Posted by: notdeaddinosaur | April 24, 2007

Why an Electronic Medical Record is Not Right For Me

Note on terminology: Electronic Medical Records (EMRs) and Electronic Health Records (EHRs) are synonyms. I’ll mainly be using the term “EMR,” except when quoting from elsewhere.

Family Practice Management recently ran an article on Myths about EHRs; how they don’t fix everything, why they won’t eliminate errors, and so on. The problem with this article, though, is that it’s from the point of view of a practice implementing one, implying that they have at least bought into the idea that there is in fact something to be gained by working their way through the “myths” they proceed to debunk in the article. As I read it, I was struck by the mythology of those underlying assumptions. I’m no Luddite. I’ve thought long and hard about whether an EMR is a worthwhile investment for me at this stage of my life and the life of my practice. Over and over again, I find that each pro-EMR argument is based on assumptions that do not apply to me. Here are some of them, in no particular order:

  • An EMR produces better documentation.

“Better” is one of those nebulous terms that is very much in the eye of the beholder. Certainly an EMR has the capability to spew out voluminous notes that don’t actually say very much. “More” is not “better” by a long shot. The FPM article actually discusses this, using the term “signal to noise” ratio. The vast majority of EMR-generated notes I have seen have so much noise that the signal can barely be found.

What are some objective qualities that might constitute “better” documentation?

  1. Legibility
  2. Organization
  3. Completeness

Come with me and peek into my charts for a moment; see how I’m doing now before insisting that an EMR can do it better.

Legibility: I hand write my charts, but I happen to have beautiful handwriting. Something about teaching myself calligraphy in high school, it’s the artist in me that finds indented, outline-style notes easier to look back at when I need to review.

Organization: I have templates in my head of what questions need to be asked for a given problem. The trick is to fill in the answers as the patient gives them, then ask only those questions that are left. In many ways I think like a computer, and I have considered “creating my own EMR” by using a database to create the same notes I currently write. It might allow better functionality for searching, but that’s about it.

Completeness: Again, those templates in my head serve me well. The inside front cover of my chart serves as Problem List, Med List, Allergies and preventive care flowsheets. I review and update those lists every time I open a chart, including phone calls and prescription refills in addition to patient visits.

The bottom line is that whenever my charts have been reviewed — as they have by countless insurance flunkies, QA nurses and the lawyers involved in my lawsuit — they have been uniformly praised on all counts. No one has any complaint with my documentation. I can easily find what I need when I need it. What do I have to gain from an EMR?

  • EMRs save time.

Giving this statement the benefit of the doubt by assuming that it does not count the initial learning curve, I still don’t buy it. One EMR ad touts the time-saving advantages of its system: “Get out of the office at 5:00 every day.” I already do. About half the time I’ve got the entire note written by the time the patient leaves the office; the rest of the time I slip it in between patients and during other miscellaneous slots of free time through the day. Even if I have an entire stack to write after hours, it rarely takes me more than one minute (by the clock) per chart to finish them. It’s the phone calls to patients about lab and test results — not to mention playing phone tag with other doctors — that eat up the time. EMRs aren’t going to do anything about that.

  • EMRs improve reimbursement.

Bullshit. That’s just bullshit. How exactly does this happen? Through P4P incentives? Allow me to plagiarize myself for a moment. From the mouth of a recognized “expert” in P4P and performance enhancement who came to give a talk to a regional meeting of my state academy:

A man in the back spoke of the new EMR he had just purchased for $30,000. Once all the numbers were crunched, though, it turned out he was only going to see about $3,000 in P4P bonuses. The response, delivered somewhat more softly than the stentorian tones of the main presentation, was that his return was more likely to be in the areas of quality and lifestyle. I imagined presenting a proposal to an insurance company — actually to any kind of business — and saying, “Now, you’ll only make back about 10% of your initial investment, but you’re likely to see improvement the areas of quality and lifestyle.”

A related point:

  • EMRs improve performance.

Performance of what, as measured by whom? The usual example trotted out is something like, “How many of your diabetic patients have hemoglobin A1Cs under 7%?” Who cares? I do not take care of populations; I take care of patients, one at a time. Being able to say “87% of my patients are at goal for LDL” is a completely meaningless exercise for me.

  • The government is pushing EMRs hard, and are working towards providing incentives to practices that adopt them.

Yeah, right. The government thinks it’s a good idea. Don’t forget this is the same government that was so sure there were WMDs in Iraq and that still believes, despite the evidence, in the efficacy of abstinence-only education. Sarcasm aside, this point may be true, but I don’t see them getting their act together any time soon enough to make a meaningful impact on me or my practice.

  • An EMR will add value to the practice when you go to sell it.

Once upon a time, medical practices were actually bought and sold. The assumption was that patients “belonged” to a practice, so the value of a practice was calculated as the sum of the hard assets of the practice (equipment, furniture, etc.), the accounts receivable (money owed to the practice that hadn’t come in yet, such as insurance payments) and “goodwill,” that indefinable thing that basically meant patients walking in the door. If this were still true today, I suppose this argument would have some merit, in the sense that a practice with nice new modern equipment would be worth more to a buyer than one with all old beaten-up stuff. Still, I’m not looking to sell in the near future, and this advice sounds kind of like selling vs. living in your house. It’s not worth putting a bunch of money into home improvements you don’t really want or need, but would enhance the sale price, unless/until you’re ready to sell.

Here’s the line from the Family Practice Management article that inspired this post:

An electronic record is not a paper record on the computer, and you will maximize your efficiency only by making significant changes in your workflow. Expect to work differently to make the most of the EHR system’s advantages as well as overcome its disadvantages compared to paper (yes, you will find some.)
(Emphasis mine.)

Why do I have to change my workflow? It works — very well indeed — for me. This is not to say that I’ve never changed anything in my practice. In fact, I’m continually modifiying and adapting my workflow, often in response to evidence-based practices. But so far, no one has been able to credibly show me that the benefits of adopting this new technology outweigh the considerable disadvantages, starting with the initial monetary outlay, when addressed in the specific context of my practice.

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