So, the question has been raised: why am I doing this? Why re-invent the EMR wheel? What is so different about what I am doing that makes it necessary to go through such a painful venture? I ask myself this same question, actually.
Here’s my answer to that question:
What medical records offer:
High focus on capturing billing codes so physicians can be paid maximum for the minimum amount of work.
What I need:
No focus on billing codes, instead a focus on work-flow.
What medical records offer:
Complex documentation to satisfy the E/M coding rules put forth by CMS.This assures physicians are not at risk of fraud allegation should there be an audit. It results in massive over-documentation and obfuscation of pertinent information.
What I need:
Documentation should only be for the sake of patient care. I need to know what went on and what the patient’s story is at any given time.
What medical records offer:
Focus on acute care and reminders centered around the patient in the office (which is the place where the majority of the care happens, since that is the only place it is reimbursed)
What I need:
Focus on chronic care, communication tools, and patient reminders for all patients, regardless of whether they are in the office or not. My goal is to keep them out of the office because they are healthy.
What medical records offer:
Patient access to information is fully at the physician’s discretion through the use of a “portal,” where patients are given access to limited to what the doctor actively sends them.
What I need:
A collaborative record, sharing most/all information with patients so they can use it in other settings for their care. Also, I want patients to have edit privileges for things they better suited to maintain, like medication lists, demographics, insurance information, and past history items.
What medical records offer:
Organization of information is not a high priority, as physicians are not reimbursed for organized records. The main focus is instead on meeting the “meaningful use” criteria, which gives financial incentive to physicians who use a qualified record system.
What I need:
Since the goal is to share the record and to maximize care quality to make communication more efficient, organization of the record is crucial. The goal is to put the most important information up front and to give easy access to the details sought. I am the “curator” of the record, organizing it and prioritizing information in a way that is useful to both me and my patients.
What medical records offer:
Top priority is paid to billing workflow, with second billing given to in-office patient management. The least attention is given to clinical workflows for patients outside of the office.
What I need:
My priorities are 180 degrees from this. My top priority is keeping people outside of the office healthy and happy. which will keep them paying their monthly payments), so maximizing organization and communication need to be the focus of my records. Certainly in-office care needs to be efficient, but not in the same way as the rest of the healthcare system (efficient documentation for payment); it must focus on getting the most accurate information into the system and making it easiest to get information out. Billing is almost a non-issue, as it is very simple in my system.
What medical records offer:
Task management is again a low priority, as it increases potential non-reimbursed work for physicians (and staff) in the typical office. For example, there is not much emphasis put on phone office follow-up or making sure the plan is communicated to the patient. This is not strictly avoided, as most medical professionals do want to give good care, but the high-stress overworked atmosphere in most offices makes most medical personnel reject any tool that gives “extra work.”
What I need:
Task management is near to the top. I am focused on coming up with a care plan for each patient and making sure the patient understands that plan. The goal is to reduce the chance of misunderstanding, as it increases my work and decreases the patient’s chance for health. So an integrated task-management tool is very important, as is education resources which can be accessed directly from the patient record and given to the patient to keep (ideally) in an online “folder.”
What medical records offer:
Mobile communication is becoming more available, but it is very much system centric., meaning that it is built by the EMR vendor to only be used by patients of physicians who use that EMR and to only be for viewing information from the physician, not as a patient-centered tool.
What I need:
My goal is to give patient access to accurate medical information and access to me in a way that is easy and efficient. Mobile technology is the most obvious means to this end. I want patients to be able to access their entire record, not just what I generate, from a mobile application (or at least a web application). I want any place they get information to also be the communications hub, as it allows them to communicate with as much information as possible. In short, I am looking to have a “one stop shop” for all patients’ needs, not a “walled-garden” that only gives them access as long as they see a doctor that uses the system.
What medical records offer:
Mobile communication is becoming more available, but it is very much system-centric, meaning that it is built by the EMR vendor to only be used by patients of physicians who use that EMR and to only be for viewing information from the physician, not as a patient-centered tool.
What I need
My goal is to give patient access to accurate medical information and access to me in a way that is easy and efficient. Mobile technology is the most obvious means to this end. I want patients to be able to access their entire record, not just what I generate, from a mobile application (or at least a web application). I want any place they get information to also be the communications hub, as it allows them to communicate with as much information as possible. In short, I am looking to have a “one stop shop” for all patients’ needs, not a “walled-garden” that only gives them access as long as they see a doctor that uses the system.
What medical records offer
Payment for health services generally depends on two things: a problem being treated and a procedure code and are therefore the focus of the record system. Problem lists are in the record, not primarily because they help with care, but to allow billing for services.
What I need
I believe we should focus far more on reducing risk factors than on treating “problems.” My goal is to avoid problems and do fewer procedures when and where at all possible. Problem lists should not be focused on code, but instead to give the most accurate information to lead to the best decisions, and to help understand the risks the patient faces so problems can be avoided. If this happens, I will have less procedures, a fact that will make both me and my patients happy.
Optimistically, the ultimate goal of the typical EMR is to allow a physician to practice the best medicine possible while not going out of business. It allows physicians to give good care despite the system that rewards them for bad care.
The goal of my record system is to promote the success of a new business model: pay doctors more to keep people well and to keep people out of the rest of the health care system. The ultimate goal of this record system is not to make money for me as software I can sell, but to make it so I can extend the model efficiently to a larger population, ultimately making this new system of care an attractive enough alternative to physicians, employers, and patients to make the switch. Perhaps in doing so the “do more, spend more” system can be replaced by a welcome alternative.
So here is the goal:
- Create a prototype of a system that allows me to give my system of care efficiently to a large population.
- Use that prototype to “prove concept” – that the care I give is better for patients, better for me, and saves money.
- Create enough interest in the model that people are willing to develop the system. I think this is best done through making it open source and setting up a foundation to fund the program (and let me gladly hand it off to people who are better at this than I am).
- This will ultimately lead to more adoption of the practice model (by making it easier to make the transition), which will in turn lead to more interest and funding in the software.
I don’t believe we can retro-fit a standard EMR product to do this job; I think their focus is too different from the goals of this practice model. I may be wrong, but I looked at numerous systems and found that they fought against my goals instead of enabling them. I turned to this idea not out of ambition, but out of a desire to survive and see my practice model succeed.
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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Thank you for a clear and concise pathway forward. Please keep us updated!
http://www.afchealth.net/ is very useful to EHR.
Any thoughts, Rob, of how you communicate with other providers – hospitals, nursing homes, other healthcare professionals? Do you use diabetes educators or physical therapists? Co-management with specialists? Providers in other geographic areas if your patients travel or move? Just wondering how you’re thinking about this issue.
Sorry, gentlemen. The way you think and set goals will never result in anything real, primarily for two reasons:
a) Rapid changes to the way medicine is practiced influenced by the development of medical science and technology as well as changes in government and industry requirements;
b) Personal preferences – two physicians often disagree on the way they practice even when both have the same specialty and work within the same practice.
Any attempts to spell out any particular requirements even being ideally implemented will result in a perfect system for the only one who spelled these requirements and only for a short moment of time. The elusive goal of having a “perfect” system at best may please your “sweet dreams”, but that is it.
The real solution is to develop an electronic system which is “smart” enough to understand rules you set in YOUR personal practice and which is capable to learn the way YOU practice. Of course, such a system should come to you already with a set of commonly known and adopted rules – just as a newly graduated medical assistant just out of school, but you should be able to add/change these rules and the system should be able to watch and learn from your workflow. Only such a system may make most of you happy and productive because it will work differently adjusting to your personal preferences and patterns.
A tiny suggestion: read the post. Your suggestions may carry water if I was practicing like everyone else, but since the new system of care necessitates a totally different IT infrastructure and requires such a system to thrive, these are hardly “personal preferences.”
Sigh.
In the very first “What I need” you wrote: “No focus on billing codes, instead a focus on work-flow”. Do you believe that your workflow is the same as every other physician within your specialty? If not – how do you envision an EMR which will satisfy everyone’s workflow?
In your second “What I need” you wrote: “Documentation should only be for the sake of patient care. I need to know what went on and what the patient’s story is at any given time.” In a real world all the information about patient health, your evaluation and treatment is needed for very different “players”.
a) Sure for you – the treating doctor. But probably the best way to present this information to you is not in a form of a traditional document but rather as a set of various views on a computer screen;
b) To the referring doctor. This may look more as a report;
c) To the patient emphasizing explanations and advice;
d) To the payer (insurance) – one way or another but you need to present a document justifying your charges.
Thus, an EMR should produce more than a single document.
I could go on and on about every “What I need” in your post and when one wants to implement any of your “focus on…” there will be many ways to do so. And if we get ten physicians even having general agreement that a good EMR should focus on A, when it comes to a practical implementation we may easily get twenty opinions on how “focus on A” should be designed.
Sigh.
Why reinvent the EHR wheel?
Simple, the EHR wheel is currently triangular in shape. Each wheel which comes from the factory is of different size and the legs randomly vary in length.
Even moving to a square wheel would be a significant (25%?) improvement over what we have.
Feel free to come visit. Either virtual at hrfp.net or in person.
integrated systems, ehr and phr upgraded.
Dr lamberts, good post. Been doing much of this since 1990. Patients had access to medical records and messaging since 2006. Coding and documentation for biking won’t go away, until primary care and physicians are paid appropriately.
You silly boy! You want an EMR to help you take care of your patients! That is not the purpose of an EMR!
The purpose of an EMR is:
1) For the Feds to make sure you are making “meaningful use” of one and more accurately track what you are doing.
2) For hospitals and billing entities to capture every charge.
Any other use of an EMR is “off label” and according to some “dangerous”.
You have found yourself in the same situation as the U of Oregon residents, who frustrated with what was available, decided to make your own.
You are a dangerous non-conformist, your attempt to improve your practice’s ability to help patients is “double plus un-good”. Perhaps you need to be sent somewhere for “re-education”.
I’m sorry to be so naughty.
Rob, I also applaud your project! Good software, like good science, requires experimentation. Your criticism of current products is spot-on, especially in regard to their lack of workflow and task management features. As a doc who has led an EHR development project and who still writes software, I look forward to hearing more about the start of your project, and possibly, even contributing.
http://ehrscience.com/2012/09/24/from-data-to-data-processes-a-different-way-of-thinking-about-ehr-design/
Let me say that I went to an ACP class you led way back in 1995 regarding this, became an early adopter of EMR (1996, got MedicaLogic. Got to be friends with Mark Leavitt, Blackford). We (me and the smart people trying to help me in this project) want to get a team of advisors and/or collaborators to help this move from lab to reality as quickly as is reasonable. Again, the idea is to harness the opportunity afforded by the different payment system to think as creatively as possible and design something that will really center on prevention, not consumption. If you are interested, contact me at rob (at) doctorlamberts (dot) org.
Good for you, Dr. Rob and godspeed!
I don’t think you need to explain anything, just BIDMC doesn’t need to apologize for their homegrown technology. It’s your business and your vision and your mission. All innovation and competition is welcome in this abysmal market. Let everybody engage, and let the best man/woman win….
Nice post Rob! I heartily endorse your wish for collaborative task/project management.
Am curious to know how many patients with active multi-morbidity you have. It’s nice to focus on risk factors and keeping people well, but I’ve been struggling to have my EMR support me in helping people manage several chronic diseases. And in not losing track of anything.
I would suggest that in chronic disease we need to address risk factors as well: treating only problems that are a risk to cause morbidity or reduce life expectancy. For example, do we treat high cholesterol (or obesity, for that matter) as a disease, or shouldn’t we think of it as a risk factor for the problems we want to avoid: death and disability? If it is the former, we will (and do) try and fix it even when doing so has no impact on death or disability. It is why we use antibiotics for sinusitis despite the fact that it has no impact. We like to “fix problems.” I say, tailor our treatment of “disease” to the patient as a whole. I think our “disease” approach to these risk factors has caused significant confusion in patients.
Is a triglyceride of 250 in a thin 35 year old female with no family history of heart disease worth treating? Do we call it a problem? I have such a patient who took a lot of explaining to convince that what most docs do (give a fibrate) is actually worse than not treating.
Most of my patients are comlex internal medicine patients, not simple ones. But I treat diabetes to avoid heart attacks, kindey disease, neuropathy, and eye problems; I don’t treat it to lower the A1c. My goal with this record system is to give quick access to the information that aids in helping our patients achieve what they really want: to live long and to have a high quality of life. The important information, however gets lost in the triglycerides (and E/M graffiti).
I think we are in agreement and both focus on collaborating w the patient to address their problems in a person-centered way.
I do think in problems, not risk-factors, but that may be semantic. Here’s something related:
https://thehealthcareblog.com/blog/2013/03/01/zen-and-the-art-of-charting/
BTW after I wrote this post people pointed me towards Larry Weed’s problem-oriented medical record; this was the first I’d heard of it but after learning about it I liked the concept. Curious as to whether you are using some of those stuctures in your EMR.