I haven’t talked about the Electronic Medical Record (EMR) and how it has affected the practice of medicine. I don’t need to use the Electronic Medical Record as much as my other clinical colleagues. However, I have seen how it has affected my wife’s work. She was involved with the switch-over of her residency to Epic and was even an “Epic Superuser” (extended training).  Needless to say, she’s pretty facile with EMRs in general, especially Epic.

Lately on Twitter I’ve seen a few interesting facts pop up regarding documentation and EMR, mostly having to do with increased time spent using the EMR and decreased face-to-face time with patients.

This worries me and it should worry everyone.

Ok, so here’s the deal:

EMR was supposed to replace pen-paper documentation because pen-paper was messy, easily lost, and doctors have the worst handwriting that has ever existed. We even have a meme:

(Don’t worry, I don’t know what it says either.)

So then EMR was supposed to make everything easy to read, everything was backed up, and there would be better accountability. The cloudy skies would part and a ray of sunshine would breech the clouds and illuminate a glorious computer with an EMR… still running Windows XP.

So what happened…?

A recent article was published in the Annals of Internal Medicine:

September 6, 2016 – Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties

Now, I don’t have access to the journal because well, I’m not an internist and I have subscriptions to other journals in my subspecialty (Radiographics, Radiology). However, the abstract is free to read and the most important points are found in the conclusion:

“For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work.” (emphasis mine)

Let that sink in for a minute.

Your doctor spends nearly twice as much time with the computer than they do with you.

Even with all that. Doctors go home and instead of playing with their kids or trying to watch the game or going for a walk or something… they open up their computer at home, log in remotely to the EMR and…

SPEND 1 TO 2 MORE HOURS WITH THE EMR.

Now I ask you… are we now slaves to the EMR? Slaves to what was supposed to free us?

What is your experience?

Like I said before, I’m a radiologist so I am a little buffered from the whole EMR thing. However, my wife is a psychiatrist and she brings home work every-single-day. Here’s the thing though, it started slowly at first. She didn’t used to bring home work before. However, the work load increased and she had more patient to see. So the amount of documentation needed increased. And so there wasn’t enough time in the day… so:

“I’ll just finish this note at home.”

That’s how it starts. Now, my wife isn’t one to complain. She’s an excellent psychiatrist and does a very good job with her patients. She would never let a day go without making sure her inpatient notes are done on time. Her sense of responsibility to her patients is second to none. But the work load just kept increasing.

Rather than the exception, it became the norm.

She would come home and have 2-3 notes, then 5-6, then maybe even up to 10 notes to finish. She would get home at 6pm and do notes till 9 or even 10 pm. Sometimes I am working evenings, so she would have to feed the kids, get them all bathed and in bed and try to finish notes before sleeping. Then priorities had to be exercised.

“I just need to make sure I finish the inpatient notes.” “The outpatient notes I can sign off tomorrow, they aren’t urgent.”

My wife, an excellent psychiatrist, is now a slave to the EMR, to her computer. So let me ask you this: When does it end?

So… we’re drowning?

Yes. It happened slowly, like a slow leak from a faucet. So you turn away to focus on helping patients.

It’s just a slow leak, it’s not a big deal.

It’s just a little puddle, no big deal.

It’s just a little pool of water, only up to my ankles, I can handle it.

It’s just up to my waist, I’m still functioning just fine.

I can still breathe if I stand on my tip toes.

Glug glug glubg glugg  (I’m still fine.)

Ok, so EMR is broken, how can we fix it?

I don’t think the intentions of EMR were bad, I think the implementation just didn’t happen correctly. Of course, hindsight is always 20/20. I am not judging the current EMRs, I am just trying to come up with solutions on how to fix them.

One of the mantras of any early stage start-up that you will always hear is : “Build something users love, and spend less than you make.’’ – Paul Graham

The problem with this in regards to doctors is that we are all different. Every specialty handles a situation differently. More so than that, each hospital, each clinic, each academic center will all handle things differently. If you are a small community hospital with only a few subspecialties available, you should not have to navigate a list of 50 specialties or very uncommon labs to find what you want to order. If you are a large academic center, you will want to have access to even the most exotic of subspecialties and their respective jargon/labs/etc.

So what I am saying is that an EMR is not a one size fits all solution.

When my wife meets a patient for the first time, they may come to her on 5-7 different psychiatric medications. In the first encounter, she clearly explains to them which each medication is supposed to do, understands the history of why they were put on the medication and what was added and deleted.

Then she tries to remove some. Less is more.

Unfortunately, I don’t think EMRs do that. They try to add on more and more options and more and more things in a seemingly endless number of additions. They don’t want to miss a possibility and try to make a contingency plan for everything. In the event that the EMR does not have the option the physician or other provider is looking for, then of course they will be getting a call to fix it. Fix the problem before it happens right?

I understand that line of thinking, however, EMR has now devolved into wading through a swamp of information, dropdown boxes, check boxes, and pop-up boxes. 

This problem of “overcommunication” and “information overload” filters down to the physicians:

“Well, I have all this information, I better document that I saw it and copy and paste it into my note.”

The article I linked above was information every single clinician who uses an EMR already knows. It makes me less efficient. 

Ok, it’s easy to judge EMRs as they are now… but how do we fix them?

The answer is one that no one will like:

We have to start over again.

Notice that I didn’t say “they”. I said WE.

EMRs were made by CEOs, COOs, CTOs, and lots of other titles to create a package to sell to hospitals. I’m sure they had a lot of consulting doctors to help build the product as well.

However, that was EMR 1.0. EMR 1.01 and 1.02 and EMR 1.42, etc, etc will just be iterations of the current EMR. Obviously, iterations are… iterative.

Here’s what we need:

EMR 2.0 needs to be built from the ground up as modular, not just a bunch of things packaged together.

EMR 2.0 needs to have doctors at the helm and not just consulting for a fee (hired gun), but with skin in the game (paid in equity).

EMR 2.0 needs to have doctors of every specialty involved. Not just “famous” administrators, but doctors who are “in the trenches”, using the EMR on a daily basis.

EMR 2.0 needs an elegant, intuitive UX/UI which needs to be heavily tested by clinicians

EMR 2.0 needs to be affordable for the small one person clinic, but also scalable to the largest academic center or hospital system.

EMR 2.0 needs to be mobile and portable, easily accessible through a smart phone.

EMR 2.0 needs to be infinitely customizable. It should not be a one stop buy and forget package, but should be re-evaluated on a regular (weekly?) basis.

EMR 2.0 needs to actually make doctors more efficient.

*I am using the EMR 2.0 moniker because it parallels the Web 1.0 and Web 2.0 descriptors:

‘Web 1.0 refers to the first stage in the World Wide Web, which was entirely made up of Web pages connected by hyperlinks. Although the exact definition of Web 1.0 is a source of debate, it is generally believed to refer to the Web when it was a set of static websites that were not yet providing interactive content.” (Techopedia)

Basically, EMR 2.0 is the evolution of EMR 1.0, not an iteration. EMR 1.0 didn’t “fail” persay, but was an experiment to see if Electronic Medical Records could improve efficiency and outcomes. I think that we can argue that efficiency and outcomes have improved in some ways, but have become significantly worse in others. However, EMR is here to stay and we need to look forward now.

Ok, so talk is cheap, when are you going to build EMR 2.0?

LOL! You are absolutely right. Talk IS cheap.

For someone to build EMR 2.0 like I outlined above would require billions of dollars to create. It would require a ton of of money to hire a genius CTO and genius programmers working under him. It would also require a ton of doctors “in the trenches” working on their time off. The ideal solution would be to hire early or mid career physicians “in the trenches” who are doing clinical work part-time and willing to accept a consultant fee and/or equity. It would require a rock star team of UX/UI designers to make an elegant, intuitive design and a ton of research/testing.

Someone like me can’t even dream of making EMR 2.0. I don’t have the money,  skills, or connections to hire the people with the skills to create it. It’s also a ton of risk. I like my job as a radiologist which I spent many years of schooling to acquire the skills to do. It’s just not possible for me (and doctors like me) to throw that all away to try go create EMR 2.0 without any money, skills or connections.

A ton of research must also be done into WHY is the EMR making doctors so less efficient? Is is the UI/UX? Is it too slow? Does the presence of the EMR alone make doctors overdocument? How can we make a 20 click process into a 3 or 5 click process? Can we just get rid of that whole process completely? Will implementing touch screens help?

If you make every piece of your system incrementally better, in your 1,000,000 piece system, then your system is now way better than the competition.

Let’s back up for a second:

These are just my opinions on what I think needs to be fixed and… I may be completely wrong! 

The current big players are: Cerner, McKesson, Epic and Allscripts. Maybe they’re already doing what I outlined above. Maybe the big players in EMR don’t need to start over and can iterate their EMR 1.0s to evolve into 2.0. I don’t know. I hope so.

However, one thing is for sure, the EMR needs to evolve, not just iterate.

Whoever evolves first will win the $27 billion market. But they will need “in the trenches” doctors to do it.

TL;DR

Doctors spend almost 2 hours with EMR for every 1 hour with a patient.

They also work 1-2 more hours with EMR at home, after-hours.

Are we slaves to the EMR…? Which was supposed to free us?

EMR is not a one size fits all solution.

EMR 1.0 needs to evolve to EMR 2.0, not just iterate.

“In the trenches” doctors need to be at the forefront to make the evolution happen.

Talk is cheap. I can’t make EMR 2.0.

-Sensei

Agree? Disagree? Questions, Comments and Suggestions are welcome.

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