away as Idaho and San Francisco wondering if they can be my patients.  Now the pressure is really on to make this thing work.  I can no longer be indecisive; I will either live by the database or die by it.

So far, it’s been going well.  Despite a few “unfortunate” moments where I deleted all records of everything (thank goodness for paranoia about backups), I have broken the code of working with a relational database, and my nature as an internal medicine problem-solving nerd has served me well.  In truth, this is not much different from what I did with the EMR system at the old practice.

  • I think about where the greatest pain is for me and my nurse, and fix those problems.  Where can time be saved, and jobs be made simpler?
  • I think about where the greatest risks for patients are, and fix those problems.  What things are easily forgotten or missed?  How can I set the system up so it assures the safety of my patients?
  • I think about where I want to go with the practice in the long run, and set up a system that will set us up to go in those directions when we are ready.
  • I think about the questions I ask myself when dealing with a patient, the information I want to know the most, and put that information in a place where it’s easily accessed.

In reality, the software borrows heavily from software real businesses use:

  • Contact Relations Management to keep track of interactions with customers (patients)
  • Business financial management to keep track of costs and of who has paid (and who hasn’t)
  • Document management to handle the reams of information flung at me on a daily basis.
  • Task management to keep important tasks in front of me and my nurse (and eventually patients)
  • Spreadsheets to organize numbers
  • Reminders to tell when important things are due
  • Communications systems both between office staff and with patients

It’s really a hybrid of all of these, with the additional plan to securely share much of the data with my patients online.  My hope is to build something good enough to get the interest of someone who actually knows what they are doing in writing software.  I know what problems need to be solved, and am learning much about how a good database program can do that (I am using Filemaker Pro because it’s cheap, it’s easy, and it works on both Macs and Windows), but I know my limitations.

I still have no desire to become a software tycoon.  I am doing this only because it’s the only way I could see to make this practice work.  The practice is still at the center of my motivation.  If it doesn’t help me serve my patients better, I won’t do it.  The amazing thing is that we used it all of last week and my nurse didn’t quit.  That’s a good start, but the real test comes this week, as we take on the barrage of new patients brought on by our recent publicity.

I’ll keep you posted.

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.

17 replies »

  1. I have created my own EMR (ComChart EMR). For many reasons, I would recommend against creating your own EMR. At a minimum, it will require 1000-2000 hours of programming time before you begin to have anything significant.

    Contact me off line if you want to discuss.

    Hayward Zwerling
    cell 978-407-0101

  2. Hi Rob,
    I have across your article as I am trying to make decision whether I should write my own EMR using filemaker or use something already available.
    I wonder how it is going with your EMR?

  3. I was searching online for an EMR made with Filemaker Pro and came upon your blog. I retired from work where I developed databases using Filemaker Pro and those databases varied from simple accounting to a complex system involving medical statistics, demographics, medical records, modalities for PT, exercises for rehabilitation and more.

    The last version I used was 11 and that version had a lot of bells and whistles. I am hoping you have achieved your goal and your database is serving your practice well.

  4. I agree with this article.
    I bought Vitera Intergy EHR and it is so complicated to use, cost me hundred of thousands of dollars, and has poor support. What a nightmare!!!
    Either don’t use EHR or go to open source EHR internet based.
    These for profit companies are ripping off the medical field.
    Dr. B

  5. I am so happy I found your site. I really found you by mistake, while I was browsing on Bing for something else. Anyways I am here now and would just like to say thank you for a useful post and an all round inspiring blog. (I also like the theme/design), I don’t have time to read through it all at the moment, but I have added your website to my favorites, so when I have time I will be back to read more. Please do keep up the awesome job!

  6. Rob,
    I apologize for the unnecessary advice! I did not realize how much time and effort you had already put into this decision. I am surprised at the HelloHealth pricing, that seems outlandish, and quite a bit different than free, which they state on their website.

    I wish you all the best in your DIY adventure, and I will be pulling for you.

  7. Let me make this clear: I am committed to this course. I’ve spent the past six months looking at hundreds of other options (including HelloHealth), trying a number of them and failing miserably with them. I am not doing this brashly, nor without lots of advice. I talked to two of the bigger names in IT (friends of mine from the good ol’ days of EMR) and they advised much caution too. I hate the fact that I have to build it myself, but I really, really feel that it is the only hope for my business. Changing to another system at this point would inject chaos to where I am finally achieving a bit of calm.

    This is purely a move for my business. I never thought I was building an EMR that anyone else would buy. I simply need a tool that works with my business model, and none of the EMR products I see out there have done it.

    In truth, the HelloHealth product was OK, but with my plan to do 1000 patients on the EMR, they would charge me the equivalent of $5000 per month. When I pointed this out to the HelloHealth salesman (that it would cost far, far more than any other product), he started telling me my practice model was unrealistic and that was all I needed to hear.

    I appreciate others who have great ideas, and wish I had found the holy grail before I went on this quest, but my business absolutely requires I commit to something. This is a move of survival. Sorry.

  8. Without going into too much details as to why I started my Foundation years ago, it has taken us about 4 years and now we are working on the second and third phases of our system. We will gladly review any ideas or wish list, and see if we have not already incorporated into our current or future phases. We don’t fit the mold of commercial software nor ever will because we are not, as a whole we charge the user 20 some dollar annually and donate the funds back to people in need. One quick read of our “About Us” page would give you an idea as to our Mission and goals. http://www.emhr.org
    Fell free to contact me via the site directly.

  9. Hi Rob,

    Initially, I intended to echo Hayward’s sentiment from above, and try to discourage you from this effort, but instead I will pass on some thoughts from my favorite authors, the Heath brothers. In their great new book, Decisive, they talk about how most of us do not have a process for making decisions, so they created one they call the WRAP process- an acronym for “Widen your options”, “Reality test your assumptions”, “Attain distance”, “Prepare to be wrong”. I would encourage you to check out the book for more. One thing the brothers Heath might recommend in your case is to “ooch”, to make a small move in the intended direction, like develop one module for your EHR, which it sounds like you are doing. They also advocate to “set a tripwire”, say by giving yourself 2 months to see how far you have gotten and if you like the work of building your own EHR.

    And in the spirit of widening your options, consider checking out hellohealth.com (I have no affiliation with them), but this is an EHR from Myca which Jay Parkinson worked with several years ago to adapt to fit his direct practice. In looking at their website tonight, it looks like they have advanced a lot in the last few years, and perhaps they have a financial model that would be interesting to you.

    Whatever you choose to do, I wish you lots of luck with it, and I look forward to reading about your adventure.

    Mike Coffey

    Family physician

  10. Rob, enjoy your posts and your continued innovations; and your writing style, thanks for the great stuff to read. You may recall my prior comments on THCB posts – I’m now in private small group adult primary care practice, and we use one of the major mainstream EMRs. I’d like to chime in with the others who would say don’t reinvent the wheel. I think your main issues of documentation, e-prescribing, keeping basic chart notes, and allowing you, your patients, and your staff access to the chart can be met in many of the mainstream EMRs. What I personally have been doing now for over a year is to keep a ‘living and breathing problems list’ as the Past Medical History section of my basic H&P style note. Nothing high-tech about this other than you copy the PMH, surg hx, fam hx, soc hx, list of specialists, and updated list of tests and studies from one note to the next to start out with; and just edit these sections with anything new the pt tells you that visit. For example, my HPI section for a typical note I write while I’m in the room with the pt: “fu; home bp runs 120-145/70-90 per log; gluc runs 90 – 180 and no lows; new issue is Lt shoulder pain, see below. needing refills. went over lab in detail” then I edit the PMH section to be quite detailed. For example, on the shoulder pain, the bullet point for Lt shoulder pain would include ‘started 1995 with football inury; initial tx PT at that time; has tried OTC with no good effect; trialing tramadol ______” the blank denoting an open item being worked on. Regardless of being paid for exact diagnoses or not, it might be logistically useful to have an ICD-9 coder and organize the diagnoses that way to have a CCD keep a ‘mechanized’ problems list for the patients as their segue into the mainstream world, along with an updated meds list etc.; but your actual working problems list should be something more meaningful and dynamic like I describe above. For extraneous papers like outside labs or forms or reports from outside places, you scan those into the imported documents section of the EMR. Having all this in a mainstream system makes your inevitable request for records feasible (for patients leaving the state for example), just hit print or burn them a CD; and don’t forget you will be subject to the law of the land in regards to ePHI (electronic personal health information) which will require encrypted data, which the major systems all should be able to do but might be quite hard with a home-brewed EMR.

    Bottom line, try to be dogmatic about defining what exactly you really cannot do with an off the shelf system, and brainstorm with your friends here on THCB or otherwise about possible work arounds. De novo EMR is not advised by this well-wishing colleague, unless you want to go into that business full-time.

  11. Unfortunately, the speed at which the rest of the world works is not fast enough to save my practice, and my needs are 180 degrees from that of a standard practice. The systems (including the open source ones, I’ve concluded) are built on the foundation of an encounter- based and problem-oriented care paradigm. This is built from a billing reality, not because it’s good care to do this. My goal is communication and minimizing visits, and this would be harmful to any practice not doing my kind of care. So, despite fearing this leap, I could not get any traction whatsoever with any EMR system (including open-source). It’s kind of like putting wheels on a horse to try and use the EMR systems built to succeed in the regular payment system. What I’ve accomplished in 2 weeks is far more useful than anything I’ve seen (by far). I am finally organizing my business and moving toward better care.

    I am not concerned about Federal EMR mandates, as I am off the Medicare Grid and so cannot qualify for the money (and am not hurt by the sanctions).

  12. EdwardH is pointing the way forward. With open source software, you can fix what you need fixed, while letting someone else fix what they need fixed… eventually you end up with a system which is better than any proprietary product.

  13. Do not do this. I wrote my own electronic medical record program beginning in 1992. I promise that this decision will cost you more time and effort than you could possibly image. You will need to put in at least 2000 hours of programming time before you have anything that provides utility and with the Federal EMR mandates, I think you will regret this decision.

    I would be happy to talk to about this off line, feel free to email or call me.