Our Greatest Wealth Is Health

Andrew Siegel, M.D.   Blog # 82

My apologies for not producing a blog entry for the past two weeks—I had a nice run with weekly posts for over 18 months and plan on continuing the weekly uploads indefinitely.  However, Hurricane Sandy had her way with me, rendering me literally and figuratively powerless, and was true to Shakespeare’s words: Hell hath no fury like a woman spurned.

I have an “ax to grind” and writing this blog helps me grind away, as well as serving as a means of therapeutic venting of my deep-seated frustration with a system that is premature and not ready for prime time.

About three months or so ago, my office—as have many other medical offices—converted from the standard paper medical charts, the norm for many years, to Electronic Medical Records (EMR).  I might be old school, but I liked the paper charts.  Although imperfect, paper worked rather well. Our charts were neatly organized into multiple sections not dissimilar from a middle-school student’s loose-leaf notebook, including a section for clinical notes, one for lab and pathology results, one for imaging, one for operative reports, one for communications from other physicians, et cetera. By picking up a patient’s chart, I had complete access within a matter of seconds to all of his/her pertinent clinical information. The intent of the chart was to convey relevant medical information for one’s own reference as well as to one’s partners, who might be taking care of a patient under certain circumstances.  With the transition into EMR, the objective has remained the same but has also expanded into documenting patient visits to satisfy billing and insurance criteria and to fulfilling government regulatory demands.

For established patients or new patients, there are five “levels” of care in terms of the complexity of the office visit.  As physicians, we have to code each visit in accordance with its complexity, based upon a number of criteria, many of which seem arbitrary as well as trivial and frivolous. Our reimbursement is predicated upon this coding.  Even if a medical issue is extremely complicated, if it is not documented in the proper way in accordance with the demands of insurance companies, it will not be reimbursed at the appropriate level.

Over the past decade or so, is has become the scheme of many insurance companies to review our charts in an effort to “down code” them.  By seeking out charts with what they consider to have “improper” documentation, they then demand payback for medical reimbursement that they consider overpayment.  Documentation demands and coding is not a fun game—and that is exactly what it is—and when I entered medical school, never did I consider that I would some day have to participate in a ruse like this.  One of the enticing things about EMR was the potential advantage it would give us in terms of fighting off the efforts of insurance companies to “mine” our charts and demand payback for charts that they considered to contain improper documentation.

I genuinely enjoy seeing and helping patients, but find that the kind of documentation now demanded is an extraordinarily time-consumptive and arduous process that does not contribute positively to patient care; in fact, in my and many others opinions, it detracts from patient care by occupying time that would be better spent in direct clinical contact with the patient.

Over the past two decades or so, I had refined my means of documentation in a very efficient and streamlined manner.  Previous to EMR, when a new patient came to the office, he/she filled out a very detailed medical history, including a page where the patient was asked to write in narrative format an answer to the following question:

What is the main reason for your visit today?  Be sure to document when you first noticed the problem, the location of the problem, how long the symptoms last, if the problem is constant or variable, if anything seems to improve or worsen the problem, and the number  (on a scale of 1-10, with 1 being least severe and 10 being most severe) that best describes the severity of the problem. 

The response to this particular question proved very valuable information to me.  It required patients to reflect on their problem, organize their thoughts and articulate them as clearly as possible.  I read this over before seeing the patient and it provided me with significant insight in terms of the content of the response. What can be more meaningful than the patient’s very own words?

Over the years, I have designed numerous one-page templates that essentially are summary letters to referring physicians for the major complaints a patient sees a urologist for, for example: incontinence; pelvic organ prolapse; blood in the urine; lower urinary tract symptoms; vasectomy consultation; etc.  From the response to the narrative as well as the content of the other pages of filled out medical information, I was able to complete much of this template before even meeting the patient face-to-face.  During my interview with the patient I continued filling out the one-page summary, and after the physical examination was performed, I completed the template.  In most cases, before the patient had left the office, all my paperwork was done, including this one page summary letter to the referring physician.   This was an extremely efficient, effective, and streamlined system.  The beauty of it was that the summary contained all of the relevant information and by reviewing it at a later date, it would quickly provide me with every bit of medical information that I needed to know.  Furthermore, referring physicians appreciated the very prompt response and the concise summary of the urological situation.   My point is, I had a system and it worked.  And when something works well, I always question why we need to replace it.  We have a saying in medicine: If it ain’t broke, don’t fix it.

The federal government has committed a significant amount of financial resources to supporting the adoption and use of electronic medical records (EMRs). Their very reasonable and well-meaning goal is to improve physicians’ medical decisions and improve the outcomes of patient care via the expansion of information technology into medicine.  Nobody can argue with this.

The government is using the carrot and the stick approach to achieve implementation of EMRs. Through the Health Information Technology for Economic and Clinical Health Act (HITECH), the federal authorities have provided incentive payments to launch a nationwide system of EMRs. The Centers for Medicare and Medicaid Services (CMS) is mandating implementation of EMR with the punitive stipulation that physician reimbursements will be reduced if this is not adopted by 2015. The goal is not just integration of EMRs, but also the “meaningful use” of EMRs— their use by physicians to achieve advances and improvements in health care processes and outcomes.  Once again, seemingly sensible and rational objectives to which there is no arguing with.

Very unfortunately though, EMR is just not there yet.  Someday it will be there, but I predict not for a decade or so.  Don’t get me wrong – EMR has great potential in terms of improving quality of patient care, increasing patient safety, reducing errors, increasing efficiency, and reducing the cost of healthcare.  An integrated system—which is already in place and functional in many other countries—would enable rapid digital communication of a patient’s medical history and thus easy access to any physician who treats the patient.

The problem lies in the fact that EMR in the USA is rudimentary, cumbersome and chock full of glitches. It is not an intuitive system—frustratingly so—and unlike the intuitive and simple Apple products that I have become accustomed to (including my iPhone, Macbook, iMac, and iPad)—EMR doesn’t “just work.” If Steve Jobs saw the way many of the EMR systems performed—including the XYZ system that we are using—he would likely become enraged and would go on a massive firing rampage to pink slip the B and C players who have designed these clunky software programs.

EMR has proven to be extremely time-consuming and seems to have been designed more for bureaucrats than physicians.  It is typical for the system to crash at least several times a day, and last week the system was down for three hours, requiring us to pull out the paper charts again. When we temporarily had to resort back to that “antiquated” paper system, it literally felt like someone had freed me from the burden of heavy shackles. Dr. David Brailer, the first national coordinator for health information technology recently stated: “The current information tools are still difficult to set up. They’re hard to use. They fit only parts of what doctors do and not the rest.” 

An integrated EMR system needs to be established—a system such that any medical doctor in the USA can access the records of any patient, and one that is integrated across hospitals, private practices, clinics, laboratories and imaging centers. What we have now is dis-integrated and spotty, in its most primordial phases of development and just not ready for prime time.  Right now there are an abundance of different EMR systems and they don’t communicate with each other.  Because of this disintegrated state of affairs, in my office we have numerous scanners working overtime to scan in lab studies, imaging studies, pathology reports, communications from other physicians, etc.  These documents are all placed in the electronic chart in chronological order with no organizational scheme in which “like” is put with “like,” as was the case in our paper charts.  It thus becomes very difficult to navigate through the electronic chart, because it is dis-organized. 

I’m puzzled as to why quality information technology has been so slow and late in arriving to medical recordkeeping in the USA, but it is truly an unfortunate situation that needs to be rectified.  It is quite ironic in terms of the marvelously engineered clinical tools we have at our disposal, including robotic technology for surgery and sophisticated diagnostic imaging capabilities. Some brilliant software engineers need to come to the rescue with an intuitive, simple, universal and integrated EMR system.

In August, we made the conversion to EMR.  The implementation and transition was extremely difficult.  The complexity and Byzantine nature of the software has slowed down the ability of my partners and I to see patients to the extent that we can only see approximately half of the number of patients that we used to see.  This has forced us to arrive earlier and leave later every day.  This has also led to a great deal of frustration from the perspective of our patients, who are unable to secure timely appointments because EMR has so backed us up.  The particular vendor that we chose—XYZ Medical Technologies —has failed to understand urology workflows. Their support team was frankly not very supportive.   As a matter of fact, what we discovered—ex-post facto—is that the bulk of the personnel on XYZ’s support team were outsourced.   Fact: when something is outsourced, the outsourced party is usually less responsible, reliable and dependable than the primary source that has more “skin” in the matter.  This was completely true of the XYZ outsourced support team. This “support” team was often unavailable and, when available, was baffled with many of the problems, glitches and malfunctions of the system.

When I questioned the support team about the precise means of recalling cancer patients and other patients who need follow-up but do not show up for their visits, they looked perplexed and related that they would get back to me on this one.  With paper charts, we employed a somewhat crude—but workable—system for such follow-up in which a red marker was placed on every chart of patients with a cancer or pre-cancer diagnosis who demanded follow-up; every December, these charts were reviewed and if the patient had failed to show up, they were contacted and an appointment was set up.  Go figure that this EMR does not have a failsafe mechanism of achieving what seems like a very simple and is obviously a very important task.

For the past several weeks, when I click on the template for a prostate exam, the prostate template appears allowing me to input size, consistency, etc.; however, also appearing is an examination of the neck that I did not request and I cannot delete, so many of my clinical notes include a prostate exam that I did do and a neck exam that I did not do.   Additionally, this past week, the whim of the XYZ software did not allow me to send a copy of the report to the referring medical doctor.   The system often freezes up before data is saved, resulting in loss of that information.  I recently found out that a patient who had a urine culture that I reviewed in September was never treated with antibiotics because in the process of routing the order for the antibiotics to the person in my office responsible for calling in the prescription to the pharmacy, the order was lost in cyberspace.  We are supposed to be able to “e-prescribe” (electronically prescribe) with this system, but XYZ has not yet managed to get that functioning to date.

The general rule of thumb is to never take financial advice from a physician, but I can assure you with all likelihood that if you were to purchase XYZ stock and short it, you will probably make a handy profit— to quote my brother who is a MBA/MHA and manages a large physician practice in Atlanta: I do not think that this company is going to be in it for the long haul.

XYZ, aside from clinical EMR, also provides administrative, practice management and billing/financial capabilities. Although the packaging of the clinical EMR along with scheduling, administrative, and billing information technology sounds enticing, the reality of it is when you have so many functions served by one platform, the individual components are not going to be very good.  What comes to mind is a television with a built-in DVD player; generally neither the television nor the DVD player is a high-performing item.

XYZ filed a company description with the SEC (Security and Exchange Commission).  I read through this carefully and found a number of their statements to be flagrantly incorrect.  To wit, the following are verbatim excerpts (I have taken the liberty of underlining what I consider to be untruths):

• We are a leading provider of integrated information technology solutions
• Our software is innovative and flexible
• Gives a comprehensive view of the patient record
• Supports efficient workflows throughout each patient encounter, reduces clinical and administrative errors and allows for the seamless exchange of data between our provider customers and the broader healthcare community
• Our solutions and services enable providers to deliver more advanced care and improve their efficiency and profitability

One very useful aid that my partners and I have used in conjunction with the EMR software is the Dragon dictation software, made by a company called Nuance.   This is truly amazing software and I’m using it at this moment to dictate this blog.   When one speaks slowly and clearly, it is amazingly accurate in rapidly transcribing the spoken word to the written word. Additionally it is trainable, unlike our EMR system. It is like Apple’s Siri on steroids and if one good thing has come out of EMR, it has been the introduction of this wonderful software to me, which I now use to compose e-mails and all other kinds of written materials.  The Dragon system is not perfect and makes some funny mistakes:  for example, for ejaculation:  Jack elation; for erectile dysfunction: reptile dysfunction; for gynecologist: con ecologist; for urination: urine nation.  But it can be taught so that these errors do not reoccur.

By nature, I am a very streamlined and efficient person who despises “fat,” waste, and inefficiency.  I particularly despise wasting time—our most precious resource—and the EMR is consuming an unfair share of my time.  It used to be that I had a pile of charts on my desk, each with a laboratory result attached to the front.  I would review the lab, review the previous labs to put the current results in context, write a short comment, sign my name and date and then hand the chart to my medical assistant to call the patient. Now with EMR, the simple act of getting a patient’s lab results back, putting them in context and communicating the results to the patient has become a burdensome and onerous task that takes a ridiculous amount of mouse clicks.   The essence of the problem is that only one document at a given time can be viewed and in clinical medicine it is often necessary to view a number of documents at the same time.  This is a far cry from evolving and would more aptly be described as devolving.

What I have done to cope with this major issue of context—“forest, trees and leaves”—if you will, is to utilize the Dragon dictation system to create a personal rtf (rich text file) document on every patient of mine.   This document summarizes all of the essential findings.  It gives me rapid access to the “tree” of pertinent clinical information, as opposed to the “leaf” of data that I can only view one bit at a time on EMR.  How regrettable and unbelievable is it that I have to resort to this measure in order to make the XYZ EMR system less user-unfriendly—using another software program to facilitate navigating through the software program that was supposed to make medical record keeping easier and more efficient! I have found that my own such file of succinct summaries of my patients’ medical information has come in handy, particularly when the  XYZ system is not accessible—as was the case yesterday when the system was down most of the day because of a power outage.

As a direct result of all the time I spend sitting at my desk perched over a computer, I have developed a literal pain in my neck that is basically a knot within my right trapezius muscle that has affected my flexibility in such a way that my Pilates instructor has noticed it.   Massage therapy is a great antidote to it, albeit a temporary one.

There clearly are some beneficial and advantageous aspects of EMR to medical practitioners.  EMR corrects illegibility issues that run rampant in the medical field.  With EMR, one can “cut and paste” to rapidly craft a very lovely medical note, particularly of value not on the initial patient visit, but on subsequent visits, especially when there is little change in medical history.  With one quick click of my index finger, an entire physical exam can be documented.  Very lengthy and impressive appearing medical notes are created, even though the substance of the note is no different than the paper note.  The only difference is that the EMR note contains a lot of irrelevant fluff that serves to satisfy insurance companies demands for documentation to support a certain level office visit and reimbursement that can vary from a level 1 (very simple visit and the lowest level reimbursement), to a level 5 (very complex visit and the highest level reimbursement).

One of the intentions of government in promoting the widespread use of EMR was to conserve financial resources. In actuality, EMR has increased health care expenditures, creating more expenses for the federal government as well as the taxpayers. An integrated system, in theory, should result in less duplication of services, as lab and imaging results would be easily accessible to all health care providers.  But the system is not integrated!  Furthermore, physicians are notoriously bad businessmen and traditionally tend to under-code patient encounters, but the implementation of EMR has provided us with the tools and gear to aggressively play the coding game.

Another potential advantage of a good EMR system is that it should easily be able to provide mechanisms to ensure proper patient follow-up as well as to be able to rapidly cull through and extract clinical data for the purpose of doing clinical studies and trials.  So far, these two objectives seems way beyond XYZ’s purview.

I adore and embrace technology, but this non-intuitive, non-integrated, not-easy-to-use, so-difficult-to-navigate, clunky, first-generation EMR software—so vulnerable to crashes and glitches, which cause a disturbing loss of context—is just not ready for prime time.  Not only is it a huge financial investment, but it also has resulted in a major disruption of both our clinical and administrative workflows.

E.D. (Electronic Dysfunction) can have dire consequences on the emotional and physical health of the physician, and is not a diagnosis to be taken lightly. My sincere recommendation to physicians is to NOT be an early adopter of this technology, but to delay integration of EMR as long as feasibly possible, in order to allow the technology to improve and become intuitive and user-friendly enough to merit its incorporation. Don’t be one of the early lemmings to jump off the cliff! Before settling on a particular EMR vendor, do your due diligence with the utmost of care, and be sure to speak to several physician practices who have the system in play.

Finally, I am seriously concerned about the medical-legal implications of EMR—there will be errors of omission, errors of commission and so many other potential opportunities for errors and mistakes.   So, in addition to physician beware, I must put out a caveat of patient beware.  So far, I have not found much “meaningful use” to EMR.

Comments from my office staff:

-Too many clicks in every process and procedure.

-As a direct result of this, everybody’s job responsibility has expanded creating more work, more complexity, and more complications.

-It has made simple tasks very complicated.

-As a consequence of EMR, the frustration level in the office is as high as it’s ever been and morale is as low as it’s ever been.

-It has been an extremely frustrating experience and clearly both efficiency and accuracy is down.

-The fact that it is only possible to have one window open at a given time makes the system extraordinarily inefficient; the simple act of calling a patient with his/her laboratory results has become a burdensome, major ordeal.

Bottom Line: Clearly, EHR is nowhere near ready for prime time.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

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Tags: billing, CMS, coding, context, electronic health records, electronic medical records, EMR, federal government, HITECH, information technology, integration, templates

This entry was posted on November 15, 2012 at 7:03 PM and is filed under Uncategorized. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.