Electronic Health Records

Yes, I confess, I am an EHR enthusiast. I’ve even been called a “poster boy” for the electronic health record. So, why aren’t you? Oh, I’ve heard your complaints:

  • “An Electronic Health Record is much too expensive for my practice.”
  • “I can see patients faster without a computer.”
  • “You ‘computer people’ never look up from the screen to talk eye to eye with your patients.”
  • “I can write faster than I can type. And, those computers, they aren’t really safe anyway!”

Yea, I’ve heard these excuses, and they’re wrong.
How can I say that? Well, I’ve been using an electronic medical record, recently renamed electronic health record (EHR), for the last nine years. I guess I am considered an “early adopter” – one of those physicians crazy enough to start using a computer health record in early 2002, before the Medicare “Final Rule” or the Office of the National Coordinator for Health Information Technology (ONC) ever existed. At the time I finished residency in Family Practice, I realized that there were a vast number of menial, time consuming tasks in the office that a computer could do much more effectively. My initial interest in electronic health record was not one of conforming to the government reporting standard. My interest has been to make the practice of medicine simple, efficient, and enjoyable. In the words of Albert Einstein, “He who joyfully marches to music in rank and file has already earned my contempt. He has been given a large brain by mistake, since for him the spinal cord would suffice.”
WHAT WAS MY MOTIVATION?
Really, there were six motivating factors that convinced me going “paperless” was in my future. 
Automation:
In medical school and residency I found that I was often rewriting the exact same information over and over and over: “Cardiovascular exam reveals heart with regular rate and rhythm without murmur. No lifts or thrills. . . ” There really are no ‘lifts or thrills’ to writing this 23 times. I found I was re-writing much of the same information multiple times throughout the day with only a few variations between patient exams. And, if you want to get paid for evaluating it, you better record that you looked. From my recollection of basic computer programming courses taken in high school, I knew I could get a computer to legibly chart those things that I repetitively evaluate in every patient, and do it a whole lot faster than I could with my gel pen.
Efficiency:
I knew that my home computer could calculate my checkbook for me, and my telephone could store all my contacts at my fingertips. Why couldn’t my office computer make the writing of chart notes easier, more legible, and then transmit that data to a pharmacy or to a lab? Why couldn’t I have all my laboratory data in one place that I could compare and trend?
Two very important things were clear. First, doing today’s work today (and actually finishing it) seemed to make me feel better at the end of the day. Second, I spent 13 years of my life and thousands of educational dollars learning to make difficult life-or-death decisions. I spent years being trained to access and analyze diagnostic data in order to make important physical health decision. Why, then, was the majority of my day cluttered with other time consuming clerical activities? I found that my electronic health record could streamline the reception of data for evaluation and allow me to efficiently finish all of today’s work today. 
Mobility:
I can’t tell you how many times I have been at the grocery store or the restaurant after hours when a patient would call with a question about a lab or an x-ray I had not see or reviewed yet. If I can check my stocks, my bank account, my email and even see Lady Gaga’s “dress made of meat” over my smart phone, why couldn’t I use my phone in real time to check my charts? Well, now, I can, and I do. Via a simple phone application, I can now log in to my office and review that lab or CT scan anywhere I have cellular service. 
Legibility:
My handwriting looks like chicken scratch, especially after a long day. The busier the day, the more hen pecked it looks. I can type 60+ words per minute, and in the last years advances in voice recognition software, I can now dictate 400-600 words per minute right into my EHR. Why am I still writing in paper charts? I’m not. 
No, I don’t sit and stare at my computer, ignoring my patients while typing or dictating. My software has allowed me to created hundreds of pre-examination questions based on the patient’s chief complain. My nurse asks and enters this information, the patient’s medications, and other pertinent history into the chart before I ever get near the exam room. Then, when ready, my nurse presents the chief complaint to me as well as the patient’s history in the room in the presence of the patient. I spend the entire time in the room communicating face to face, counseling, asking additional questions and educating my patient while my nurse or medical assistant transcribes my additional questions, exam and assessment into the computer. My plan, medications and orders are transcribed while still in the room. And with a just few keystrokes, super bills, prescriptions and detailed instructions are ready for my signature on the printer. Between patients, I can review the transcription and make any needed corrections to the note with the voice recognition dictation software that works seamlessly with my EMR. 
Retrieve Data, Understand Data, Make Your Decision:
Yes, data tracking, quality monitoring and electronic interchange of information appear to be the wave of medicine’s future. The powers that be want to convince us that these are the Holy Grail of EHR adoption. But that isn’t really why EHR adoption is important. You and I were trained to make decisions – often difficult decisions. Any tool that will help you rapidly retrieve data, rapidly understand that data, and then make relevant decisions based on that data is well worth significant consideration and any reasonable cost. That’s what your EHR should do for you, and it should be fine tuned to your style. 
The electronic health record is NOT just a medical record in digital form. It is a tool that should allow you to do what you were trained to do much more effectively. If your EHR doesn’t do that, you need to find another piece of software.
Colonoscopy Anyone?
Yes, adoption of an electronic health record can be likened to a GI prep and colonoscopy without the sedation. The conversion to EHR is doable, but “it ain’t painless.” If anyone tells you otherwise, they’re lying.
I spent a few weeks reviewing software companies, contracts and service plans. I evaluated web based and on site systems. I reviewed as many as I could. I played with the demonstration models of them. Two of my favorites took up an entire Saturday while I playing with them on my home computer. Don’t take this decision lightly. Your EHR software is like a marriage. I’ve seen some bad marriages.
I quickly realized which one I liked after working with the demo for over an hour. It took an entire day to load the software on each of the workstations and server in my office. It took another five days to train my staff to use the software effectively. It took us 2-3 months to recognize that the computer will change your office workflow drastically. (It took me a week to realize that there is nothing wrong with changing the office workflow.) It took me a month to understand that you can practice medicine “outside the box.” The workflow methodologies you learn in medical school and residency and establish in your office are malleable. And, often, your efficiency drastically improves when you change them. There is a learning curve – it can be much bigger for some. When you accept this curve and stop fighting it, using your EHR becomes really enjoyable.
Cost:
Cost you say? Yes, that’s important. These systems are not cheap. They can run anywhere from $50,000 – $150,000 to install. I know. Stop for a minute, take a deep breath, and check your pulse. I got palpitations, too, when the salesman quoted the price. But I realized when I did a little math that it is actually doable.

  • How much do you earn with each patient visit? I shot low estimating $50 per visit.
  • How many days do you work per month? Let’s say you only work 20 days.
  • So, you and your partner pick a system that costs $75,000, and the term of your loan after installation cost you each $1000 per month. How many extra patients will you each need to see per day to cover the extra loan expense? Only one extra patient per day.

I found that once we began using our EHR to its full potential, I can comfortably see an extra 8-10 patient’s per day in the same amount of time.
Murphy’s Law:
The probability that the buttered side of the bread will fall face down on the carpet is directly proportional to the cost of the carpet. Hiring a database manager is essential. Your system will crash. Your system will hang. Hard drives will fail. The internet will go down. The power will go out. Your database manager does not have to be on your payroll, but should be available to you throughout the day for computer and database emergencies.
What really makes it all worthwhile is when all the parts of the puzzle fall into place. Lab interface, electronic prescribing, interoffice and inter-patient communication links allow streamlining of processes. It really is possible to do today’s work today.

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