Monthly Archives: November 2012

The Adoption of EMR

It is no news a lot of doctors like to stick up a rather snotty nose to EMR, despite all the rage in town. The defenders of the EMR tend to label such doctors as archetypal Luddites, sticking to their archaic ways and unbecoming of change and the new times. But as is usually the case with any two heated but opposite arguments, the truth likely lies somewhere between the two extremes.

On an objective basis, there is no denying that automatisation of medical record keeping is the new way forward. In theory, if the machine could keep records for you and give it back to you when and where you want it, thus freeing up valuable time for the patient encounter, that should be winsome for everyone. That alas, is a vision of the EMR utopia, and let alone being anywhere close to such utopia, it is difficult to ascertain if we are even set in the road leading us there.

Sometime ago, exasperated at the sheer waste of time that the clunky new discharge module was causing because it would not work the way it is supposed to (my hospital is means challenged, so they are building a patchwork of cheapskate EMR suite on top of their legacy system from the 90s, just to placate the gods of CMS), I complained to the IT guy that the thing barely works! The guy was sympathetic and said- “look I know the discharge module sucks, just bear with it until the end of the year when we should be able to weed out the bugs” But that’s not all, I said, even if it were working just the way it is supposed to, the discharge still takes me longer than what it used to with paper. “That’s something you will have to learn to live with” he retorted, “computer records do take a longer time than paper, and there is nothing I can do to change that”.

Right there, I think is where EMR loses a lot of ground against paper records. At any practice, time is the most valuable resource, and anything that doesn’t offer a straight off benefit to save time will have a hard time being adapted. Add to that the inertia people have about their old ways and you have a deal breaker right there. (digression alert) I once heard an attending at the hospital say, “I really like the feel of pen on paper. Computers just don’t give me that feel.” The attending has beautifully symmetric cursive handwriting that looks like artwork on paper. And needless to say, she hates EMRs from the bottom of her guts!

That’s not all. Driven by the constant government whip to adopt EMR- no EMR, no pay (reminds me of junior Bush’s iconic rhetoric- if you are not with us, you are with them!), and an EMR industry that is hell bent upon imposing itself on healthcare (they can’t believe they don’t have a sizable share of the multi-trillion dollar healthcare bounty) a lot of makeshift EMR adoption has taken place. So you have hospitals where one part is using one system while the other is using a completely different one. At one clinic I recently worked at, we had to switch between 3 different EMR systems, just to get the patients records. And there still was the paper records not to mention the dictation.The constant juggling not only made the patient encounters time consuming and cumbersome, it literally made us curse at the computers and ruin an otherwise perfectly normal day at work. Patient volumes have gone down from 15-16 patients per day to a half of that after EMR adoption.

What’s wrong with the current adoption of EMR? Why are even the converted like me (most of us doctors trust me, are the opposite of Luddites, the first thing I learnt to do with a computer was write code; I freely use LaTeX and R) questioning EMR?

I think there are two reasons for such seemingly epic failure. First, how we interface with an EMR. Second how the EMR tries to impose its will on to us instead of the other way around. A keyboard and a point and click device may well have worked for many other interactions with the computer, but with an EMR it doesn’t always appear to be nifty. It is a common experience that most people find dictating their notes much faster than typing them. Accurate automated transcribers (current bunch of transcribers are known to be as much a 6 times more inaccurate over human transcribers) could really speed up record keeping, thereby selling EMR to the unconverted while saving costs over manual transcription. On the same note, no EMR is going to be see a faster adoption if something like writing a prescription takes a minute when in paper it barely takes  10 seconds. Right now doing something as simple as writing a prescription feels like running through a bunch of fire breathing hoops. Someone may argue, you can at least read it better, but don’t get me started on how the EMR can come up with its own ludicrous set of errors, something that would never be possible with paper.

Trying to impose a readymade architecture on to health care will not work. “It works for retail and banking”, some people seem to offer cluelessly. But a patient encounter is no visit to your bank cashier. And human body is not your bank account, it is way more complicated and it is bound to generate way more complex information that is difficult to straight jacket into the rigid and rudimentary pipeline of set information pathways. An ideal EMR is supposed to be a seamless body-glove; today they feel like the hangman’s cloak, not only are they cumbersome, dark and dreary and suffocating, under their apparition, they force things you to do things you wouldn’t otherwise do.

Such forced behaviour modification may make the administrator, the insurance company the government happy but I can’t understand how selecting a dozen pesky radio buttons (like the one that tells the patient to shower everyday; another one says- don’t smoke, if you do quit- tobacco counseling for the sake of the payer!) while doing the discharge makes the patient lead a healthy life or make his doctor particularly enamoured with the EMR, just because the government said so or that it made the IT companies a few million dollars richer.