Musings on EMR

[Guest guest]

The whole field of EMR is vast and chaotic.

My comments below are not meant as a blanket indictment of the EMR

creators or vendors. They are responding to the demands of the

market. Nor are EMR creators & vendors uniform in their product,

pricing, quality, support.

The problem is that - like The Invasion of the Body Snatchers - U.S.

has been consumed from the inside out by administrative trivia

masquerading as health care and sucking the life out of us all.

EMR first and foremost is a vehicle for coding and claims. The game

seems to be to enhance our ability to " win " at the E & M documentation

and coding game so we can justify codes that bring greater payment.

I'd say that 90+% of all EMR functionality is aimed at this issue.

If we didn't have to spend such an immense amount of our time

justifying our work to insurance clerks, I think that most of us

would find the current approach to electronic records irrational and

not worth the cost.

If one accepts this perversion of health care as " justification of

administrative trivia to satisfy clerks " then one chooses EMR based

on the ability to simplify capturing that trivia in a manner that is

minimally difficult to you. This means that the best EMR is one that

suits your personal style of practice and modes of computer interaction.

If you dictate well, type poorly, but can stand correcting mistakes,

choose an EMR that facilitates voice recognition technology.

If you like checklists, are facile with a mouse, and have a quick

processor, consider an EMR with drop down menus and check lists.

If you type well and can use macros, consider EMRs that have text

input capability.

To truly get the feel of an EMR means spending some time with it, and

you'd be best off going to a practice with the EMR in use and getting

your hands on to a computer.

There are some general questions that would be helpful to answer in advance:

1: Who owns the patient data?

As you may have seen on the listserv, some have been burned when

switching EMR to find that the data is difficult or expensive to

extract or in the worst case is held hostage to large fees.

2: How can I use the tool to assess quality of care?

Most will blow smoke in answer to this question. Almost all have some

report generating capability, but the reports are built on the

typical quicksand of ICD9 and CPT4 codes and are of very questionable

value. If the EMR has good QI functionality it usually means that you

have to enter data into structured fields - work that most find

prohibitively laborious.

3: What are the fees?

Like mobile phone companies, EMR vendors are very inventive when it

comes to obtaining money and no two contracts are alike. Most will

ask for all the money for a multi-year contract up front, but many

will agree to lease over time with monthly fees. Check out all the

fees and keep asking " are there any other fees? " Ask this at least five times.

4: Can my patient lab values be downloaded directly into structured

data fields at no cost to me?

The variation in response to these issues has lead good docs in many

directions. Pamela Wible in Eugene OR uses a $99 file creating

software on her Mac. Many on the Practiceimprovement list use Amazing

Charts at a fraction of the cost of the big vendors. Some elect the

all encompassing big solutions like GE's Centricity, while employed

docs are usually forced into monster vendor solutions like Epic or Touchworks.

Putting all rantings aside, I recommend an approach championed by

Clemensen and others: use simple off the shelf components that

will work as a unified whole (with effort on your part and/or hired

help of an IT support person). This is a very inexpensive solution

that allows you to swap out any parts that don't work well for you.

The monolithic vendor solution locks you into that vendor. If they

have parts that don't work well for you (a common experience), you're stuck.

Gordon