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EHRs: A Love/Hate Relationship


By Gus Geraci, MD

Note: This post originally appeared in Pennsylvania Physician magazine and is reprinted with permission.

The thought of a method for logging medical records in a way that makes sense and is easy to do drove me to seek an electronic health record (EHR) system when I started my solo practice many years ago, long before Meaningful Use (MU) or Physician Quality Reporting Service (PQRS).

I had gotten tired of hearing recommendations for good recordkeeping and documentation. Delivering better patient care meant updating medication lists, making note of acute and chronic problems, and maintaining health maintenance charts.

You had to document everything in your note, then duplicate it in other places. The more problems patients had, the harder it was to record information in all the right places. And every time recommendations changed, the doctor had to remember them for every patient with that problem – never mind the numerous guidelines, calculators, and other options depending on the complaint.

At the time, I knew that the new personal computers would offer a way to manage information better. Additionally, since I was starting a practice in the middle of my career and had spent many hours evaluating others’ charting, I knew I wanted something that would be readable a year later, even if it was recorded on my worst, busiest day.

I already had templates for repetitive visits, creating convenient “stamps” for URIs, UTIs, back pain, diabetes, physicals, and other common situations. The stamps could be plopped onto a page with the right checkboxes already checked, saving a few minutes on those visits.

I spent months evaluating different companies. I got laughed at by a few:

“What? You’re solo and you want electronic records? Good luck!”

I sat through some interesting demos:

“Doctor, this makes documentation so easy. We have branching logic – all you need to do is ask the questions.”

“But what if the patient says, ‘No, I changed my mind?’ ” I asked.

“They can’t do that!” was the response.

Finally, I found a system a primary care physician had created for himself. He had built a program, and hired software folks to continue to develop it. It respected my workflows and duplicated correct entries from my notes.

It included dictation, typed and point-and-click entry, retraceable branching logic, templates, and guidance that disappeared when the note was saved. It included reminders, “ticklers,” messaging, and later, even e-mail.

My office hummed. When I left a room without a chart, not only was my note done, but any messages that came in while I was seeing that patient were done and/or delegated for action in the ensuing minute or two.

My de-identified data was downloaded periodically and analyzed by a research network. I was graded on the care of diabetes and other chronic diseases, with suggestions on how to improve.

There was a learning curve, I found out as I acquired partners, but the system always made things better. Efficiency, better documentation, and quality were worth the price.

I hadn’t even conceived of the idea of sharing records with other physicians, or using my system to communicate with other systems to get old records and data on other encounters. EHRs can do these things now.

So why are so many physicians so unhappy with them?

Workflows. The same people who devised branching logic were charged with making systems compliant with Meaningful Use (MU), taking systems that were workflow-unfriendly to begin with, and adding new requirements.

Legacy systems designed only to facilitate billing were now asked to perform new functions. Bad systems got worse, and good systems were asked to do things they weren’t designed to do.

Legacy products created workarounds, and new workflows were unlike the realities of a real physicians’ day. Simultaneously, decisions made on those EHRs were based on the promise of extra MU money or PQRS, not on respect for the now-employed physicians, whose recommendations were judged naive, disrespected, or ignored.

The solution?

Work together. Offer your feedback. Figure out ways to overcome the barriers – use scribes, get help, get training. Complain – don’t just gripe, but make suggestions on how the system can be improved. Demonstrate why you can’t finish a note in the room, and don’t work for a company that doesn’t listen to you.

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