by wayne persky
Founder and President of the Microscopic Colitis Foundation
*Note that this article is so long that it is being published in two parts. This is part two.
Continuing Doctor Magnuson's description of her experiences with EMR
Regarding the freedom that allowed physicians to think for themselves, and manage their own diagnostic procedures, Doctor Magnuson offers these observations:
- My old written notes had only the meat, the pertinent data. They were mostly my thoughts. This was how we all communicated with each other. Our thoughts were what was important. We can't do that now. We can't be candid about our thoughts because our patients can see their charts. The open medical record is one of the worst decisions ever made.
- We used to be able to use abbreviations and blunt language in our notes to remind ourselves about a thought trail, to get a consult, to order tests. Now, we have to edit for our readership, and be evasive about sensitive issues. Often, this leads to the whole thought process being left out in service of time. So we have an issue of the forest for the trees, and all we have are junk trees.
Obviously this forces clinicians to waste a huge amount of their time, without providing any substantial healthcare benefits for either healthcare professionals, or patients.
Regarding foreign physicians
who are working in the U.S. under visa arrangements, Doctor Magnuson points out:
I've seen medical administrators treat these highly educated professionals like dirt. Just because they can.
Doctor Magnuson also points out:
In Europe, the EMR is not used for billing purposes. Doctors don't resent the EMR because it doesn't control their practice of medicine. They actually can use it to their benefit, rather than have it dictate to them what they need to do to get paid. This is mainly because of common sense methods of paying for healthcare in the civilized world, where healthcare is considered a right and some form of universal coverage is in sway.
The primary problems with EMR in the US appear to be:
1. Computerized scheduling
2. Poor compatibility between various EMR systems
3. Excessive data entry requirements interferes with the ability to efficiently access the data
4. Correcting incorrect data is so difficult and time-consuming that it typically doesn't get done
5. The EMR system has reduced physician productivity by at least 20%
2. Poor compatibility between various EMR systems
3. Excessive data entry requirements interferes with the ability to efficiently access the data
4. Correcting incorrect data is so difficult and time-consuming that it typically doesn't get done
5. The EMR system has reduced physician productivity by at least 20%
Looking at these issues in more detail,
1. Computerized scheduling with the EMR system has effectively removed the flexibility that doctors once had when they needed to squeeze a patient in between previously scheduled appointments, because the patient needed urgent care, or treatment advice. Doctor Magnuson points out that the demands of the system reduced her ability to see over 24 patients per day, to being able to see 14 patients per day. Because of this, many of her patients had to turn to Urgent Care, and neither she, nor her patients, appreciated this inconvenient change.
2. Despite the fact that the EMR was supposed to facilitate communication between physicians, Doctor Magnuson found that emergency room doctors weren't able to access her notes, and sometimes the hospital doctor couldn't access her clinic notes, even though they were in the same EMR system. And sometimes specialists with whom she was consulting had difficulty viewing her notes. And because some specialists used a different EMR system, she sometimes couldn't see the notes from a consultation until weeks later.
After the advent of EMR, when she was doing Skilled Nursing Home medicine, often, she didn't have a hospital discharge summary, and she never had the hospital record, when she received a new patient. Getting the needed information, was often difficult at best, and impossible, after hours, or on weekends. Needless to say, this is not just inconvenient — it can be dangerous in some situations. Prior to EMR, she always received a folder containing a written summary for every new patient, and it came with photocopies of important laboratory reports, and daily notes on important events that occurred during the hospitalization — it may not have been a perfect system, but it was dependable, and it worked.
3. As the American Medical Association (AMA) points out, the term "meaningful use" defines certain minimum U.S. government standards for EMR data entry. These standards outline how patient clinical data should be exchanged between healthcare providers, between providers and insurers, and between providers and patients.
Medicare imposes the requirement that physicians must use certified electronic health records technology, and demonstrate meaningful use of the system by completing an attestation process at the end of each meaningful use reporting period, or they will be penalized by reduced Medicare reimbursements. The use of diagnostic codes [International Classification of Diseases, Tenth Revision (ICD-10)] is required, and must be exactly correct. The ICD-10 code is normally printed next to, or under the "Diagnosis" (or "Dx") heading on a medical report, bill, or provider letter. All insurance claims are based on these codes.
To receive full Medicare reimbursement, physicians must document items (for the patient) such as a family history review, medication and allergy review, social history review, past medical and surgical history review, active medical problems, and various other details, and these must be documented for every patient encounter. Information not entered with each appointment (even though it is repetitive) may be lost from the system. The complexity of all the requirements requires a physician's full attention, lest something be overlooked.
4. Correcting problems that arise in the records can only be done by certain medical professionals. And errors in medical records are likely to be made, because for one thing, EMRs include a step that basically amounts to a Catch-22 situation.
Remember the movie, Catch 22? The movie focused on a U.S. World War II Army Air Force base located on an otherwise desolate, inhospitable island. Almost everyone who was stationed there soon tried to apply for a transfer to a more pleasant location. But according to military regulations for the base, the only justification for granting a transfer off the island was insanity. And obviously, anyone who wanted off the island was not insane.
2. Despite the fact that the EMR was supposed to facilitate communication between physicians, Doctor Magnuson found that emergency room doctors weren't able to access her notes, and sometimes the hospital doctor couldn't access her clinic notes, even though they were in the same EMR system. And sometimes specialists with whom she was consulting had difficulty viewing her notes. And because some specialists used a different EMR system, she sometimes couldn't see the notes from a consultation until weeks later.
After the advent of EMR, when she was doing Skilled Nursing Home medicine, often, she didn't have a hospital discharge summary, and she never had the hospital record, when she received a new patient. Getting the needed information, was often difficult at best, and impossible, after hours, or on weekends. Needless to say, this is not just inconvenient — it can be dangerous in some situations. Prior to EMR, she always received a folder containing a written summary for every new patient, and it came with photocopies of important laboratory reports, and daily notes on important events that occurred during the hospitalization — it may not have been a perfect system, but it was dependable, and it worked.
3. As the American Medical Association (AMA) points out, the term "meaningful use" defines certain minimum U.S. government standards for EMR data entry. These standards outline how patient clinical data should be exchanged between healthcare providers, between providers and insurers, and between providers and patients.
Medicare imposes the requirement that physicians must use certified electronic health records technology, and demonstrate meaningful use of the system by completing an attestation process at the end of each meaningful use reporting period, or they will be penalized by reduced Medicare reimbursements. The use of diagnostic codes [International Classification of Diseases, Tenth Revision (ICD-10)] is required, and must be exactly correct. The ICD-10 code is normally printed next to, or under the "Diagnosis" (or "Dx") heading on a medical report, bill, or provider letter. All insurance claims are based on these codes.
To receive full Medicare reimbursement, physicians must document items (for the patient) such as a family history review, medication and allergy review, social history review, past medical and surgical history review, active medical problems, and various other details, and these must be documented for every patient encounter. Information not entered with each appointment (even though it is repetitive) may be lost from the system. The complexity of all the requirements requires a physician's full attention, lest something be overlooked.
4. Correcting problems that arise in the records can only be done by certain medical professionals. And errors in medical records are likely to be made, because for one thing, EMRs include a step that basically amounts to a Catch-22 situation.
Remember the movie, Catch 22? The movie focused on a U.S. World War II Army Air Force base located on an otherwise desolate, inhospitable island. Almost everyone who was stationed there soon tried to apply for a transfer to a more pleasant location. But according to military regulations for the base, the only justification for granting a transfer off the island was insanity. And obviously, anyone who wanted off the island was not insane.
According to Britannica,
The “catch” in Catch-22 involves a mysterious Army Air Forces regulation which asserts that a man is considered insane if he willingly continues to fly dangerous combat missions but that if he makes the necessary formal request to be relieved of such missions, the very act of making the request proves that he is sane ...
Clinicians have to order certain medical tests in order to make accurate diagnoses of their patients' issues. But the EMRs essentially require that physicians must make a diagnosis before ordering any tests, due to the fact that they are required to enter a diagnostic code before the system will allow them to order the needed tests — a Catch 22 situation. Obviously, in the long run, this is bound to result in many incorrect guesses, and these, and other errors tend to accumulate in the records.
Doctor Magnuson also points out that specialists never clean up incorrect data. They always leave this for the primary care doctor to deal with. But because of excessive demands on virtually all primary care clinicians' time, no one ever removes most of these errors from the system.
5. Adoption of the EMR systems have resulted in at least a 20% reduction in all physician productivity, and the productivity loss has been significantly worse in primary care. More than 80% of physicians attest to at least some measure of burnout, and EMR is responsible for much of that. As Doctor Magnuson says:
We didn't train to be coders or secretarial staff. Doing EMR tasks is such a waste of our education and skills.
Clinicians have to order certain medical tests in order to make accurate diagnoses of their patients' issues. But the EMRs essentially require that physicians must make a diagnosis before ordering any tests, due to the fact that they are required to enter a diagnostic code before the system will allow them to order the needed tests — a Catch 22 situation. Obviously, in the long run, this is bound to result in many incorrect guesses, and these, and other errors tend to accumulate in the records.
Doctor Magnuson also points out that specialists never clean up incorrect data. They always leave this for the primary care doctor to deal with. But because of excessive demands on virtually all primary care clinicians' time, no one ever removes most of these errors from the system.
5. Adoption of the EMR systems have resulted in at least a 20% reduction in all physician productivity, and the productivity loss has been significantly worse in primary care. More than 80% of physicians attest to at least some measure of burnout, and EMR is responsible for much of that. As Doctor Magnuson says:
We didn't train to be coders or secretarial staff. Doing EMR tasks is such a waste of our education and skills.
So "Where's the beef"?
10 years after virtually every healthcare facility in the U.S. has implemented an EMR system, why aren't the results being praised, rather than criticized. Why are any major benefits still invisible, if they do, in fact, exist? When will any tangible benefits of this tremendously expensive mandate begin to materialize? Or will its problems and inefficiencies eventually prove to be the downfall of U.S. healthcare, as it continues to drive disenchanted, and burned out primary care physicians out of healthcare?
