Electronic medical records (EMR’s), also called electronic health records (EHR’s), are in the news a lot these days, along with buzzwords like healthcare reform and tort reform. The topic is currently of greater importance to doctors that are contemplating or implementing EMR in their practices. The federal government is offering a financial incentive to offices that make the leap now. Less than half of practices have done so. By 2014, the incentive will switch to a financial penalty for not having done so.
EMR is basically a software program that allows the user to obtain and digitally store a patient’s complete medical history, progress notes, laboratory and X-ray reports, photographs and other images. There are many advantages to doing this compared to the standard manual chart with handwritten or transcribed notes with lab and X-ray reports attached. The biggest advantage in my view is accessibility to the chart at all times in the office and even after hours in an emergency as long as the user has an authorized personal identifier and password to protect confidentiality.
In very large multispecialty group practices, such as the Veteran’s Administration, Mayo Clinic, and Cleveland Clinic, wherein many different doctors, specialties and labs provide services to an individual patient, EMR’s have become a necessity. In the past I worked in VA clinics and the Cleveland Clinic where charts were either “in transit,” in another doctor’s office waiting for a dictation or lab report, or simply “lost.” It was even acceptable at that time to ask patients to hand-carry charts to the appointment desk and then from the dermatology office to their next appointment in the hematology department, for example, a practice that would be unthinkable today. It was not unusual to observe patients reading their charts in the corridors, waiting rooms, and even the cafeteria! Not so any longer.
In large healthcare systems like those mentioned above, nearly all the laboratory and radiology services are performed in house. Thus, the results of ordered tests can appear in the record, and the provider can be notified of this event by email as soon as the test is completed. But in many private practices, patients are given prescriptions for blood and urine tests and X-rays or scans. The patients then in turn take these orders to their local hospital or private commercial lab mandated by their insurance carrier. The hospital or lab then faxes or mails the report which then has to be attached to the paper chart and reviewed by the physician. You can see that there are many points along the way where the result may not connect to the chart or that that the doctor might not receive it in a timely manner.
When the private practice doctors obtain EMR’s, they may be able to integrate their most commonly used hospital and lab systems into the ordering doctor’s notifications or “task list.” Any result that is not digitally integrated has to be scanned into the medical record otherwise a new paper file for that patient begins to accumulate, has to be stored and brought out for each susequent visit. Even the large centers with well established EMR’s have to do this now when a patient arrives for a second opinion consultation carrying over 100 pages of photocopied chart material, a fairly common occurrence.
Thus, while I am a proponent of EMR’s, I am not in favor of moving so fast, especially for the specialty of dermatology about which I possess the most knowledge. First of all, EMR’s are expensive, and while we all must have them eventually, I do not think the best one exists yet. And naturally, just as telephones have gone from land to cell to smart, television from black & white to color to HD to 3D, music from vinyl to tape to CD to MP3 to iTunes, the latest EMR program will be the fastest, cheapest, most robust and specialized.
When a medical practice decides to adopt an EMR, they will usually first adopt a practice management system that allows for digital appointment making and integrating billing and collection systems. When everything is on line and operative, the EMR can even calculate the appropriate level of service and the charges before the patient reaches the checkout desk and without the doctor having to also fill in the “superbill.” That’s if everything is working smoothly. Let me tell you about my experience working with two very different EMR systems, Epic and Nextgen. The views presented here are my personal opinions; I have no conflicts of interest, and I am not currently using an EMR.
I believe that most of the larger EMR programs were at least initially intended for use in general medical practices that provide primary care, such as family medicine, internal medicine, and pediatrics. Then as specialists joined these groups and had to be converted to using the EMR, the vendors added layers of new appropriate programs to piggyback on the already established default program without reinventing the wheel. In some cases, a better more efficient product could have been developed if they had trashed the entire program and wrote a new one which included dermatology, ophthalmology, plastic surgery, ENT, and so on. Or had just created a separate product for each specialty that wants to use an EMR with input from the specialty societies, not just a few consultant doctors.
It is difficult for doctors who have been in practice for 10 or more years using paper charts to convert to EMR. It is somewhat easier for the newer generations of doctors who grew up using computers at home and in school for doing research, homework, and writing papers. Besides the initial outlay in the tens of thousands of dollars for the software, hardware–computers in every exam room and printers and scanners at nurse stations–contracts for classroom, on site and on the job training with all clinical staff are necessary (often included in the price package), as well as maintenance, updates, troubleshooting, and customization which usually cost extra. In order to accomplish all of that with everyone working in the practice, there is naturally down time from clinical practice, that is, you see less patients which increases cost.
When the Cleveland Clinic installed Epic in its Naples facility, the program had been in use for years in Cleveland and Weston, Florida, and there were experts in all of its many robust features available for troubleshooting. However, they were not readily available to help. The training process was brief, only about 3 weeks, and very superficial as I came to understand much later. Moreover, it was not the policy that all physicians were required to use the Epic EMR in Naples which really defeated the purpose of the EMR. I was unable to view the results of some other physician exams on the digital record because they were never entered, even though I was the one who had requested that doctor’s consultation in the first place! Epic was also not integrated into the billing system, thus the doctor also had to manually complete a superbill for the charges. On the other hand, I was able to see for the first time the results of examinations and lab tests on my patients who also had seen my colleagues in Cleveland and Weston, which was an unexpected bonus that improved communication and patient care.
Epic has features for creating diagrams and anatomic figures which are very helpful for the dermatologist for documenting biopsy sites on a face or the distribution of rashes like psoriasis or eczema on the body. These were not taught to me, and it wasn’t until my second year of using Epic that I was comfortable enough to experiment with all the buttons and search through all the figures to be able to the use the program more efficiently. Epic slowed down my progress through a schedule until the beginning of the second year after implementation, and by the end of second year I could see the same number of patients as before with the manual chart and not run late.
Vendors of EMR software advertise that their products allow the doctor to see more patients with less staff. I firmly believe that this is false on both accounts. My experience has been with two different EMR systems that you must reduce the appointment schedule to be able to use and learn the new system for up to 3 months, not including time for classroom and home study for the doctors and staff. The same number of support staff or more are needed to document the reason for visit, medicines, allergies, etc. on the computer and then scribe for the doctor in order for the doctor to be able face, touch and perform procedures on the patient instead of facing a monitor and touching only a keyboard.
Nextgen was a doozy. I haven’t looked at it in over a year, so it may have been improved. If it hasn’t been improved, then HMA “wuz robbed.” HMA is the Naples-based hospital management company that bought the Cleveland Clinic operation in Naples, Florida in good faith in 2006. They renamed the hospital Physicians Regional Medical Center and were granted rights to use or lease Epic for a certain length of time after the sale. When that deadline came, the Cleveland Clinic abruptly turned off Epic by contract and HMA gave us Nextgen. As I stated earlier, this program was not sophisticated and consisted of layer upon layer of primitive systems requiring multiple keystrokes and pages to accomplish one function. Unfortunately, a simple office visit requires dozens of functions, and a complex consultation many more, thereby equalling hundreds of keystrokes. You might as well type the note, except most of us doctors are neither fast nor accurate typists!
To be fair to HMA, they did try to patch some of Nextgen’s weaknesses and deficiencies by purchasing Dragon Naturally, a superior voice recognition program that allowed us to insert templates for review of systems and normal exams related to our specialty which saved some time. Dragon also worked very well for dictating a more complicated specialty consultation which Nextgen itself had no way of accomodating because it seemed to be designed mainly for general medical histories and physical exams and straightforward cases.
I know that the ophthalmology and ENT specialties had a hard time with Nextgen. They had to completely redesign and customize their visits. I understood what was going on a little better with dermatology. It appeared that one group of dermatologists advised a software writer what they mainly did in their practice, the order and flow of procedures, and what diseases they treated. There were short programs for basal cell carcinoma and acne, but no physical exam for a full body skin exam. I guess they expected us to use the internal medical exam including heart and lungs, except dermatologists rarely ever use a stethoscope nowadays. There were some anatomic diagrams in the images section, but they were poor for a skin exam. The trainers from Nextgen were helpful. Although they weren’t there for us long enough, they did help add better skin anatomic diagrams and taught us how to mark the spots where procedures were performed.
Phototherapy using narrowband UVB and PUVA is a large part of my psoriasis practice, and we were accustomed to documenting all of the parameters of treatment, i.e. skin type, energy, time, on Epic for each visit. Apparently, the dermatology practice that advised Nextgen employed only the Xtrac laser for psoriasis. So we gained a program to document Xtrac treatment but not UVB or PUVA and didn’t have the laser at that time, rendering the system impotent for our needs.
Because it took so much extra time free-typing data or using the word recognition software for dictating, I usually worked about 1 1/2 hours after the last patient was seen and had to come in at least one weekend day for a couple of hours to clean up my in-box which contained the results of all the blood tests and biopsies that came in electronically from the in-house labs and answer the prescription refill requests which came electronically 24 hours a day from pharmacies.
Here is my bottom line advice to doctors in general and dermatologists in particular. Remember, I am not a tekkie, just a practicing dermatologist.
1. If you don’t already have an EMR, don’t get one until after the government deadline.
2. The money lost in federal bonuses for going on line early and the money paid in penalties will not exceed the cost for a bad system that needs reconfiguring or replacement.
3. Buy the least expensive and most customizable EMR program which has been developed or recommended by your specialty society.
