The Number One reason to hate EMR is that it slows down doctors.
The ‘it’ that is being referred to is what happens in the exam room with a patient; the clinical encounter. Doctors are no longer scribbling on paper, they are using computers, and they have to collect data, click on templates. Worse, they have to type or somehow enter their findings, assessments and plan into the computer.
For some doctors, it is a piece of cake, others hate it with a passion.
EMR has gotten a bad name because of this – SMD (Slow Me Down) Factor I had written earlier about.
Even if all other elements of the Practice Software help improve the office productivity significantly – front-office to back-office workflow, productivity, better collections, efficiency etc. don’t matter if the doctor is afflicted with SMD Factor.
Do Not Despair – there are choices and options.
There are 6 choices. You will pick the most appropriate choice for you depending on following factors:
- Technology comfort, savviness, and ability to use computers.
- Number of Patients seen (or you would like to see) per day.
- Relative importance and value of time vs. money.
1. Templates and Keyboard. Standard, out of the box, nothing to add. No additional cost if the system had the templates you need.
- Assumption: You can type reasonably well, you can manipulate templates and click fast enough to keep pace with your patient volume.
- Cost: No additional cost.
2. Templates and Dictation software like Nuance Dragon. The difference compared to the first option is that you can use the templates reasonably well, but you are not a good typist and you need to enter your findings, plan and HPI in detail. The use of Dictation software allows you to ‘cut the keyboard’. I recommend this option if you are not a good typist.
- Assumption: You are willing to work with Dragon software for voice recognition. This technology has come a long way. If you tried it few years ago and found that it did not work well with your accent, try again. A lot has changed, you may be surprised.
- Cost: One time charge that is approximately $2000 for Dragon Dictation software.
3. Digital Pen and Dictation software. Option 2 was good if you were good with computers and templates in general but not a good typist. If you are generally computer averse and don’t even like clicking on templates, this is a good option for you.
Digital Pen is a wonderful advance piece of technology that allows you to use normal paper. When printed with custom paper templates, it takes your markings on paper and maps them to your computer templates as if you are clicking on-screen. The best part is, if well designed they can convert paper to discrete data.
- Assumption: As with earlier option, you must be willing to use Dragon software for dictation.
- Cost: Cost of preparing custom forms for Digital pen can vary from $1000 – $2000 per form depending on the complexity of the form. So, if you need 5 custom templates, it can cost up to $10,000. This is generally a one-time fee. The cost of the pen can be up to $500 and perhaps a $60-$70 monthly fee.
If you add total upfront costs, when amortized over 3 years, it will be less than $350 per month, but it gives you tremendous peace of mind and productivity gain for yourself.
4. Transcription. Most Doctors are aware of this option and have probably considered this at one time or the other. This option is perhaps the simplest one, but there is now a new twist. The transcriptionist needs to listen to the dictation and not only type a narrative, but also to work the EMR to select options in the templates for discrete data – physical exam, assessment etc. In addition, when the provider uses a paper superbill that must be sent to the transcriber to enter in EMR – this expands the role of the traditional transcriptionist.
- Assumption: Expansion of transcriptionist responsibility to be able to work and use EMR.
- Cost: Can vary, but consider $10-$15 per hour.
5. Scribe: The concept of having a scribe do all the work on EMR has been in the news quite a bit and is being widely discussed. There is no doubt that it can completely eliminate the SMD Factor. You must be comfortable with a scribe being present during the encounter with a patient. This is generally not a good practice for certain specialties like Psychiatry, but for others like Pediatrics, Family Practice or Internal Medicine it may be generally acceptable.
Scribe as an option has two variations: A Remote scribe that can be out of clinic somewhere else or an in-clinic scribe.
- Assumptions: Willingness on part of the provider and patient to accept presence of a scribe during the encounter.
- Cost: Remote scribes can cost an average of $15-$18 per hour, whereas in-clinic Scribes (Medial Assistants) can cost anywhere from $25-$30 per hour.
6. Combination: Sometimes a Combination of various options mentioned here can also work.
You need to analyze each option’s Return on Investment, your desired goals, comfort levels and pick the one that makes most sense. You should seek an expert’s help to help you analyze your objectives and choose what works for you. There is no single best method when it comes to how you interact with EMR.
2 thoughts on “The Number One Reason to Hate EMR is…”
Excellent article describing SMD and remedy too! Whatever you try to convince but there are doctors who just do not like to use computers and EMR. They are doing because it is mandatory by law and probably this ‘compulsion’ irritates them like any thing. As a doctor, practicing in India, I would say, Indian doctors are not forced to use this and that is the reason they are not using it! The most important thing is HL7 standards, unfortunately very few system addresses it. If that is done, doctors will have more choices for their EMR software and no worries for data inter operability.
Dr. Amit P. Shah, Ahmedabad, India (Medical Informatics Specialist)
Most certified EMR systems in USA are compliant with "HL7". However as you probably know, HL7 is a very broad set of standards. Those elements of HL7 pertaining to Lab results are being used quite well but not the clinical data elements that can make EMR systems truly inter-operable. ASTM combined efforts with HL7 to construct the CCD. A CCD document isn’t intended to be a complete medical history for a patient. It is intended to include only the information critical to effectively continue care between various providers. By itself, this can work for inter operability between care givers.
Implementation of CCD within EMR systems that are certified would make them partly inter operable.