Why still some physcians are hesitaant to adopt the EMR and put it into meaningful use?

In the US still most of the doctors have not adopted the EMR and put them into meaningful use. Please discuss

I am a solo specialist. I have tw o proplems with EMR

1. Most EMR are done by software engineers who believes in 1+1=2. In medicine it is not the same. Template writing with clicks is so bad and waste of time. Software designers really believes that you can have one HPI for headache. It is difficult to take headache history with wording and same symptom order in two patients. The way symptom is described should give you a hint of the differential before you done with history. This idea appear to be very hard to convey to IT/software people. The order of symptom, description,details lead to the diagnosis 

most software on headaches: 

severity  so so so   aggravating factors so so so  location  so so so

you may as well get computer to make your diagnosis.

2. Most EMR needs extra personnel to do the other clicks which suppose to be done before I see a patient. It is so funny how software marketing people descibe your work flow with EMR  (front desk check in patient, nurse aid checks vitals and records them in chart, nurse takes social histoy, medications, etc. and documents then in chart, then you go to see your patient, then check out nurse finish the ordersand send ppatient to check out front desk). I do not know about you but I do not have 4 people including nurse and nurse aid working for me considering I am getting $50 per patient.

 

BI

 

Thanks for your reply. Do sent me any updates on EMR, EHR, medical transcription, Health care industry,  HIPAA to me

Regards

Kevin

Point and click does not need to be as bad as you describe.

First, an EMR should allow you to have many templates and some of those templates could be of your design.  That is, have several templates for headache ("Worst headache of my life" where you may be most interested in a SH, maybe another called "Recurrent migraine HA" for your more chronic migraine suffers, another simply called Headache designed as a more generalized template, another for cluster headaches, another for pseudotumor cerebri if you're a neuro-ophthalmologist with an interest in that, another for analgesic abuse, etc. 

More important than should an EMR allow point-and-click, is how well an EMR supports efficient use of point-and-click.  It is far faster to click than to speak into voice recognition software.  The greater problem is not point-and-click, but allowing it to be used efficiently.

For example, template design should allow a mix of pre-answered questions and unaswered questions.  For example, regarding the onset, you may very well want to document sudden versus gradual, but almost all the headaches you see are gradual in onset, so you include in your "general HA" template, a preclicked "gradual" but with 1 click, you can change it to "sudden".

Important in the design, is to have links from your template to more involved answers.  Perhaps as you document, you do discover that the onset was sudden, and severe. How does the pt describe the onset?  You have an editbox to type those words.  Let's face it, the pt is unlikely to say the classic "like a thunderclap", but perhaps said something like "I checked my head to see if I got shot because it struck that fast".  Fine type it, but you may wish to still click on other symptoms (nausea, vomiting, visual changes, confusion, even witnessed seizure activity, perhaps stiff neck, etc, etc.

I saw enough SH in the ER to know that there are still a checklist of signs and symptoms that you want to ask about and check.

A neat feature that we include is the ability to add, by typing, to the clicked response.  So regarding onset, you click "sudden", but then double click it, and the control takes the clicked text (in this case, something like "Onset described as sudden"), and places it in an editbox, and you simply type the rest of the sentence "Onset described as sudden and even like a gunshot to the head, or maybe a  like stone thrown by a lawnmower.  The patient checked his head".

Another important design consideration is called persistence.  In a point-and-click environment, there are usually controls with a number of choices.  In the headache case, you may wish to show as positives and negatives items such as associated visual symptoms including blurry vision, flashes of light, floaters, sensitivity to light, visual field defects, or visual loss.  Once some of these are documented, you may wish to return to that list and add something else.  You want that list to be as you left it, not in a complete sentence form, allowing you to simply click a new positive,  a new negative, or change a previous click.

Still another important design consideration is the ability to edit these "clinical items" on-the-fly.  You note that the visual symptoms list is lacking scotomata type symptoms.  You need a simple, such as right-click-to-edit ability to include that into this list easily.  Then it will be there forever after.

Another is the ability to add and delete items from your template as easily.  You never ask about family history of migraines, let's say, so you want it excluded from your migraine headache template.  Right click and remove it from the template.  That's how you decrease the noise of a template.

Finally, another feature is the ability to Save your documentation, including all the controls you utilized, as a pre-answered template for reuse.  A good example is when influenza hits in Dec and the patients all start sounding alike.  Document on one of these patients and save it as your personal Flu template for reuse.  With persistence, you can uncheck the nausea you checked on the original pt if the next patient denies that, but add dry cough that the first patient may not have had.  Preanswered templates dramatically increase efficiency while still allowing point-and-click choices.

As for requiring four extra personnel, I am not sure why some EMRs may require so many.  We have an octogenarian using our EMR for house visits.  He doesn't take a staff with him.  At $50 per patient, you need efficiency.

 

I actually agree with you, selecting a template takes less time than dictating a line. However , as you said to change any wording you will click and add/change some of the words and that takes a lot of time much more than dictating the whole HPI (takes about 2 minutes in Dragon, and sounds more intelligent). You have to factor the assistant entering some of the required information in EMR.  AT $20,000-25,000 per employee, the money you are getting from the goverment is not going to cover much. (by the way, I mentioned that to one of the marketing EMR people and the answer was you getting $44,000 which much higher. I had to explain that $20,000-25,000 is per year salary, I did not believe how they are focused on selling a product which does not make any business sense) 

So, my preference is a blank area for dictation (similar to AmazingCharts) with patient able to populate the first section of the chart (SH, FH, Meds, etc..), associated with billing software  and all in web browser (no hardware) with cost connected to Medicare payments (goes down if payment goes down). Otherwise the whole idea of EMR is bad business decision in long run.

BI

So template the social history, the family history, surgical history, meds list, problem list, and allergies.  And really, the physical exam should be templated-- I mean how many times do you want to say "regular, rate, and rhythm without murmurs, rubs or gallops" before you simply click to show that finding.  "Clear chest", "Soft, non-tender abdomen", etc, etc.  The exam should be templated.

The assessment should be templated too.  If you are using a sinusitis template, you do want the ICD9s or 10s listed for selecting, right?

And the plan (For the pt's GERD, our goal is to eliminate the heartburn......start an H2 blocker, avoid foods that aggravate the symptoms such as caffeine, chocolate, citrus fruits.....etc, etc.  Do you goals change that much.  Maybe add upper endoscopy, pH monitoring, etc for those resistant to therapy, but all available as clicks (or some pre-clicked because you almost always include them).

Pretty soon we're talking about a point-and-click EMR.  If you want an editbox (one capable of using voice recognition), just have that included in the history section of each template.  (For example, we have 1000 templates.  In about 30 seconds, you could include an editbox as the first item in the history section of every template....if that is what you want).

So now we're really talking about patient flow and more importantly, about the cost of EMRs.  And I agree with you-- they are too expensive.

 

 

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Hello Doctor, I can understand your difficulty in handling EMR. But I think your problem can be solved easily by using PracticeSuite software. It is simple, easy and user friendly to all Physicians. Also this software can be customized according to physician's use.

Hello Doctor, I can understand your difficulty in handling EMR. But I think your problem can be solved easily by using PracticeSuite software. It is simple, easy and user friendly to all Physicians. Also this software can be customized according to physician's use.