Once again, I’m attending the annual NextGen EMR Users Group Meeting on all that’s new and shiny in the world of high-end, integrated electronic medical record and practice management systems.

New faces and new directions this year, of course. And a terrific keynote address by Pat Croce, former owner of the Philadelphia 76-ers.

But this year, the prize for the most awesome personage goes to Dr. Jan Lee — engaging, encouraging, and passionate about quality health care.

And her focus this year is on a revamped version of an older technology: report generation. And if there was ever a cornerstone of The Next Big Wave of electronic records, this is it.

Gold Mine

What the heck is report generating, and why should you care?

You may have heard of a related, sexier phrase: data mining. Simply put, it’s the ability to treat your EMR like the database that it is, and to ask it all sorts of questions that you could never logistically do with paper charts. Every major EMR vendor should have some version of this capacity.

Without it, good luck taking your patient care to the next level of quality. It’s really as simple as that.

What Kind Of Questions?

Here are some typical examples:

• How many patients do I have taking Lipitor?
• What are the phone #s, mailing addresses, and emails of all my patients taking Drug X, which was just recalled this morning?
• Who are my female patients over age 40 who haven’t had a mammogram and breast exam in the past year?
• What percentage of my diabetic patients have had an HbA1C in the past 3 months?

Once you “ask” your system these questions, it should take something like 5-10 minutes, tops, to get answers for all four of them.

Any one of those questions would have previously involved manually pouring over each and every paper chart in your chart stacks. Just visualizing the manpower needed to do so for all 4 questions, accurately, should make you want to curl up into a little mewling ball.

It’s not hyperbole to say that pre-EMR, asking these kinds of questions would have been impossible.

Who Should Care? EVERYONE!

The benefits of asking and answering questions like this apply to everyone: you, your patients, your insurers, and potentially the entire American health care system. I’m a big proponent of win-win-win scenarios, and this is definitely one of them.

YOU win, of course, because you can generate actionable information that could save your bacon, or bring home more of it.

• All those patients overdue for various health maintenance actions — a physical, a mammogram, a colonoscopy, an eye exam — can be found and listed, then reminded to “maintain” their health.
• If you keep track of when patients with problems have closure — coming back from a specialist, or getting specific lab tests — you can search for those patients who have failed to close the loops, and remind them to do so, and why it’s critical that they do.
• Negotiating with payers about your reimbursement rates? It’s a lot easier to argue (especially from an organizational standpoint) when you can prove your patients’ compliance with Pay For Performance guidelines exceed national or local standards — like how 97% of your diabetics are up to date on their HbA1C’s, 92% have LDL’s less than 100, and 100% of them have had a dilated retinopathy exam.

THE INSURERS win, because their patients are demonstrably getting quality care, which translates into fewer and shorter hospital stays, and less sick (i.e. costly to insure) people.

And of course, YOUR PATIENTS win, because the natural human tendency towards procrastination and self-delusion — letting things slide generally means letting medical problems ripen and spoil — is being countered by a passionless but tireless EMR, that focuses on the facts.

If you’re too cynical to believe in win-win-win scenarios, think of it this way: Is it in your patients’ best interests to have you remind them to take important action on their health?

Increasing awareness of the plight of American Medicine. Costs way up, access questionable, uninsured numbers growing. Primary care disappearing, and inverted in proportion to specialist:PCP ratios in other countries. The Graying of America. Talk about universal health care. Healthcare costs as being the #1 cause of personal bankruptcy in this country. Mid-level provider extenders.

Retail clinics.

Defensive medicine, and the over-utilization of expensive tests.

Just defining the scope of the problem is enough of a challenge, and lies outside the scope of this medical record blog.

But whenever I’ve read about strategies to fix the system, all of the serious ones involve EMR’s.

It Wasn’t Us, Honest

Although EMR’s have been guilty of many things in their short time on the planet, tanking the American healthcare system isn’t one of them. We were doing a fine job of opening the vents long before they came on the scene a decade ago (and even now, nearly 90% of physicians still don’t use them).

None of the issues at the beginning of this post have any kind of genesis with electronic medical records. And before you want to file EMR’s under “costs way up,” think about that $1500 MRI you ordered last week, or how a PCP after 40 minutes of coordinating care and counseling, earns 1/4th of what specialist can in 5 minutes.

A handful of those ka-chings, and you could pay for a high-end EMR for a year.

Think About Losing Weight

Consider it from another angle: What do you do when presented with a supposedly insurmountable problem?

If possible, you start by comparing it to something similar that you know how fix. The Weather may be way too complex — I only quote Chaos Theory, I don’t actually study it — but obesity is about right: it’s all around us, it’s a big problem, and very resistant to change.

And what’s the first thing you tell patients who want to lose weight? The thing that people who have successfully lost tons of weight - 80, 90, 100+ pounds tell you?

You’ve got to write everything down.

Put it down in black and white, all the stuff that pertains to your weight: nutrition, exercise, morning scale weight, etc. Count those calories. “I think I ate properly this week” is notoriously imprecise and generally wrong. What did the numbers actually show?

If you don’t measure it, you can’t correct it.

And there are an awful lot of administrators, public policy makers, and economists looking very closely at correcting the course of the USS Healthcare.

Lesson #1: At least for the clinical end of the stick, we aren’t going anywhere nationally, without EMR’s to record and measure what we’re actually doing, and to give us real data to work with.

Gathering said data with paper? With the expansion of the patient population? Then extracting, mining, and otherwise analyzing the info? Forget it.

But We’re Doctors, Not Statisticians Or Politicians!

Does the phrase “data mining” set your teeth on edge?

Or how about the thought of actually manipulating something with those numbers, like changing how you order certain meds, or whether someone needs to be called on the carpet because of a patient satisfaction survey? Don’t you just hate that?

It’s time to get over ourselves.

Our aversion to doing exactly that may well be a major factor in the ailing American healthcare system. An unexamined healthcare spending life may or may not be worth living, but we’re all sure paying for it. And it doesn’t need to be that way.

As medical providers, what our politics and numerical analyses often tell us, is that Doing What’s Best For The Patient is the overarching Rule Of Gold. Not realpolitik, and not zero sum game theory.

What works best in our daily slog through the mud, is what helps the patient get or stay healthier. This is less of a theory, than an observation — and if we disagree on this one, the whole rest of the argument falls to pieces.

Physicians who are policy makers and number crunchers may disagree on economic theory, but find it hard to argue this fundamental premise of medicine. When the numbers don’t add up at the end of the day, it’s sometimes the one thing that lets you sleep at night.

Lesson #2: There IS a lodestone, and that’s Taking Care Of Your Patients.

The problem, of course, is that it’s not always obvious what the best way is to do that. Especially across multiple practices, regions, disciplines, and regulatory bodies.

But That’s What Evidence Based Medicine Is For, Isn’t It?

Yes.

Forget about the legal hole you’d be in, if you did medical therapy instead of an angioplasty and your patient died — science itself, much less medical science, exists precisely because What Is Obvious Ain’t Necessarily So, and Common Sense Is Not So Common.

If a treatment works, it should hold up to scrutiny; if not, it’s time to revise our understanding of the problem, not cling to shadows. Evidence based medicine is the scientific method, writ large on the page of healthcare, and most of us understand the need for it.

So where does EMR come into this?

Evidence based medicine changes patient care patterns among clinicians, using analysis of hundreds or thousands of patient cases at a time.

But front line clinicians are only one part of the healthcare system. Just like documenting a patient care visit is only a small part of the benefit of an integrated EMR/EPM system, there are many, non-clinician aspects to the healthcare system that can be tweaked.

• What would you need to change not only patient care patterns, but also marketing patterns among medical groups?
• How would you analyze what went into setting the price point for a service, involving physicians, therapists, office and hospital stocking practices, and suppliers?
• How would you track waiting time trends, or the time needed to get a first appointment?
• How could you compare long term outcomes data for subsets of patients, not only weeks after a procedure, but months or years after?

How, in other words, would you track everything else in the healthcare system beside what the doctors do?

It all begins with an integrated EMR system.

If we can track it, we can kill and eat it.

But without the capability to analyze and optimize all aspects of the healthcare system, we’ll be forever stuck in our corners, trying to grab whatever fast moving targets flit by that day.

And the system’s problem isn’t a grab bag of small, quick, elusive targets. It’s a big, leggy Kraken that’s gotten used to waving its limbs around pretty much whatever way it wants to.

But then again, so are most medical practices, pre-integrated EMR’s (medical records, medication lists, chronic conditions, scheduling and appointment management, consultant coordination, follow-up tracking, etc). And though I defy any integrated EMR practice to precisely corral The Slimy Beast, taming it is, we’d all agree, both possible and pretty commonly doable.

But the first step is to track it. And for the magnitude of what we’re facing system-wide, nothing less than widely adopting EMR systems will do.

In this neck of the woods, there’s a goodly number of folks who’ve taken the plunge, and adopted an EMR.

Cold sweats, galore.

With that in mind, here are some thoughts from a fellow user who’s been there and done that, to remind you that you can, too!

Old Charts Are Old Hat

Remember that scanning and abstracting is a temporary fix.

This is pretty key, since it’s easy to get bent out of shape over the old paper chart contents. Many new EMR users have a Linus-like fixation on their paper charts as security blankets, or the scanned and hopefully abstracted version thereof. Totally natural, since the early go-live days feel like flying without a net — but it’s ultimately a short-lived, transitional state.

Within one to two years (which can seem an eternity away when you start), you will no longer be digging even digitally into the “old chart,” since your EMR by that point will be the old chart. And finding info in your EMR should be infinitely easier and quicker than flipping through scanned images of paper documents.

That’s why it’s important at the beginning, to have your scanned info be categorized for relatively quick access, either by filing them in obvious categories like LABS, IMAGING, EKG, and CONSULT NOTES, or abstracting whenever possible (summarizing paper chart data in brief entries into the EMR itself). Scanned images take time to load and display, and often can’t be flipped through rapidly. When you have to dig for info, you want to know approximately where to go looking, instead of “somewhere in that 67 page document file.”

Just remember - you won’t be relying too heavily on those scanned documents for long.

Getting Quick And Smooth, Baby

Next, there’s getting comfortable — and fast — with the system.

Most of this is sheer repetition, like the flying hands of ultrasound techs as they twiddle the trackball and tweak the sliders and knobs with one hand, direct the sono wand with the other, while looking at neither. Practice, practice, practice.

It’s important to avoid tripping yourself up, and one of the biggest hurdles is the “I must click every button and fill in every blank line” syndrome. Unless you were the original designer of the templates, doing so is very unlikely to resemble your old workflow, and you will lose valuable time filling out what feel like financial aid forms for every patient encounter.

Your biggest ally is your technical support. Good support will be always available to assist you, by analyzing your prior workflow and helping you transition to a new, EMR inclusive workflow. They can tell you — and reassure you — about what needs to be filled out, and what can be left alone. Often, they can show you much speedier ways of filling out standard history or exam items, than you painstakingly typing out every finding.

Remember — these systems were designed to be used in real-world patient care environments. The EMR vendors wouldn’t exist as viable businesses, if they required users to multiply their workloads by a factor of 5 at every turn. You have the option of documenting each pertinent positive and negative, one at a time, in as much detail as you desire — the system has to give you that drill-down capacity. But just as you’ve developed efficient ways of being speedy yet detailed over the years, so have the EMR developers.

It is an entirely attainable goal, documenting a patient encounter accurately and completely, so that the entire note and all actions related to it are done before you see your next patient. Ask your support folks to show you how, and with practice, the speed and ease will come.

“Is It Safe?”

Finally, there are Good Habits.

Good and Safe, from an EMR perspective, doesn’t just mean speedy and accurate, it also means medico-legally sound. That means taking advantage of the extraordinary power that an EMR gives you, that relying on your own fallible protoplasm alone cannot.

Workflow analysis from your tech support will again be key, here. Your EMR has the capacity to remember every data element, and to remind you when things were done, not done, or when they are due. It won’t forget something because it felt tired one day, or because it got distracted.

You can basically take advantage of your tireless digital servant in 2 ways: what I call automation with patient encounters, and automation by time frame.

Automation by encounter is you paying attention when the system tells you to do something during a patient encounter — whether that be during a patient visit, a phone call, or prescription refill request. An “encounter” occurs whenever YOU or an office staffer lay hands on the chart.

Most EMR’s can alert you when certain pre-defined criteria have been met. These are either preset by the manufacturer (e.g. your 50 y.o. female patient is now due for her mammogram), or defined by you with your tech support (I want the system to jog my mammogram memory with my 35 y.o. female patients). A Good Habit to get into is routinely paying attention to and acting upon these alerts, regardless of the reason for the encounter.

• Is a patient seeing you for a sprained ankle, but overdue for their mammogram? No harm at all in printing up the mammo order and gently reminding them as they limp to the check-out.
• Is the pharmacy calling for a refill on the patient’s nasal spray, and the system telling you he’s overdue for his annual physical? Why not remind the patient to schedule one, and document that you did so?

The law looks upon every contact you have with the chart as an opportunity to act on deficiencies that are documented there. Fair or not, you may as well take advantage of the EMR’s ability to remind you of the biggies, and act on them whenever the chance presents itself. Look at your system’s version of an Alerts page with every encounter, and don’t ignore little red flags when they pop up.

Automation by time frame requires a bit more work — the idea is to systematize a method of acting on those patients who rarely if ever contact your office. And who would therefore be missed if you relied on “capturing” them during an encounter that may never materialize.

Since EMR’s don’t ever forget, you should be able to periodically generate reports of patients who fit certain search criteria. Getting your system to spit out a list of all your female patients between 18 and 65 who haven’t had a Pap smear in the past 12 months should be easy. Or a list of all your patients who missed their follow-up appointments this last month.

Whatever criteria matter to you, you can have the system track patients down using them. Decide upon a limited, implementable set of sweep criteria (start with 3 to 5, not 38), and strain your practice periodically.

You’ll pick up more tidbits as you go along, especially if you participate in a local users group meeting or regular EMR Committee to finesse the system, and your own use of it. Start slow, don’t hesitate to ask for pointers, and get some good habits started at the outset.

And you’ll do fine.

You will have to get cozy with your IT support staff.

Really cozy. On better terms with them than your spouse, cozy.

Unless you want to be spending at least as much time working with your hardware, software, and systems integration issues as you do with patient care — and even then, not fully taming the tech side.

I’ve been up to my armpits in EMR related work, advising an MSO that supports a local implementation in Southern California. New upgrades and conversions, retraining folks and developing teaching materials, testing the new features with the MSO programmers, filing down the rough edges to fit…

Finding new rough edges, and filing those down.

Pulling all nighters.

It’s a full time job, and I’m only consulting half time!

And I’m an interface and end-user testing guy; I’m not even writing or re-writing the actual software code.

Not In the Military, But…

Think about what you, as a provider of medical services, do daily:

You have a supply chain a mile long, relying on phone staff, back office assistants, pharmaceutical suppliers, and colleagues in other offices or hospitals.

Communication with your patient is critical — and often less clear than both of you would like.

And technology — whether electronic record, appointment reminders, or email, blog, and text messaging — can either help you or hurt you, as is true of any tool. But it can’t substitute for the basic human skills of attentiveness, empathy, and careful consideration through the lens of experience.

I don’t have a hidden wish to be in uniform, but I believe we really are the civilian version of the military’s “pointy tip of the spear.” When it comes to health care, what we do is about as mission critical as things get.

No argument so far, I trust.

Pobody’s Nerfect

There’s always been what’s been termed “the fog of war,” and likely always will be. No matter how many good people and good intentions and conscientious preparation you have on your side, there’s no such thing as a guaranteed, painless path to victory.

“Real boats rock,” as Frank Herbert said. No day starts off so gloriously that it can’t go to heck in a handbasket in an instant.

Poop happens.

This isn’t a theory; it’s a historical observation of the entropy of the universe. While it may not be as bad as my senior surgical resident said (”See that parking lot out there? Every one of those cars is full of people just waiting to bag you”), there are imperfections in any system. Chaos Theory, in fact, tells us that imperfections aren’t oversights or the consequences of poor parental upbringing, they are by definition going to be present in any sufficiently complex system.

Real boats don’t rock because the shipwright didn’t design the keel properly. They rock because that’s what the ocean does.

And of course, in the grand system of EMR, IT staff, office support, family, and colleagues, one of the biggest parts that can “rock,” will be us.

How many of us can even control our selves enough to traipse smoothly through life’s dandelion patches?

The best we can hope for is a setup that corrals our imperfections, that will encourage us to do our duties better, and that will do so forgivingly, instead of fighting against us.

So What Can YOU Do?

There are imperfections, and there are eye-crossing logistical nightmares in the making.

Having your IT support “distant” from your peculiar implementation falls under the latter category of SNAFU.

Out of the area tech support works, if you have an ultra standardized setup — the exact same hardware, software, and interfaces in your office that the tech support person in Bangalore has during your phone call.

But in today’s EMR world, that just ain’t so. Customizations unique to your office typically occur within weeks or months, and as I alluded to in a prior post, the network partners change locally within just a few miles of any implementation (different pharmacies, different hospitals, different laws, different interfaces).

Distance does not make the heart grow fonder, in the EMR support world.

In my opinion, you keep your friends close, your enemies closer, and your EMR IT support closest of all. Get them to marry into the family, if possible. You will need them much more often than the proverbial plummer, auto mechanic, and lawyer.

Next, reconsider slitting your own throat:

In my experience, the best clinicians and workers among us are often somewhat demanding and periodically rigid – you have to be, to get things done in a sea of entropy. You know people like this, may even be one of them: they tell it like it is, say bald, unvarnished things, and are generally a little unpleasant to go visit.

IT people love folks like that. Really, they do.

There’s a difference between the clinicians that don’t read the instructions and don’t care to, and the clinicians who have an honest beef with the system because it isn’t helping them win the war. Professionally, IT staff always admire and respect the latter.

Those clinicians are trying to close the distance between what wins battles here, and what doesn’t out of the box from the manufacturer over there. And closing the distance is what makes everyone smile, in IT support.

BUT, there’s too much of a good thing sometimes: piss and vinegar can make smiles tight, real quick. And if you could care less about irritating people while you loftily maintain your personal integrity, think back to the military analogy, or even your med school days:

• Do the lieutenants piss off their sergeants?
• Do the sergeants piss off their supply contacts?
• Do the med students piss off the floor nurses?

Kind of universally vital, those “support” folks.

Get thee hence from the prima dona mindset; your digital future rests squarely on the shoulders of a village of IT support staff, shucking and jiving at the speed of light. You will never voluntarily want to be far from them, and they wouldn’t have jobs without you.

Make nice.

I take issue with that recent FPM opinion piece by Dr. Christine Sinsky, “e-Nirvana: Are We There, Yet?”

As an EMR consultant who works with both physicians and an MSO, I find it lopsided and unhelpful.

Yes, I’d like my EMR to be seamlessly integrated with my personal workflow, unobtrusive, and a snap to use. But as one of my junior high teachers used to say, Well, there are a lot of things I’d like in life. Simply “putting Google on the project,” as Dr. Sinsky suggested, might or might not take us closer to making the magical EMR a reality.

Google’s essentially unlimited financial and programming resources do tip the odds in favor of success. But so would putting the Almighty behind the project. And while I do pray daily, I believe there’s a certain due diligence in getting the apple down off the tree and into my mouth.

The plain fact is that for medical providers, stakes are high, time is short, and the amount of info to be juggled is frickin’ monumental.

We are in an EMR transitional period: relatively few doctors’ offices use one, yet there’s a clear federal as well as medical community mandate to get “EMR literacy” within the next several years. Not surprisingly, EMR’s are evolving, and are not as transparent, elegant, and powerful as they doubtless will be someday.

Google is, as a matter of fact, already on the case, and it will be interesting indeed to see what comes out of the Mountain View headquarters, with its essentially limitless financial and programming resources. All combined, the big EMR vendors can’t match the programmer and support staff numbers of Google.

But as much as I like the idea of having Google on the case — I gratefully use Google online apps — I’m not interested in faulting NextGen, AllScripts, or eClinicalWorks for not being the equivalent of The One True Google. From my “insider” perspective as a physician EMR user, who assists with EMR implementations, and works with programmers and support staff to customize a particular EMR, that’s a pointless comparison.

If I were an American pilot helping the Brits fly Spitfires in the Battle of Britain, I wouldn’t be criticizing Vickers-Armstrongs (the manufacturer of those fighter planes) for not being Lockheed Martin (the maker of the F-22 Raptor, the current supposedly best air superiority fighter in the world).

Plus, that Spitfire was one awfully sweet plane to fly, by all accounts…

What We Can Learn From Aviation

One of NextGen’s teaching mavens, Dr. Cephus Allin, used some aviation videos when discussing EMR’s, which is curiously apt. For better or worse, modern physicians — especially primary care physicians — are being put in the position of fighter pilots, although without any of the glory:

• They are THE “pointy tip of the spear,” usually the first point of contact for any and all medical issues, simple or nauseatingly catastrophic
• They have limited time frames to view, assess, and act on each patient encounter
• The amount of data they must process to do this well is enormous - past history, chronic conditions, meds, consultants’ notes, lab results, tests done and not done…
• They must routinely juggle other unexpected inputs during patient encounters, such as oh-by-the-ways as well as office matters outside the exam room

Thirty years ago, fighter pilot info overload was an area of intense study: there were too many dials, too many sensory inputs, and way too many ways to crash a jet that had long surpassed humans’ ability to control without computer assist. Heads Up Displays (HUD’s) were born, and dials and knobs were reduced from hundreds down to a dozen or so. And none of the critical data required taking your eyes off where they had to be.

It doesn’t take a rocket scientist — just an aeronautical engineer — to realize there will be some happier doctors out there once EMR interfaces become more streamlined.

If Only It Were That Simple

But any doctor who’s surveyed a bunch of EMR’s could have told you that. A doctor in the market for an EMR will light right up, if you can convince him your system is uncluttered, transparent to his workflow, and speeds his patient visits along with documentation shortcuts.

If you have to keep your eyes “on target,” where is the target? The patient in front of you, of course! Right?

Nope.

The person in front of the provider is more like altitude or airspeed information on a jet’s HUD: critical, absolutely, but — unfortunately — not the whole dogfight. Of course it’s important that you care for the patient, listen and empathize, and that your EMR doesn’t get in the way of that. But you’re not just trying to make them feel listened to, or leave happy.

You’re trying to make sure that they not only leave happy and healthy, but that they stay happy and healthy. Longitudinal goodness.

Now a lot of things can happen once a patient leaves the office, not the least of which is ignoring medical advice; it’s hard to make warranties that last beyond the front door. So maybe a better analogy is, you’re trying to guide your patients, to periodically nudge them back on course.

What’s outside of the cockpit for a PCP, then, is that snarling, furball-shaped, ever swirling target: the long term health of the patient with lots of attached variables, including compliance issues, who sees the doctor intermittently and not entirely predictably.

Ergo, how a patient looks, or what they may say during a visit, is only part of the picture.

Ergo, having an EMR that “stays out of your way” during a visit should only be a part of the search for a better EMR.

Quick and intuitive are great, I want those qualities in my EMR, too. But not at the expense of corralling the furball.

Why Google’s Win Isn’t A Sure Thing

I’m not interested in betting money against The Big G.

But there’s one thing that Google does not have an overabundance of, and that’s mucho man-hours of “flight test”: multiple iterations over thousands of medical provider and staff users using the product and giving corrective feedback.

The Cleveland Clinic announcement just came 2 months ago; most of the large EMR vendors have been refining and struggling in the crucible with patients, providers, and each other, for years

And as I’ve alluded to in this prior post, one of the biggest advantages to an EMR isn’t actually from the EMR — it’s from an integrated Practice Management and office workflow system. Doctors are understandably focused on documentation, but that’s only a fraction of what goes on in an office: appointments, billing and insurance confirmation, interoffice messaging, individual pharmacy and lab interfaces, and connections to referral specialists and hospitals. The greatest streamlining can actually occur in these so-called “other” areas, and all of them must be individually integrated practice by practice.

There’s no such thing as a standardized implementation; ten miles in any direction and the players change completely.

Google can teach us all a lot about cleanliness of interface and portability of data. And of course, a whole lot about searching for data in the middle of haystacks.

I’m just not sure how it’ll handle the part of an EMR system outside of the doctors’ hands. Managing millions of users’ accounts containing a handful of apps isn’t the same thing as managing thousands of medical practice accounts, each containing thousands or tens of thousands of databases (patient files). And at the end of the day, I personally haven’t found that it’s about a pretty interface, or finding my patient named John something who has a dog named Chip.

It’s really about helping the provider keep the patient on track. And there’s nothing like experience in defining what the track is, and individualized, local attention to set up specialized systems that’ll survive long enough to track that track over a patient’s lifetime.

And those are two things that Google doesn’t have in the EMR area. Not yet.

To borrow a line from an old Paul Newman film, “what we have here is a failure to communicate.”

Whether you’re a physician, an office manager, an office staffer, or an EMR vendor/service provider, if you’ve ever sighed deeply or gritted your teeth, there’s a certain eye-to-eye linkage that just isn’t happening.

The stakes are too high to mess around: at the top level, everyone really does want an EMR adoption to succeed. Nobody can afford to let it fail.

Why can’t we all just get along?

The ONE Key Thing

One of my favorite books describes what the most persuasive being of all time used as a deal closing question: Is there anything I can say that would change your mind? References to Lucifer aside, this is one of the most critical and overlooked issues in marketing, or the art of persuasion:

To be successful, don’t make what you think people want and try to sell it to them; ask what they really want and then provide it to them.

The key word here is “ask.”

Many of us come from hard-won positions of authority. You know what you know, by dint of hard work, navigating the treacherous waters of office politics, or years of carefully accumulating critical data.

And when someone asks you a question that they really ought to know better than to ask, what happens? Your eyeballs cross — especially if it’ll cost you time, sweat, or money to deal with.

A natural reaction. But exactly the wrong one, if you want your implementation to succeed.

The Wrong Vibe

The problem is, everyone involved in the implementation process thinks they know what the real problem is, and the finger is never pointing at themselves.

• Office staff are fed up with templates that repeatedly hang at the same spot.
• Physicians are frustrated at a workflow that in no way parallels their natural habits.
• Medical directors are flustered at being nickel-and-dimed for support services that they’ve already bought.
• EMR support staff are tired of wrangling with third party hardware and software services outside of their own control.

Everyone is right, from within their own section of the world.

But how far is anyone going to get, saying “You just don’t get it, do you?”

Internet infopreneurs learn what works faster than anyone I know — because they can change their information marketing quickly if need be, and if something works, they earn money in a hurry, and if it doesn’t, they starve.

And Important Lesson #2 they live by:

You won’t make any long term, mutually beneficial relationships by pissing people off. Telling them you know better than they do what’s good for them is a prime formula for doing just that.

Your tech support guy is very probably right when he says the modification you desire would crash your system; you telling him “it’s not the way I do things” isn’t going to make the silicon chips grow wings and fly. If you’re a techie and your users tell you your new upgrade will multiply their workload by a factor of 10, insisting on its other benefits will not make their repetitive tasks any easier.

Even if you actually do know better than the other guy what the problem is — especially when you know better — you need to put on your humble, “Let us reason together” hat. Or you’ll be spending a lot of time staring at each other over crossed arms.

The Natural, Obvious, Best Vibe

Think back to the last time you were really in a bind — time’s up, no resources in sight, you’re totally screwed — and you suddenly got saved and you were so grateful, you wanted to kiss your savior right there and write them a letter of recommendation that’d get them promoted to the vacation spot of their choice, forever.

• Did your savior know their business? Of course.
• Did they lord it over you? Probably not.

They probably made it look easy, no trouble at all, like this was what they were there for, they did this kind of thing all the time.

They probably put you at ease, this will work out, we can handle it.

Most important of all, they quickly identified and acknowledged your fears, and made resolving them their immediate top priority.

Would you go back to them over anyone else, if you needed assistance in the future? Would you recommend them to your friends and colleagues? Would you be well-disposed to their organization, because of the incredibly helpful human face they gave it that day?

See where this is going?

The Hat You Wear Should Be The Other Guy’s

You may not choose to wear that Ultimate Service hat; maybe your momma never showed you how to be that nice, or you’ve forgotten how. Perhaps it’s not entirely appropriate, in your position in the organization.

But even from a purely mercenary standpoint, you need to know what works for the long haul. In the short term, it’s enough to know your material — just barely. But for ongoing relationships and word of mouth buzz, you want people to be deeply, totally convinced of your awesomeness.

Ultimately, we’re all of us in a service industry, either as health care providers to patients, or tech support for the providers. Being thoughtful, clear, and pleasant will always be useful both for giving good service as well as receiving better service yourself.

And if you don’t quite know how to do that, just ask: “What can I do to help you out of your difficulty?”

Any New Year’s resolutions, yet?

We’ve got a good one floating around the office these days: becoming more adept with the EMR.

“For goodness sakes,” said our nurse practitioner after being shown a keystroke shortcut. “What a time saver!”

“THAT’S the kind of thing we need to share with each other — shortcuts and tips it’d take forever to find on our own.”

What a concept: taking advantage of community wisdom. Something you can’t get out of your system’s instruction manual.

Something only you and your fellow users can make happen, once you get some momentum going.

Take Advantage Of An EMR Committee

It doesn’t take a village, but it sure is easier if you’ve got a posse behind you.

If you don’t have a group of fellow EMR users already, strongly consider starting one, as previously recommended here.

If there’s already a group, attend the meetings regularly. With systems administered on an ASP model, your tech support should already be there, telling you about the latest bug fixes and customizations that can make your life easier. Customizations that YOU can have input on, now that you’re in attendance.

Invariably, you’ll catch sight of how more experienced users are “working” the system to save time and effort, doing critical tasks more smoothly and consistently.

That kind of thing is worth the price of admission alone — picking up a single tip that saves you a couple minutes, each and every time you touch a patient chart.

Learn By (Watching The Other Guy) Doing

Invariably, we all work in the thick of it with our heads down, grimly approximating lightspeed as best we can.

If you get through the day intact, you assume that your charting style was “good enough.” You don’t know how other folks do their charts, you haven’t had time to really think about that. Enough like you for everyone to muddle through, right?

Like the Gershwins said in Porgy and Bess, It ain’t necessarily so.

Using your EMR well involves a constant dance of automating and improving upon your existing workflow. But to improve upon it, you have see it first — and have an idea of what a “better” version would look like.

Chart reviews are a good way to see how other folks are charting well (or not). The committee can do this randomly, or groups can do this internally.

Profiling good charts helps the most: showing examples of what successful users of your EMR are doing. Such “power users” can demonstrate how they handle a typical encounter, sharing what the advantages for them have been, while illustrating exactly how you can achieve similar results. Other group members can chime in and critique, creating improved hybrid strategies on the spot. Everyone, including the power user, benefits.

Sign Up To Become A Power User

If your EMR vendor has a Users Group meeting or convention that meets annually, guess what? The newest developments are revealed here, as well as time lines for drool-worthy features, and tutorials on getting your processes smoothed out. I strongly recommend that you attend — didn’t see that one coming, did you?

Additionally, there may be local vendor-sponsored educational opportunities you should also consider attending, along with your staff.

Once your office has developed some basic overall competence, these classes may be your quickest way to becoming a power user. NextGen for example has courses you can sign up for, that teach what the best practices using the system are doing. Sort of a corporate-approved EMR committee, drawing from the collective wisdom of a much bigger user base than yours.

There are important principles you need to keep in mind for optimal EMR use — like what The EMR Show tries to pass on. But there’s no substitute for direct experience, with a system just like the implementation you’re using.

And if it takes a few man-months to get reasonably adept at your system, why not combine the experiences of a room full of users to cut that learning curve down to size?

You know: what everyone else is using to learn and talk about current events, their health, their job prospects, their friends and coworkers…the latest developments in their respective fields…

The critical stuff.

Health and Human Services Director, Michael Leavitt, recently put it like this:

It’s obvious that the medical establishment has yet to complete the jump to the Internet Age. Our health care system has fallen behind every sector of our economy, from car repairs to manufacturing to air travel, for no good reason. There’s something wrong when you can walk away from a bank or mechanic with a detailed, easy-to-read printout but, when it comes to your health, you’re left hoping the pharmacist can make out the doctor’s handwriting.

He was referring specifically to the lack of EMR adoption in 90% of doctors’ offices, but the problem goes way beyond that. For the vast majority of American physicians, it’s an Internet mindset problem of epidemic proportions.

If you’re reading this, you’re by definition ahead of 99% of our profession. You know what a blog is, what an EMR can do, and you’re possibly even familiar with terms like RSS, social networking, and New Media.

Even if you’re not fully on EMR just yet, you likely communicate via email, use computers in your daily personal life, and garner information about The World via online news services or feed readers.

Many of our colleagues — you don’t want to know how many — still think of the Internet as a collection of fancy, online Smith Corona typewriters, and EMR as one of those fancy typewriters off in a room somewhere. If this vaguely sounds familiar, please note: this way of thinking was the vogue about 20 years ago.

Check out the following YouTube video, and compare your tech competence to some savvy power users. Only, this isn’t about how businessmen in Belgium communicate and think via the Internet, or surgical chiefs in Hanover, or even Silicon Valley geeks.

It’s about how typical American college students — the cream of the world’s crop, the pinnacle of human intellectual development — have integrated the Internet, social media, and computer technology in general into every aspect of their lives, of which studying is (still) a small part.

Sobering, yes?

Dr. Cephus Allin spoke in some detail about it, as did at least one other presenter; I’m pretty sure this is passing into the NextGen cannon of “Successful Practices Do THIS — So Should You.”

It sounds so simple, but I can attest to its profound effects on reclaimed time — and best of all, it works regardless of your EMR platform. And with a sensible use of technology, it will work regardless of your office size.

The concept is “Having everyone in the office practice to the top of their licensure.” It basically means this: docs should do doc level tasks, MAs should do MA level tasks, and clerical/phone staff should do clerical and phone intake tasks.

Or more bluntly:

• Do you really want the $100/hr physician spending 5 minutes per encounter rooming a patient (an MA level task)?

• Should the MA spend 3 minutes per chart entering lab values (a clerical level - or better yet, automatable - task)?

Many tasks that physicians now assume they need to do can be handled by staff empowered to do so, within the upper but acceptable limits of what they’re supposed to do.

Make Your MA Your Faithful Scribe

HPIs and Systems Reviews are usually taken by the physician, but often can be done just as well — and much more consistently — by the MA.

Common HPIs can be filled out by the MA as he or she rooms the patient by clicking through a template, then reviewed in seconds by the physician upon entering the room. Same for a Review of Systems during an annual physical. These two tasks alone can free up minutes per visit - and even 3 minutes per visit over 20 patients a day means an extra hour of free time.

Concerned about the defensibility of that “all normal” ROS button, or the “past medical history reviewed - unchanged” button? Not if your customary practice is to have your MA read, verbatim, each line or question, and click the appropriate box.

This isn’t about shoving the scut onto your support staff - that would be suicidal. Ultimately, it’s about improving the workflow for everybody in the office, by having them sensibly do what they’re best trained for, and not burning gears doing other folks’ busywork while their own duties get put off.

If you’re a physician and you’re updating the meds lists, or an MA and you’re abstracting paper chart info, your office needs to step back and rethink your duties.

Trim The Fat And Snap To In 3 Steps

The basic mechanism goes like this:

1) ASSUME from the beginning that each team member in the office has a finite set of doable, key tasks, that if performed well, will have the EMR enabled office running smoothly. This is actually a reasonably safe assumption to make, for a perversely inverted reason: you’re screwed if this isn’t true, so you might as well start off on a positive note.

2) EXAMINE those tasks, and group them into categories appropriate to the particular team member: physician level tasks to the docs (needing higher level decision making, training, or “the boss” factor), clinical assisting and communicating tasks to the MAs, and clerical or phone duties to the front office or phone staff. Those meds lists should be updated by the front office or the MA, not the MD.

3) AUTOMATE whenever possible to reduce each team member’s tasks to manageable levels — something that an EMR enabled office can excel at.

Not sure where your MA is going to magically find the extra time to do data entry of all those incoming lab values? Push for that interface with the lab, so the results are automatically entered electronically into the chart, for your review and approval - MA properly out of the loop, saving her hours per day.

Have access to a secure email communication portal with your patients? Run, don’t walk, to get it incorporated into your EMR. Especially if it allows boilerplate text macros for commonly given instructions or responses to frequent questions, it will save tons of time that your staff now spends on simple patient notifications.

• Example: time yourself typing the instruction to adopt a low fat diet and regular exercise in response to that most common of primary care lab abnormalities, the elevated cholesterol result.

• Then time your MA re-transcribing that, putting it in an envelope, stamping it, and putting it in the outgoing mail pile, or worse, calling a patient, finally getting the patient on the phone, having to chat about it, then documenting it.

• THEN compare that total time to 2 mouse clicks — one on the “exercise and diet” instruction button, the other on the SEND EMAIL TO PATIENT button. Multiply that by the dozens of times daily a typical PCP gets abnormal cholesterol values, and you begin to see how supposedly itty bitty efficiencies can reclaim hours of lost time.

Me Scan? I Thought You Scanned?

What about abstracting and scanning old charts — who decides what’s important, and who feeds the sheets through the scanner? This is a whole topic in and of itself, but the same rules apply:

While docs are arguably the best arbiters of key chart info, it’s not an efficient use of their time to have them abstract or scan (see $100/hr, above). Everyone needs to have a pitch-in whenever needed attitude, yes, but do the math: if you fit in just ONE extra patient per day, that’s 23 extra patients in an average month, or an extra day of income. That’s enough to hire an extra scanning staffer who can even do the abstracting, if you give clear and simple directions on pulling info from a patient chart.

And with the increased efficiencies throughout the office, you should be able to squeeze in more than one extra patient, in addition to the cumulative savings of all those other process improvements (better billing and coding, less time wasted, etc).

Share The Wealth

The examples are almost limitless where practice life can be made better all the way around — that most desirable win-win-win situation for everyone in the office including the patient.

When the EMR alerts you when patient is overdue for something like a mammogram or a diabetes lab, any of the support staff should be able to generate the order and contact the patient to do it. Empowering them to automatically do so de-pressurizes the MDs and frees them up for higher level tasks. And EMR automation can make the generating and contacting processes quicker than ever for the MA or front office staff.

Just remember to combine the proper delegation of “top licensure” with workflow changes that will make that delegation possible. Delegate down, but pull staff up, so to speak.

Okay, so maybe that’s gutting inefficiency in TWO moves.

It addresses one governmental (i.e. Medicare) solution to the traditionally low adoption rates of physicians of EMR’s: lower the upfront costs to essentially zero with the VistA system built by the Veterans Administration.

The clincher for me was the following observation:

While Medicare’s plan is to offer the software for free, one must ask what free is. Currently, free is software but not training, installation, and ongoing support.

My commented response, heavily informed by the collective wisdom garnered from the recent NextGen Users Group Meeting, is reproduced below:

Interesting development.

The issue with support and adoption rates are key, and intertwined.

If you want an EMR to do several, fairly high-level tasks, it is going to be a relatively complex beast, and you will HAVE to have IT/customer support. That’s as much a given as water being wet.

At a minimum, an EMR will need a database to organize patient data, and enable data actions like checking to see how certain populations are doing by certain criteria, for just one example of tons (the exception being a word processor, which is not what I’d consider an EMR). Most docs want it to also do prescriptions, which means a fax or electronic prescribing capacity, another drug database (constantly updated), ideally with formulary checking, and interactions alerts.

EMR’s should, in my opinion, enable phone messaging and intra-office tasking, notifications of when patients are due or overdue for key health maintenance tasks, forward looking reminders on past tasks not yet confirmed to be done, remote log-on/work from home capability, airtight data backup, and incorporation of paper info (old chart and new notes from outside).

ANY of these tasks will require tech support. ANY combination of these, to function smoothly…it’s mind boggling to think it even possible to work smoothly without tech support and maintenance — which the physicians cannot possibly do on their own, unless they become full time IT folks, at which point they’re not practicing medicine anymore.

The answer to adopting an EMR isn’t to make it cheaper.

The key is educating physicians and their offices: this can absolutely be done, but it WILL be the toughest transition a practicing doctor will ever make. It is NOT about a training session or two to get acquainted with a fancier word processing program, tied to a snazzier billing software for the front desk.

In tech terms, EMR is not a “kludge”; it is a fundamentally different way of doing what a doctor used to do, that will enable doing 10 times more eye-popping and productivity enhancing and patient safety increasing activities than ever before.

A vague sense of it being an new wrinkle on an old way of documenting…will result in the emotional equivalent of walking into a harvesting machine. An hour or two with the manual — like what you might do with a new word processing program — is nowhere near enough. 10-12 physician training sessions, about an hour each, of progressively more challenging practice cases, is more like it.

Until doctors and their offices realize this isn’t a step up from a Ford Focus to a Mercedes, it’s a leap up from driving a car to flying a jet, successful adoption rates will remain low. And price of the product will have very little to do with it.

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