Monday, March 31, 2008

Electronic Medical Records - The EMR Funk

I’m something of a combined wonk and a monk when it comes to EMRs. Experts proclaim EMRs as the answer to health care woes, yet physicians resist them. Why this funk? This is a question only a wonky monk like myself can answer.

The word “wonk,” my dictionary says, is someone who is boringly, narrowly, and obliviously preoccupied with something For some time, I have been boringly, narrowly, and obliviously preoccupied with EMRs and why they are in such a funk in the real world of medical practice.

This funk stuns a lot of people after all the EMR hype. You’d think doctors would flock to EMRs. Instead 80% to 90% of doctors don’t install these electronic marvels..

The word “monk” comes from an Old English word, meaning “alone.’ A monk contemplates and prays alone. I pray EMRs will succeed, I contemplate why they don’t, and I tend to be alone in my opinions.

Out of my meditations have come these thoughts.

• First, the unworkability of EMRs. EMRs may not work for physicians because of high costs, practice disruptions, productivity losses, opposition by staff or partners, harassments of data entry, miserable returns on investment, and paranoia among physicians that EMRs are for the benefit of health plans, rather than for the benefit of patients or themselves.. The data gathered, doctors fear, will be used against them to rank them and even tank them.

Second, the irrelevancy factor. Every specialty has its own work and thought flow patterns. Many of these patterns share little in common. For some, throughput is most important; for others a comprehensive understanding is paramount. A chief information office of a large multispecialty groups pointed out to me dermatologists, obstetricians, and ophthalmologists, and other specialists have completely different electronic needs than generalists. For a dermatologist, whose interests are skin-deep, a comprehensive EMR may bring nothing to the practice. It is simply irrelevant.

• Third, lack of application of EMR information at the “inflection point.” An inflection point is that point in patient care when the patient and the doctor need information the most. For the patient, this may be when a cancer diagnosis is first made, what specialists to go to, what tests will ensue, what lies ahead. For the emergency room doctor, the inflection point may be when a patient enters the ER after being referred by a primary care doctor. What information do I have on this patient, and how can I get it quickly? A simple email from the primary care doctor will do and is preferable to a personal health record or an EMR download. A standard EMR does little to address inflection points.

• Fourth, the emphasis on documentation rather than doctoring. Doctors are trained to be doctors rather than data entry clerks or documentation experts. Doctors don’t give one whit about complete documentation, unless, of course, it results in getting paid. One model that may work is the worksite clinic, in which others enter the data, an EMR is on site, the EMR contains relevant best practice information, and the doctor can spend his or her time doing real doctoring rather than dealing with documentation details.

• Fifth, failure to appreciate the importance of chunking.

In an excellent book, Edgeware: Insights from Complexity Science for Health Care Leaders (VHA, Inc, 1998), its authors point out most effective decisions occur at the edge, the margins, of care. Striving for complexity can be the enemy of good care. The book talks of “chunking,” allowing complex systems to emerge out of the links among simple systems that work well and are capable of operating independently. Simple workable systems build confidence, and simplicity is something complex EMRs that try to be everything for everybody sorely lack.

Sixth, failure to stress “readiness training” for EMRs, EMRs and health 2.0 enthusiasts have failed to recognize practices must be made “ready” for EMRs. Electronic practices and paper practices are different ballgames with different work flows and thought patterns. Paper practices don’t become electronic at the snap of a finger, or the click of a mouse. In electronic practices, patients often don’t have to be present at the point of care; doctors hesitate to do anything without examining the patient. The American Association of Family Physicians (AAFP) addresses this problem with a formal readiness program. The AAFP claims 37% of its 93,000 members have adopted EMRs and another 13% have signed contracts to have systems installed. This is two to three times the national rate of EMR adoption. Doctors are conditioned to think: Ready, Fire, Aim! This doesn’t work with EMRs.