Doctors in the Typing Pool

An interesting blog from Westby Fisher on the failures of EMR systems that what it has turned our clinical staff into:

"...the world's most expensive typing pool has been born"

As he notes

Each morning, without fail, there's one or two individuals circling the computer terminals waiting for access to these electronic monetary portals, like children waiting to grab the last chair when the music stops.

That's true but I think the missing comparison here is how it used to be before the advent of the EMR's.....I can remember the same scene on the wards I worked on but instead of waiting for a seat in front of a computer it was waiting to get access to the "notes trolley" and the wait and frustration was no different and in many respects worse since there was only one record and therefore only one person could access it and enter data into the record. Much of this could be fixed with more accessibility, more computers or even better mobile access to the clinical data (here's one example combining the latest user friendly gadget with EMR access - you can see a video of this in action here:

But the issue of canned content being generated in large quantities with shortcut codes and pulling information from other sources to create a document is a problem. To create my note I can type
.id .pmh .psh .cmed .all .soc ....... you get the picture. These commands pulling data from other sources that add little to the actual clincal value of the document:

....demographics from the Central Registration.....four pages of Past Medical History...the original work was completed by the patient's poor primary care physician, neatly organized, but never to be updated again

.......page and a half of the current medications, their dose, prescribing physician, half of which come from self-generated 'CYA' hypoglycemia orders are also self-generated in the interest of 'safety'.....

......."Mother died of CA" automatically spits out previously entered by the hospitalist - bless their soul - so that billing to Medicare can go from Level 4 to Level 5 for the rest of the health care team

When clinical documentation really was clinical documentation and not just an automatic regurgitation of previous clinical notes captured by other people, the process of documenting was part of the clinicians analytical process. Entering the details was important as it afforded an opportunity to think about the patient, their history, symptoms, and signs and provided real input to the diagnostic process to arrive at a differential diagnosis and plan for the next steps. Clinicians are still trying to do this but all the while working to satisfy the documentation requirements so they can bill for their services

The rest is for Medicare and has been added repetitively and
identically by countless other individuals, all whom enter the same
content to assure achieving the maximum amount billed by law for their
services. Not that any of it is read, mind you, but it'd better be
there, lest the Medicare auditors descend on your facility.

Technology has helped kill the richness and detail of clinical documents and turned detail rich
reports into dumbed down "fill in the blank" cookie cutter reports that do not
reflect the richness of the information that physicians wants to provide to the colleagues.

In a recent discussion with a busy radiologists he remarked that what the referring physician needs from him is "more detail". He wants to provide the referring physician
the clinical information they need to treat the patient giving them the confidence in the information they receive with a rich detailed report that speaks their language.

So as not to reach the destination for the future of medicine painted by Westby Fisher:

Will they (future doctors) actually process what is entered, or merely become
highly-efficient typists and plagiarists in the never-ending quest to
become more "efficient" health care providers?

we must provide the tools that allow for clinicians to document clinical information efficiently with the richness of medical language while still providing the computers and clinical systems with their bits and bytes of data that allows these tools to function and help support the clinicians in the delivery of clinical cared

Only 14% of Doctors Using an EMR

The July 2008 For the Record newsletter contained an interesting article that reaffirms the lack of penetration of EMRs in healthcare today

Electronic health records seem so intuitive. Most of us assume our medical records are digitized to save time and help doctors track patients’ medical history. Americans would probably be surprised that a mere 14% of doctors in the United States use electronic medical records (EMRs)

In this particular instance the point is brought home in relation to the daughter of the Queens who was diagnosed with a rare condition DiGeorge syndrome that requires multiple visits and complex treatments. It is true that this example is at the higher end of complexity and requires many more medical interactions and participation but we will all experience some level of medical interaction that will certainly not be getting simpler or less detailed. Medicine continues to innovate at an ever increasing pace and customized drugs therapy and treatments and personalized medicine is within sight. So the problems this family faced which included

....when a procedure was delayed for more than fours hours, while doctors and nurses waited for Courtney’s lengthy file to arrive from another hospital floor. Finally, the records arrived when an aide brought the soaring stack of papers and manila folders on a wheelchair

Will be our problems now and in the future as well. We can look to other countries for their experiences and perhaps even be a little envious as the article cites:

• 90% of doctors in Sweden
• 60% in the United Kingdom

Although the United Kingdom's experiences is not without its own set of challenges and problems and there are those in the US that would question the value derived from such implementations, in general, clinicians and the health care community is agreed - we need to implement electronic medical records for everyone and allow this information to be shared. There is and will continue to be discussion and disagreement on what should be shared, who can see the information and even how it is shared but sharing medical knowledge effectively and efficiently is highly desirable.

Even the technology press is getting in on the commentary with an article from ComputerWorld that makes the point that much of the lack of success in rolling out these systems boils down to the old adage

"Follow the Money"

But the biggest obstacle may be a payment model that offers little financial incentive for most health care providers to invest in using electronic records internally, let alone share them with other providers.

And John Halmka, the CIO for Harvard Medical School and Beth Israel Deaconess Medical Center is quoted as saying

"The provider bears the cost, but most of the benefits accrue to other parties," mainly "payers" -- insurance companies -- and patients who reap the benefits of higher-quality care

So while we wait for the government agencies to fix the incentive problem we need to show value in the implementation and improve the working environment for our clinicians. Taking a leaf out of Apple's play book might help given the impressive (recent stock slides aside) of Apple in the Music Player business (one they were not even in until 2001) and the more recent iPhone. They do come with faults, contrary to the pleadings of your average teenager everyone does not need an iPhone and lining up for hours or even days to get the latest model is not typical behavior. But with their attention to detail and focus on ease of use and intuitiveness I have to believe that with that same level of attention to detail and actually designing a solution that physicians want to use we could accelerate adoption. I'd bet that an EMR designed to be accessed using an iPhone would be a lot more attractive and receive wider uptake and participation by clinicians than one designed using older technology.

And the market is large:

....there are 921,904 physicians, 723,118 practices and 5,756 hospitals in the U.S., according to the American Medical Association and the American Hospital Association.

But more importantly based on the US Census population clock there are around 304 Million customers and the numbers increasing....so perhaps the key driver as Grannis suggests will be Personal Health Records

....efforts by Microsoft Corp., Google Inc. and others to build personal health record repositories...... will put pressure on the industry to embrace EMRs

I know Courtney Queen and her parents are grateful for some level of EMR's in the "Vandy Zone" but I am willing to bet that everyone would benefit. 304 million people asking for electronic records and real sharing of their medical information rather than endlessly filling in the same information on paper forms has to carry some weight....