All Things EMR | athenahealth News & Views
Is That My 400-page Paper Chart or Are You Just Happy to See Me?
In my entry last week, I said that I’d review some additional examples of technology playing a key role in easing my experience as a patient battling Stage 4 colon cancer. I am going to loop back to that train of thought later and instead discuss one of the shortcomings of technology that I experienced just prior to two of my four surgeries.
Have you ever read The Wall Street Journal (WSJ) or The New York Times (NYT) on an iPad? It’s a lovely experience. The iPad is completely intuitive in a way that allows a reader to easily cover a myriad of information. Within seconds, I can go from the front page to the opinion section to the market news. Then, I can see unrelated articles within those sections. It’s ingenious, easy and fun to use.
So, let’s compare that experience to searching the massive quantity of information that is collected in an EMR for a patient like me. You’ve got basic family history, presenting illness, medication lists, op notes, infusion notes, visit notes, scans and reads from radiologists, EKGs, etc. Basically, like the WSJ or NYT on an iPad, a medical record holds a lot of disparate information that is tangentially related. Clinicians want quick and easy access to the data that they deem relevant—they don’t want to lick their fingers and turn pages to find this information.
So, let me talk about my first pre-op visit. I’ve had four surgeries since my diagnosis and all have had the exact same pre-op process unfold. I meet with my anesthesiologist or a stand-in, as well as several nurses and physicians, to talk about prep for the operation and what’s expected afterward. They draw some blood and give me an EKG test. Standard stuff, I think.
Well, about 30 minutes into my first pre-op meeting, I almost started to cry.
That’s because each person I met with during this three-hour pilgrimage was lugging around their own copy of my 400-page chart. HERESY, I thought! An institution that has utilized technology quite well, thus far, was clearly in the neonatal phase of life as it related to sharing (or viewing) vast quantities of information across a wide group of people.
The computer/EMR just didn’t cut it, obviously. I asked several doctors if the paper medical chart was standard for this part of the care process and the answer was “yes.” It must be viewed as the quickest way to access random pieces of information buried in various portions of the patient’s vast chart. The format of the EMR must have limitations in this regard – likely designed for quick data input, with little regard given to the consumer who needs a specific view of a patient’s information further down the line.
This scenario was illustrated quite starkly to me. As a patient this time around, I could see the dichotomy between an EMR as a “piece of software” to input and store data, and this institution’s particular EMR as a “piece of software” to share discrete data across a broad group of stakeholders. It’s clear that, in some cases, an EMR can accommodate quick data entry. It’s also clear that an EMR can be useful as a data-sharing tool—when you know what information you need (e.g. when viewing a specific scan or blood tests).
Having said that, based on the fact I was going through my pre-op process watching physicians thumb through my paper chart for awkwardly long periods of time, it was evident that the EMR does not offer a simple way to organize and render relevant information in all cases.
Therein lies a massive shortcoming. And it’s affecting the simplified coordination and sharing of relevant clinical information at the time when the clinician needs it most—while standing in front of the patient. This is where technology can be incredibly useful in determining what information is relevant based on the physician’s guidance. The utility comes from being able to present it in a manner that enables the clinician to quickly digest important information. The comparison to accessing The Wall Street Journal on an iPad quickly comes to mind because their sections, “article titles and summary” and “complete article text” can be accessed with a few finger swipes.
See the comparison for how relevant medical data could be organized for quick and predictable access?
Although some companies and institutions claim to be making strides in this direction, it is certainly not easy. Done right, it requires the institution to gain access to all relevant components of a patient’s medical history, create algorithms to determine the relevancy of the information for a specific patient case and provide a streamlined ability to serve that relevant information reliably and quickly for consumption at the right time.
As the amount of discrete data that is populated into an EMR extends beyond the limits of a human’s ability to find… search through anomalies… and digest, it is clear that information technology needs to take on that array of data, regardless of the complexity, and make it easy to access and digest.
In so doing, the lengthy process of wading through a 400-page chart, as in my case, can be avoided. Relevant information can be teed up for the physician and the chance of overlooking a key data point can be drastically reduced.
So here’s a question for you to contemplate: As you consider information technology solutions, how do you rate “ease of data entry” and “simplified & relevant data access”? What has your experience been, from either side of the exam?
Physicians have been enslaved as data entry clerks without the benefit of being able to retrieve the information in an efficient way. None of the EMRs are interoperative. However, ink on paper still is! Perhaps that is why your doctors (notice I do not use the terrible word, providers) still prefer the paper record.
Derek Hedges, you have some great points, and I hear your message. There are several things going on here, which I am sure you probably know.
There are three main purposes for the EMR
1) patient care
2) billing
3) malpractice protection
#1 is most important, but most of the recent EMR’s have a bunch of crap for #2 and #3 that get in the way of number #1. I wish there was a way to click a box on the EMR to say “hide #2 and #3″ just to see what is important for taking care of the patient.
At this point in your journey, as a doctor I really don’t care about your smoking status, ethnicity, or whether you have received a printed copy of your summary. but that is what is driving the EMR market nowdays.
In the old days, I would receive a printed page from a consultant that was one page, and describe quickly what was wrong and what I needed to do. Now I have to sort through 5 pages of crap.
I can’t possibly feel your pain, but feel the problem is partially due to the reimbursement system and the malpractice system. If the care really “revolved around you” it would be one page and would be very accessible.
Disclaimer, I use athenaCollector but use another EMR which is CCHIT-certified as when I adopted athena, they had no EMR (as a solo primary care doc, I could not likely afford athenaClinicals).
I have to echo Dr. Morris and take it a step further. Paper charts have generally allowed us to both enter data exactly the way we want to without having to shoehorn it into forms designed by non-physicians, and to retrieve data that has been stored where we expect it to be stored rather than where some programmer decided it ought to be located. I think that athenaClinicals is better than most EMRs in overcoming such issues, but there is still an awful lot of work that needs to be done. OBTW, iPads are great for examining reams of data, but data entry is still problematic, particularly if one is dealing with information such as that contained in a typical medical history.
Ease of data entry and intuitive, relevant data access are the same issue; data that is cumbersome to enter tends to be entered incorrectly, data that is entered incorrectly is impossible to access in an intuitive manner. Although I am “only” a “provider”, when I want to discuss a patient care issue with my supervising physician, neither of us want/need to spend a lot of time wandering around EMR.
As a cancer survivor (lymphoma) my paper chart had the same issues you described. Labs from outside sources, radiology reports, medical and radiology oncologists all had separate areas to review for my visit.
Our practice has used EMR since 2004; I would love to be in a position to assist the “thought leaders” on how to make health care more “user friendly” for PROVIDERS and, especially, patients!
I have now used 2 different EMRs (Intergy and Epic), 1 radiology/PACS system and 3 practice management systems. We have not adopted athenaClinicals because we have been told that the program could not accommodate our type of practice. Physician ease of use and retrieval of information is paramount, and lacking. I echo the comments above – I love that key pieces of information can be pulled in automatically without my having to reenter, but why can’t it say “prenatal vitamin” on the med list rather than the generic “multivitamin – folate – iron – B12″, why can’t the problem list just say “hypertension” instead of “hypertension in pregnancy, affecting management, antepartum”? When I look at the lab orders, do I really need to see who placed the order in the system and all the routing it went through? There is way too much information being included in the clinical part of the chart…all that extraneous detail that is unrelated to the actual patient care should be displayed elsewhere, not mixed in with the clinical information. All clinical information should be accessible in 1 or 2 clicks from anywhere in the pt chart and should be able to read in the same way as flipping through a paper chart (1 page after the other) or by going to a direct link (like choosing a tab in the chart).
I would also like to see a better way of managing scanned documents, particularly labs, with the ability to notate on the scanned image (as we would with paper), and the ability to tag particular pages so I don’t have to keep paging through to find what I need each time I need it.
Re: practice management systems, similar comments, I have not been happy with the appointment scheduling system for Athena, it is too cumbersome and not sufficiently linked to relevant data. I should be able to do all I need to do from 1 page or from the patient’s chart.
If anyone knows of an EMR that works well for surgery, I’d love to hear of it. Surgery is a unique situation and the systems that work well in offices aren’t easily adopted to in & outpatient surgery settings. ASC’s like mine are fast-paced and often have 4 or 5 people looking at the chart at once. Everyone needs access to current meds, allergies, pertinent history, and the scheduled procedure – often at the same time. Unfotunately, so many systems say “You can’t document anesthesia electronically” or “we can’t make the Nurse’s OR record view different from the Surgeon’s view.” Flexibility is not optional – it is required. If we want to continue to avoid Sentinel events, more EMR software engineers need to visit a surgery center in person. Hopefully your experiences will help the team at athena focus on this area for improvement.
Thanks so much for the comments! Keep ‘em flowing.
In follow up, a few thoughts…
Dr. Morris – your comment regarding the “enslavement of the physician” as data entry clerk is interesting and coincides (unfortunately) with Dr. Ponder’s points #2 and #3. It is true that there are requirements that need to be incorporated into the EMR to drive billing and to assist in the management of malpractice regulations. Further, as the world of US healthcare continues to migrate to more “performance-based reimbursement” (in the most general definition), these requirements will likely proliferate. In general, I hope that my doctor is using the EMR as a tool to improve my health, and so is documenting for our mutual benefit. Unfortunately, as the comments point out, it seems that too much effort is spent satisfying the lawyer and payer to the expense of the doctor and the patient.
At this point, the prioritization of work related to the usability of our EMR (athenaClinicals) has focused on productivity and reimbursement. If the EMR can drive incremental revenue for a physician, there is a rational reason to use it (so the logic goes). Many EMR’s in the industry have no verifiable proof that they can even do this. Ridiculous.
Ultimately, as any client of athena knows, our goal is to assume the burden of as much work as we can into our service offering – rendering the EMR more usable for more noble pursuits (e.g. Dr. Ponder’s point #1 – patient care). Having said that, data entry – whether handwritten, dictated, scanned or entered manually – will always be a requirement.
My hope is that as athena iterates the service offering, to Dr. Kopynec’s point, we will be able to approximate the speed, usability and simplicity of pen to paper data entry. With that as a goal, and if the result is discrete data storage, rendering that data in a simplified way (e.g. NYT’s) based on a clinician’s spec’s should be infinitely doable. I’m not saying this can happen overnight, but it SHOULD be within a reasonable line of site.
Also, I had a few sentences in the original version of the blog that echo Dr. Kopynec’s thoughts around the iPad as an input device vs. viewing device. I completely agree that the iPad can fundamentally change how data is viewed by vast numbers of clinicians, but it is fairly clear that it is sub-optimal in terms of manual data entry.
Denise, your comment regarding data entry and data access being two sides of the same coin is true. Dr. Morris’s point regarding interoperability is one example. If the systems don’t talk, the data ain’t there, and the physician and patient have a real problem. Also, making data entry easier (as I mention above) is, and needs to continue to be, a key focus for any EMR company. If it’s easy, or at least manageable, and creates clear value for a physician – it will be done.
Then, if the ease and return value of entering the data is present, the process of searching the data for anomalies and rendering that data in new and exciting ways to ease the burden on the clinician becomes a real possibility.
Ultimately, in my role as a patient, I have gained a huge appreciation for the complexity of the problem from the physician / nurse standpoint. It isn’t easy to solve, but it is certainly solvable.
As a patient with a renewed vigor for this crazy thing we call life, I am incredibly motivated to help solve this problem.
Thanks again for the comments.
My current patient notes are E &M compliant. They are on one page and the impression and plan are in BOLD and UNDERLINED type.
My referring doctors can read what’s wrong with the patient and what our plan is in 30 seconds (and just as important so can I when I look at back at them.
We looked at athenaClinicals. It cannot generate a one page report with relevant information highlighted.
So we did not purchase it.
Athena makes it difficult to interface with another company’s EHR;extremely complicated and exorbitantly expensive. It’s unnecessary but it’s part of their business plan.
JLA