OK, I am an EMR geek who isn’t so thrilled with the direction of EMR. So what, I have been asked, would make EMR something that is really meaningful? What would be the things that would truly help, and not just make more hoops for me to jump through? A lot of this is not in the hands of the gods of MU, but in the realm of the demons of reimbursement, but I will give it a try anyhow. Here’s my list:
1. Require all visits to have a simple summary. One of the biggest problems I have with EMR is the “data diarrhea” it creates, throwing piles of words into notes that are not useful for anything but assuring compliance with billing codes. I waste a huge amount of time trying to figure out the specialists, colleagues, and even what my own assessment and plan was for any given visit. Each note should have an easily accessible visit summary (but not at the bottom of 5 pages of droll historical data I already know because I sent them the patient in the first place!).
2. Allow coding gibberish to be hidden. Related to #1 would be the ability to hide as much “fluff” in notes as possible. I only care about the review of systems and a repetition of past histories 1 out of 100 times. Most of the time I am only interested in the history of the present illness, pertinent physical findings, and the plan generated from any given encounter. The rest of the note (which is about 75% of the words used) should be hidden, accessed only if needed. It is only input into the note for billing purposes.
3. Require all ancillary reports to be available to the patient. Patients are already the information interface between providers, so why not use them as our interface? Why not make them capable of giving the ER doc permission to see recent labs, or give the specialists access to their x-ray reports? Why do I have to get permission from them to get the information sent to me from the lab or the radiologist? The patient is there in the room, so why can’t they just say: “Here are my results. You can look at them.” While they are showing me them I can explain how I interpret them.
4. Require integration with a comprehensive and unified patient calendar. We have the technology to give each patient a comprehensive care calendar to look toward the future and into the past as to what tests are due and what was done. When I order a test and get the results back (thyroid tests for example) I should be able to queue up the next test on a calendar that the patient can see and use. This is the “GPS” idea I’ve had in the past, and would be simple to even share between providers.
5. Put most of the chart in the hands of the patient. Patient information, such as family history, medication list, social history (where they work, are they married, etc), and even a list of past surgeries should be managed by the person who knows it best: the patient. Keeping track of this is next to impossible in a busy practice (especially for pediatrics), and is re-transcribed for every visit the patient makes to a new provider. This is burdensome on everyone and leads to significant inaccuracies that would be easily fixed if a unified patient record were managed by the one with the most to gain from its accuracy.
6. Pay for e-visits and make them simple for all involved. One of the worst parts of my practice is that I must force patients to come to see me so I can be paid for the care I give. This is especially unfortunate because the internet allows easy communication, making many (if not most) of these visits unnecessary. It is a waste of my time, it wastes lots of patient time, and it greatly increases absenteeism from work. Yet I need to be paid for my services, as I am taking significant risk and using my training for their benefit. The technology would make this easy, but the reimbursement model stands in the way. CMS would have to make this happen, but doing so would give a huge yield to doctors, patients, and employers.
7. Allow e-prescription of all controlled drugs. This falls under the “duh” category. Why is it safer to hand a physical copy of a controlled drug prescription to a patient than to send it electronically? Is it safer to hand a person a check and have them bring it to the bank, or to send it electronically for deposit? Come on, folks, this is just so obvious.
8. Require patients’ records to be easily searchable. I spend huge amounts of time searching for answers to questions like: “Were they ever on drug x,” or “When was their last y procedure?” I would love to be able to do a ctrl-f (or cmd-f) search on patients charts to get that information. It should be standard in all EMRs to allow this, as we all spend way too much time searching, and probably order unnecessary tests because it’s just too dang hard to search.
9. Standardize database nomenclature and decentralize it. Let’s stop the proprietary nonsense. EMR products should be able to interact well with each other, retrieving information about the patient at various settings. I personally don’t think the centralized database is the best approach, as it is far more risky to have all data in one location. EMR should be able to retrieve information (with patient permission) from wherever it is. I shouldn’t have to store the CBC results in my record; I should just have easy access to the lab’s records. This has actually been done to a lesser extent with e-prescribing, which can give a unified view into the patient’s prescription history (which is often useful, although it is still quite slow). Having data in proprietary silos is a foolish and inefficient storage method.
10. Outlaw faxing. I hate faxes, and with internet-enabled communication (like you reading this), faxes should not be needed. They are difficult to transcribe to digital format, usually ending up as PDF files instead of searchable data. Most faxed medical information (ironically) starts in digital format (word documents, etc), and then is converted to paper or PDF, only to be re-imported as non-searchable image files. This is stupid, but it is so easy that the only way to prevent it is to not allow it.
So there’s my dream “meaningful use” list. I would be interested to hear what other ideas you all have.
Rob Lamberts, MD, is an internal medicine-pediatrics physician who blogs at More Musings (of a Distractible Kind).