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June 07, 2010

"The Gap": A Physician's View of EMRs


Not long ago I had reason to consult a physician.

I found myself in his office answering his questions about my symptoms and history. He dutifully entered all of my responses into a laptop program that he pronounced the best EMR available. However, every time he asked me a question, he turned away from me to enter my responses verbatim into his keyboard using a slow hunt and peck.

As a patient, I found this disconcerting. It impaired the development of my trust in him as a skilled clinician (which fortunately, it turned out, he was). I realized that the EMR required the physician to be a data entry clerk, which he had neither the skills, nor speed to do efficiently. This problem affects not just physician users, but also nurses, aides, and clerical workers.

Simply put, the use of EMRs has the problem of a functional gap between acquisition of clinical data and its entry into an EMR. So I've labeled the remaining distance that EMRs have to go in order to overcome this deficiency as The Gap. What are the hows and whys of this Gap?

First of all, think of a medical record, once created, as a piece of static information that includes at a granular level, data about a single patient encounter. These static EMR components need to accomplish four main goals in order to be worthwhile for a clinician to invest his time and money in them.

They must:

  1. Form the basis upon which the physician is to be paid.
  2. Provide an accurate record of what did or did not happen with a particular patient in order to manage the physician's liability risk.
  3. Provide the basis for compliance with regulatory aspects of modern health care.
  4. Provide the actual medical clinical details of a patient's positive history, findings on exam and diagnostic work up, as well as progress in treatment.

Note that of all these goals, only the last has any real basis in the traditional physician's chart of care for a particular patient.

Most crucially of all, EMRs must be able to capture all this without interfering in the establishment and maintenance of a productive physician - patient relationship. Many of the current generation of EMRs accomplish the four goals listed above, but not one of them accomplishes these without a major impact on the doctor patient relationship and not one of them is able to do so without taking more time than traditional methods of documentation. Most health care workers have to work quickly and accurately in order to achieve effective, quality care.

Many different technologies have been thrown into the Gap. For example, Voice Recognition: it was originally thought that V/R could be a solution, and for certain specialties, for example diagnostic imaging, it is quite effective. But there are drawbacks to V/R that act as barriers to widespread usage: the recognition accuracy is significantly below 100 percent; the user needs to loop back for correction; and there is the bothersome interference of ambient sound.

Clinical situations with noisy environments and a large volume of patients with multiple problems (e.g., busy clinics and ERs) have led to the creation of template-driven records. Their principle benefit is that they provide the means for the physician to accomplish the basic four goals listed above, and they are fairly quick to learn and use. Yet these vary widely in ease of use, comprehensiveness, and readability, and there are still "Gaps." Though quicker than traditional methods, entering data into templates is still a slow process. And with healthcare reform changes in sight, and a declining supply of physicians compared to demand, this problem will only get worse.

One answer will be to develop more rapid and more complete patient data entry systems. These should incorporate patient information from disparate sources such as a patient's previous office visits, lab test results at a distant hospital, and wireless data such as blood pressure measurements.

The speed and ease of data entry should be compared to the benchmark of how quickly wait persons at restaurants accurately enter information using machine code driven touch screen entry terminals. It appears that video pen, Smart Phones and iPad applications may offer this level of speed and accuracy. Or, work around solutions can be implemented, such as scribes, who are people coupling a comprehensive understanding of clinical terms and proficient data entry skills.

Given the amount, type, and disparity of data a physician must acquire during the evaluation and treatment of a patient, there is currently much room for improvement in commercially available EMRs. However, in future discussions, we will enlarge on these themes and look in greater detail at available technologies.
 

Dr. Chase has over 30 years experience the healthcare field. He has clinical experience in emergency medicine and has been in senior level management positions of hospital-based physician medical groups. To read more of his articles, please visit his columnist page.

Edited by Michael Dinan
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