Growing EHR Pains

It has been 2 months since we implemented an electronic health record. I’ve made peace with it, but it is oh so far from perfect. Around the office, tempers are flared and people are grumpy. There are threats to quit by staff and doctors alike. Chaotic accurately describes what the first few weeks were like.

For a week, I had a greatly thinned schedule, but was pretty much back up to my usual 15-minute follow-up schedule by week 3. This meant, frankly, that if I did not want my patients to be waiting for hours beyond their appointment time, shortcuts had to be made. And 2 months in, the trend continues. I am definitely not able to dutifully fill out each and every blank that meaningful use requires me to fill out. There is just not enough time to document every follow-up patient’s family history and surgical history all over again. If you thought pointing-and-clicking were going to make life much easier for you, think again.

The issue is that the electronic record, rather than being a blank space, is essentially pages and pages of blanks to be filled out. So instead of freely typing as the patient jumps from, say, the history of their present illness to their family history to their systems review back to their present illness – because as we all know, our patients do not tell their stories in a nice linear fashion – I find myself having to interrupt the patient as I find the right blank on the right page.

Another sore point for me, and of course this issue predates the EHR, is that I don’t like having to reduce my patients to codes. I understand that codes are useful, but they can also be limiting and, frankly, idiotic. For example, Medicare in Rhode Island will no longer reimburse for zoledronic acid for patients coded as 733.00 (Osteoporosis NOS), but will cover if a patient is coded as 733.01 (postmenopausal/senile osteoporosis). I would like to know who came up with that rule and how they came up with it.

Codes also fall short of really capturing what a patient looks like. One lupus patient can look quite different from the next. Some of my patients are extremely sick and have complicated histories that have taken many months to piece together, and those four digits just do not capture that complexity and absolutely do not do justice to the patient. Patients do not fit neatly into boxes, so why must we be forced to make them fit?

It is not all bad. There are definitely a number of things that I appreciate about having an EHR.

I like being able to access patient records from home. It makes call a lot easier when you have the ability to look up a patient, know what meds they’re on, and document what you did for them over the weekend.

I like being able to hand the patient a document at the end of the visit outlining what we talked about. Although composing this definitely slows me down, it is helpful for some of the more forgetful patients in our panel who cannot be expected to remember their instructions for tapering their prednisone or that methotrexate is taken weekly, not daily.

I like that our system has a homunculus and will automatically calculate the Clinical Disease Activity Index for me and track down the patient’s progress. The system is too new for me to use this functionality, but I look forward to trying it out.

I like being able to electronically prescribe meds. The med list can get cluttered with old medications that the patient is not taking anymore (how often do patients change NSAIDs or go from gabapentin to cyclobenzaprine to amitriptyline?), and it can get quite confusing, but I’m sure in the long run it will make life much easier. When I fill out the blasted prior authorization forms, I will now be able to check on a single screen what generic drugs the patient has failed.

I must admit that the forthcoming Medicare penalty for not having an EHR was a big motivator for us to get on board. In the end, though, it shouldn’t be about avoiding penalties. It should be about providing better-quality care. And once most doctors are on board and Medicare has access to measurable data, I fervently hope that the data shows us that all of this pain was worth it.

Dr. Chan practices rheumatology in Pawtucket, R.I.

It has been 2 months since we implemented an electronic health record. I’ve made peace with it, but it is oh so far from perfect. Around the office, tempers are flared and people are grumpy. There are threats to quit by staff and doctors alike. Chaotic accurately describes what the first few weeks were like.

For a week, I had a greatly thinned schedule, but was pretty much back up to my usual 15-minute follow-up schedule by week 3. This meant, frankly, that if I did not want my patients to be waiting for hours beyond their appointment time, shortcuts had to be made. And 2 months in, the trend continues. I am definitely not able to dutifully fill out each and every blank that meaningful use requires me to fill out. There is just not enough time to document every follow-up patient’s family history and surgical history all over again. If you thought pointing-and-clicking were going to make life much easier for you, think again.

The issue is that the electronic record, rather than being a blank space, is essentially pages and pages of blanks to be filled out. So instead of freely typing as the patient jumps from, say, the history of their present illness to their family history to their systems review back to their present illness – because as we all know, our patients do not tell their stories in a nice linear fashion – I find myself having to interrupt the patient as I find the right blank on the right page.

Another sore point for me, and of course this issue predates the EHR, is that I don’t like having to reduce my patients to codes. I understand that codes are useful, but they can also be limiting and, frankly, idiotic. For example, Medicare in Rhode Island will no longer reimburse for zoledronic acid for patients coded as 733.00 (Osteoporosis NOS), but will cover if a patient is coded as 733.01 (postmenopausal/senile osteoporosis). I would like to know who came up with that rule and how they came up with it.

Codes also fall short of really capturing what a patient looks like. One lupus patient can look quite different from the next. Some of my patients are extremely sick and have complicated histories that have taken many months to piece together, and those four digits just do not capture that complexity and absolutely do not do justice to the patient. Patients do not fit neatly into boxes, so why must we be forced to make them fit?

It is not all bad. There are definitely a number of things that I appreciate about having an EHR.

I like being able to access patient records from home. It makes call a lot easier when you have the ability to look up a patient, know what meds they’re on, and document what you did for them over the weekend.

I like being able to hand the patient a document at the end of the visit outlining what we talked about. Although composing this definitely slows me down, it is helpful for some of the more forgetful patients in our panel who cannot be expected to remember their instructions for tapering their prednisone or that methotrexate is taken weekly, not daily.

I like that our system has a homunculus and will automatically calculate the Clinical Disease Activity Index for me and track down the patient’s progress. The system is too new for me to use this functionality, but I look forward to trying it out.

I like being able to electronically prescribe meds. The med list can get cluttered with old medications that the patient is not taking anymore (how often do patients change NSAIDs or go from gabapentin to cyclobenzaprine to amitriptyline?), and it can get quite confusing, but I’m sure in the long run it will make life much easier. When I fill out the blasted prior authorization forms, I will now be able to check on a single screen what generic drugs the patient has failed.

I must admit that the forthcoming Medicare penalty for not having an EHR was a big motivator for us to get on board. In the end, though, it shouldn’t be about avoiding penalties. It should be about providing better-quality care. And once most doctors are on board and Medicare has access to measurable data, I fervently hope that the data shows us that all of this pain was worth it.

Dr. Chan practices rheumatology in Pawtucket, R.I.

It has been 2 months since we implemented an electronic health record. I’ve made peace with it, but it is oh so far from perfect. Around the office, tempers are flared and people are grumpy. There are threats to quit by staff and doctors alike. Chaotic accurately describes what the first few weeks were like.

For a week, I had a greatly thinned schedule, but was pretty much back up to my usual 15-minute follow-up schedule by week 3. This meant, frankly, that if I did not want my patients to be waiting for hours beyond their appointment time, shortcuts had to be made. And 2 months in, the trend continues. I am definitely not able to dutifully fill out each and every blank that meaningful use requires me to fill out. There is just not enough time to document every follow-up patient’s family history and surgical history all over again. If you thought pointing-and-clicking were going to make life much easier for you, think again.

The issue is that the electronic record, rather than being a blank space, is essentially pages and pages of blanks to be filled out. So instead of freely typing as the patient jumps from, say, the history of their present illness to their family history to their systems review back to their present illness – because as we all know, our patients do not tell their stories in a nice linear fashion – I find myself having to interrupt the patient as I find the right blank on the right page.

Another sore point for me, and of course this issue predates the EHR, is that I don’t like having to reduce my patients to codes. I understand that codes are useful, but they can also be limiting and, frankly, idiotic. For example, Medicare in Rhode Island will no longer reimburse for zoledronic acid for patients coded as 733.00 (Osteoporosis NOS), but will cover if a patient is coded as 733.01 (postmenopausal/senile osteoporosis). I would like to know who came up with that rule and how they came up with it.

Codes also fall short of really capturing what a patient looks like. One lupus patient can look quite different from the next. Some of my patients are extremely sick and have complicated histories that have taken many months to piece together, and those four digits just do not capture that complexity and absolutely do not do justice to the patient. Patients do not fit neatly into boxes, so why must we be forced to make them fit?

It is not all bad. There are definitely a number of things that I appreciate about having an EHR.

I like being able to access patient records from home. It makes call a lot easier when you have the ability to look up a patient, know what meds they’re on, and document what you did for them over the weekend.

I like being able to hand the patient a document at the end of the visit outlining what we talked about. Although composing this definitely slows me down, it is helpful for some of the more forgetful patients in our panel who cannot be expected to remember their instructions for tapering their prednisone or that methotrexate is taken weekly, not daily.

I like that our system has a homunculus and will automatically calculate the Clinical Disease Activity Index for me and track down the patient’s progress. The system is too new for me to use this functionality, but I look forward to trying it out.

I like being able to electronically prescribe meds. The med list can get cluttered with old medications that the patient is not taking anymore (how often do patients change NSAIDs or go from gabapentin to cyclobenzaprine to amitriptyline?), and it can get quite confusing, but I’m sure in the long run it will make life much easier. When I fill out the blasted prior authorization forms, I will now be able to check on a single screen what generic drugs the patient has failed.

I must admit that the forthcoming Medicare penalty for not having an EHR was a big motivator for us to get on board. In the end, though, it shouldn’t be about avoiding penalties. It should be about providing better-quality care. And once most doctors are on board and Medicare has access to measurable data, I fervently hope that the data shows us that all of this pain was worth it.

Dr. Chan practices rheumatology in Pawtucket, R.I.