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Physician, Vendor Agree: EMRs Should Be More Intuitive, Require Less Time, and Hide Irrelevant Information
Vol 1, Issue 13
July 17, 2008
Paul Schadler, MD says he’s just an “interested observer” when it comes to electronic medical records systems for physician practices, but he’s more than a casual bystander. He quit one practice because its EMR was “terrible.” He’s in demand on the HIMSS and TEPR speaking circuit to speak about physician EMR utilization. He also defends his physician colleagues when someone says they are irrationally resisting the benefits of EMRs.
“Most doctors believe, in theory, that EMRs are a very good thing,” Schadler says. “They’re frustrated with paper, but also frustrated when trying to use EMRs. There’s a cultural bias against that. Policy-makers believe the problem is that doctors just don’t want to use them and fewer people would die and it would be great.”
Most EMRs Require More than Seven Minutes for Simple Cases
Schadler is co-medical director at the Health Center of Auraria in Denver, CO. His main gripe about EMRs is that they don’t reflect how doctors really practice medicine. He cites a recent contest in which judges gave teams of doctors seven minutes to document a simple case using their assigned EMR. All the groups except one failed.
“That’s half the time you’re allotted in many practices to conduct the entire visit,” Schadler says. “My brother-in-law decided to get an EHR for his practice and it added an hour to his day. I wouldn’t want to give up the EHR in our clinic, but every day, I’m frustrated that it doesn’t work better.”
One problem, Schadler says, is that EMRs produce huge volumes of minimally useful, template-created information. A physician assistant seeing a patient for a common cold might generate a four-page document that contains only two critical data points – the patient’s diagnosis and his history of splenectomy.
“What do you do with all the negatives in a patient’s medical history?” Schadler observes. “You have 24 nos and one yes. EHRs don’t distinguish because they’re all equal. The only positive one is way down the page. The data quantity problem is huge. We don’t need full documentation for every visit. It distracts the doctor’s brain from the important stuff.”
Vendor Takes EMR’s Visit Summary Function Away, So Doctors Resort to Asking Patients
Schadler likes giving each patient visit a descriptive title, such as, “Depression worse – change from Prozac,” to make it easier to find information. That worked with the previous version of the practice’s EMR. A recent vendor upgrade wiped out that capability.
“That one line thing was incredibly valuable,” he argues. “In most visits, only one or two things happen that are important. The title could tell you that.”
In fact, Schadler and his colleagues often simply ask the patient what has happened previously since that is easier than looking it up. “That’s embarrassing when you’ve typed into this fancy computer each visit. We started writing a summary for each chart. That’s crazy. I’m summarizing the data I typed in into a free text box so I can get at it.”
Billing, Patient Care Require Different Level of Detail
Systems should distinguish between data needed for patient care vs. that required for billing, Schadler says. “Reimbursement drives a long chart. The computer should be able to take a billing-friendly chart and do an electronic summary so you don’t have to look at the junk. It would be nice to be able to tag data points in the medical history as important.”
Schadler believes that EMR vendors should focus on making available data easier to review and use since data input “will eventually work itself out.” He’s also a fan of interoperability. “The data I put in is mostly what patients gave me. Since they’re here, I could ask them again, so how valuable is that? EMRs haven’t been as valuable because there’s no electronic data exchange between practices. When we send patients to the ER, we have to call and get records faxed, even though we both have EMRs. They print it and fax it; we print it and type it.”
Advice to Vendors: Watch How Doctors Use Systems
What should vendors do differently? “Get people in with the doctors to see how they operate. Make peace between doctors and vendors. Doctors really want to do a good job. A lot of us are pleaser-type people who want to get good grades and have pretty charts. To bridge that gap, we don’t need to have it forced down our throats. We will seek out good solutions. Instead of forcing us to practice better medicine, help us to do that since we really want to.”
Schrader named several EMR vendors as companies to watch. “Epic, MedcomSoft, eClinicalWorks, and e-MDs. It’s not an exhaustive list, but they are really trying hardest to figure out what works. If you could save a doc two minutes per visit, that would be phenomenal.” He recommends following TooManyClicks.com., an EMR usability site run by Jeff Belden, MD, a Columbia, MO family physician.
Epic’s CEO Mandates Physician Involvement
Brett Shillingstad, MD, an informatics physician with Epic Systems, says CEO Judy Faulkner makes physician involvement a high priority.
“Judy is adamant that, before a single line of code is written, we get physicians and developers on site to understand workflows. We do a lot of web demos involving 20 to 25 customers being shown preliminary views of what’s being developed.” Epic also sits untrained physicians in front of its applications to go through common workflows and observes them to find areas that aren’t intuitive.
One goal, Shillingstad says , is to avoid pigeonholing doctors into a single set of tools. “We need to support three or four options based on type of physician and personality. Lots of vendors try to steer people down a particular path. They’ve come up with a piece of development that they think is slick or works well, so they try to sell that. Certain physicians don’t mind having a templated note, but others can’t stand that.”
A key part of usability is going out into the field to see how physicians use Epic’s software. “We do visits at three and six months, physicians paired with senior implementers who did not implement that site. We observe end users and have them show us what’s good and bad about going through workflows.” Those visits also include retraining and “tips and techniques” suggestions, he says.
Epic’s usability lab evaluates planned releases by watching physicians as they perform common tasks, counting their clicks and observing how long it takes them to find buttons or menu options. A Green Light Group of internal physicians and nurses scores each workflow. That group has the power to hold up a release until developers make changes and to move usability enhancements to the front of the development line.
Obsessive-Compulsive Doctors Struggle with EMR Data Overload
Shillingstad says that obsessive-compulsive doctors are the hardest to please with an EMR. “The 100-page chart has tabs and you know where to look. Some doctors feel they have to look at every piece of EMR data, but a lot of it isn’t useful for patient care. It can take an inordinate amount of time.” Epic provides “filtered views” to allow extracting desired information, such as visits tagged for high blood pressure or those involving specific medications.
One thing Epic has learned, Shillingstad says, is to seek out doctors who are struggling. “Most doctors aren’t propeller-heads,” he says. “We look for average physicians with high-volume visits. I like the book called The Inmates Are Running the Asylum: Why High Tech Products Drive Us Crazy. It talks about how developers write software that’s impossible to use. It has a lot of great insights, like why nobody can program a VCR.”
