ELI5: Why did doctors accept meaningful use, EMRs?

[Mr Roboto]

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Every doctor I know complains about these things, regularly. Especially senior physicians who remember the ease of using paper charts. Kevinmd has a new blog up each week about how soul sucking it is to spend more time clicking boxes on an EMR than helping patients. Even patients hate the EMRs--I get comments all the time about how "nowadays doctors spend the whole appointment staring at a screen instead of talking to us." I've also never heard anyone (except healthcare administrators, for obvious reasons) say they liked EMRs.

What I don't understand is how we arrived at this point. Why did physicians allow these to become mandated? Why isn't there more pushback against them? If they were resigned to using an EMR, why not create ones that are more user friendly?

Or am I way off base here, and a lot of people secretly love them?

Sorry if this has been covered before, I searched but didn't find an answer.

 

[22031 Alum]

Short answer: Physicians as a whole are terrible at advocating for their own interests in any organized fashion.

 

[deleted245139]

agree^ ... Finances, self advocacy, etc... We learn a lot in medical school and through our entire academic career, but much of our education comes later, and sometimes too late. As an aside, anyone ever actively lobby at a state or federal level? Man... Uncomfortable. I went to Albany for a day, and you're INUNDATED with questions about your allegiances. The lunch room is a snake pit. I don't blame people who don't like it or do it and I'm glad for those that do.... Takes a thick skin and a lot of subversion lol

 

[22031 Alum]

agree^ ... Finances, self advocacy, etc... We learn a lot in medical school and through our entire academic career, but much of our education comes later, and sometimes too late. As an aside, anyone ever actively lobby at a state or federal level? Man... Uncomfortable. I went to Albany for a day, and you're INUNDATED with questions about your allegiances. The lunch room is a snake pit. I don't blame people who don't like it or do it and I'm glad for those that do.... Takes a thick skin and a lot of subversion lol

I have been to my state capitol on a few occasions and you're right, it's not fun. Nothing like being spoken to like a slow child, about your own area of expertise.

 

[Ho0v-man]

As someone who works in a hospital, I like EMRs. They're annoying to use, but they make the doc/provider actually put the order into the system. With paper charting, there's lots of situations where routine orders that were written at lunch become stat at 3am the next day because it was missed. Stuff doesn't fall through the cracks as often with the EMR.

What sucks is that hospital administrators always pick whatever system they can get for the lowest price. And the same goes for the internet provider.


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[gmbz]

EMR's were designed for one thing. Billing.

As for how we got here, @22031 Alum hit the nail on the head.

However I have a suspicion that physicians will only put up with this for so long. Eventually enough people will get together and say no.

Isn't MU dead via Andy Slavitt's words? =)

 

[akwho]

The problem isn't EMR itself. It's that we let the business people develop the system for billing first, and patient care and provider utility were added on as distant afterthoughts. We need to rehaul EMR so patient care is number 1 and "meaningful use" is tossed in the garbage where it belongs.

 

[22031 Alum]

The problem isn't EMR itself. It's that we let the business people develop the system for billing first, and patient care and provider utility were added on as distant afterthoughts. We need to rehaul EMR so patient care is number 1 and "meaningful use" is tossed in the garbage where it belongs.

Right. I actually don't have a beef with EMRs. Vandy had a good one when I was there- designed by a physician if I recall correctly. So EMRs are what I "grew up on." But I have seen some frightfully poorly-designed systems, and when you combine that with older docs who 1) do remember paper charts and 2) aren't the most computer literate, you get a disaster. The poor IT lady gets complaints daily about our system's interface, from people who don't get that she has nothing to do with designing it.

 

[mimelim]

Every doctor I know complains about these things, regularly. Especially senior physicians who remember the ease of using paper charts. Kevinmd has a new blog up each week about how soul sucking it is to spend more time clicking boxes on an EMR than helping patients. Even patients hate the EMRs--I get comments all the time about how "nowadays doctors spend the whole appointment staring at a screen instead of talking to us." I've also never heard anyone (except healthcare administrators, for obvious reasons) say they liked EMRs.

What I don't understand is how we arrived at this point. Why did physicians allow these to become mandated? Why isn't there more pushback against them? If they were resigned to using an EMR, why not create ones that are more user friendly?

Or am I way off base here, and a lot of people secretly love them?

Sorry if this has been covered before, I searched but didn't find an answer.

I am in a large hospital system (7+ hospitals, 50k+ employees) and we have switched/are switching to Epic from a hybrid paper chart/other EMR. You will not find a single physician under the age of 35 who is not a 100% advocate of switching over. I have been working for Epic the last several months to help teach their physician classes. (They offered to pay several of the residents the equivalent of moonlighting money to help with the classes and since I'm on research, it is easy money). I have worked with probably ~200 physicians ranging from interns up to 80 year old, still practicing surgeons and heard every comment possible. I also do work and research in informatics, so obviously I come from a slightly different angle, but frankly, EMRs are a necessary step forward. Now, an easy argument can be made that many of them are poorly rolled out and have major issues. But, those are technical things that should be fixed. The problem that people forget is that what is being replaced was far from perfect as well.

Physicians are people. They feel entitled (like everyone). They worked long and hard through a decade of training in order to take care of people. They expect to show up, do what they want to do and then leave. Many older physicians were able to setup their practices in this fashion. As one senior surgeon said maybe 6 times during his class, "Why would I learn this module? I pay people to do all of this." It is a fair point, after all, he is a fantastic surgeon with a fantastic system and gets fantastic outcomes. But, when trying to administer healthcare on the scale of an entire hospital system or state or country, it just doesn't work. In this day and age, it is unacceptable to not be able to read someone's hand written note and need to call them to find out what they said, only to find out that they aren't 'on' anymore, so you need to talk to their partner, who doesn't know what they wrote, who then needs to call them directly to get the story etc etc.

We paid north of half a billion dollars for Epic. It still amazes me at some of it's limitations and its seemingly boneheaded interface. Trying to make any changes in it is like pulling teeth. But, to blanket say that EMRs aren't beneficial going forward is a bit silly. It is a little like saying that we shouldn't have smart phones because flip phones can make a call faster.

 

[mimelim]

Right. I actually don't have a beef with EMRs. Vandy had a good one when I was there- designed by a physician if I recall correctly. So EMRs are what I "grew up on." But I have seen some frightfully poorly-designed systems, and when you combine that with older docs who 1) do remember paper charts and 2) aren't the most computer literate, you get a disaster. The poor IT lady gets complaints daily about our system's interface, from people who don't get that she has nothing to do with designing it.

In the first class that I supported, there was a surgeon who literally needed to be taught how to double click. It was a lesson that needed to be repeated at least 3 times during the class. Obviously, EMRs are going to be incredibly frustrating to some and for others may simply be impossible to use effectively.

 

[AvrgPreMedKid]

Short answer: Physicians as a whole are terrible at advocating for their own interests in any organized fashion.

Aren't there laws in place so that physicians cannot band together and form a union or something along those lines?

 

[22031 Alum]

Aren't there laws in place so that physicians cannot band together and form a union or something along those lines?

There is a gap of miles between unionizing, and being active participants in policy and decision-making.

 

[AvrgPreMedKid]

There is a gap of miles between unionizing, and being active participants in policy and decision-making.

I'm sure there is. Was just wondering about the law. The physicians I work with are very much like, "That's the way it is," as if they cannot change anything. Would definitely be cool to be a part of a future generation of physicians who put the insurance companies in their place.

 

[Cytarabine]

Right. I actually don't have a beef with EMRs. Vandy had a good one when I was there- designed by a physician if I recall correctly. So EMRs are what I "grew up on." But I have seen some frightfully poorly-designed systems, and when you combine that with older docs who 1) do remember paper charts and 2) aren't the most computer literate, you get a disaster. The poor IT lady gets complaints daily about our system's interface, from people who don't get that she has nothing to do with designing it.

They're switching to epic =o

 

[ForHumors]

I spent a summer helping physicians with Cerner, but I'm just an M1 so take what I say with a grain of salt/assume I'm a *******.

Potential pros for using EMRs are that it makes it much easier to share information than when using patient charts. So it's easier to check medical history and clinical researchers can potentially extract information from massive amounts of patients much more quickly. There does seem to be some promise in double checking potential mistakes, such as ordering the wrong dose or ordering drugs with interactions/contraindications. Note that this has to be implemented intelligently or else we just click through and do not pay attention to warning messages.

One really cool potential application would be to create a system where different EMRs can communicate with each other, allowing info on a patient stored in one EMR system to be sent to a different EMR (Known as interoperability). This would allow physicians to store a detailed EMR on a single patient from all of their past and current providers. While this could result in an overload of information for a single patient, it would allow for a potentially detailed record on a patient encompassing all of their medical history. Could do things like check scans or labs from a couple years ago taken at a different hospital to check progression. Also, there would be benefits like seeing all medications a patient's been ordered (applicable to when a patient can't remember OR if there's someone going to every doc they know asking for vicodin).

However, there's no way this is going to happen because there's no incentive for EMRs to do this. Having communication between systems reduces incentive hospital systems to commit to one EMR. Plus it would be a giant, huge, difficult pain in the ass to code and coordinate between the various EMR companies. So it would likely require federal regulation.

My understanding of the scenario. Anyone who is more experienced, please let me know if I'm wrong about any of this.

 

[mimelim]

I spent a summer helping physicians with Cerner, but I'm just an M1 so take what I say with a grain of salt/assume I'm a *******.

Potential pros for using EMRs are that it makes it much easier to share information than when using patient charts. So it's easier to check medical history and clinical researchers can potentially extract information from massive amounts of patients much more quickly. There does seem to be some promise in double checking potential mistakes, such as ordering the wrong dose or ordering drugs with interactions/contraindications. Note that this has to be implemented intelligently or else we just click through and do not pay attention to warning messages.

One really cool potential application would be to create a system where different EMRs can communicate with each other, allowing info on a patient stored in one EMR system to be sent to a different EMR (Known as interoperability). This would allow physicians to store a detailed EMR on a single patient from all of their past and current providers. While this could result in an overload of information for a single patient, it would allow for a potentially detailed record on a patient encompassing all of their medical history. Could do things like check scans or labs from a couple years ago taken at a different hospital to check progression. Also, there would be benefits like seeing all medications a patient's been ordered (applicable to when a patient can't remember OR if there's someone going to every doc they know asking for vicodin).

However, there's no way this is going to happen because there's no incentive for EMRs to do this. Having communication between systems reduces incentive hospital systems to commit to one EMR. Plus it would be a giant, huge, difficult pain in the ass to code and coordinate between the various EMR companies. So it would likely require federal regulation.

My understanding of the scenario. Anyone who is more experienced, please let me know if I'm wrong about any of this.

Epic already has the capability to share patient files with other institutions electronically. Trivially easy to do between hospitals that both have Epic. They also claim to be able to send the file to other systems, but most other systems aren't capable of accepting them.

 

[Zywie]

I am in a large hospital system (7+ hospitals, 50k+ employees) and we have switched/are switching to Epic from a hybrid paper chart/other EMR. You will not find a single physician under the age of 35 who is not a 100% advocate of switching over. I have been working for Epic the last several months to help teach their physician classes. (They offered to pay several of the residents the equivalent of moonlighting money to help with the classes and since I'm on research, it is easy money). I have worked with probably ~200 physicians ranging from interns up to 80 year old, still practicing surgeons and heard every comment possible. I also do work and research in informatics, so obviously I come from a slightly different angle, but frankly, EMRs are a necessary step forward. Now, an easy argument can be made that many of them are poorly rolled out and have major issues. But, those are technical things that should be fixed. The problem that people forget is that what is being replaced was far from perfect as well.

Physicians are people. They feel entitled (like everyone). They worked long and hard through a decade of training in order to take care of people. They expect to show up, do what they want to do and then leave. Many older physicians were able to setup their practices in this fashion. As one senior surgeon said maybe 6 times during his class, "Why would I learn this module? I pay people to do all of this." It is a fair point, after all, he is a fantastic surgeon with a fantastic system and gets fantastic outcomes. But, when trying to administer healthcare on the scale of an entire hospital system or state or country, it just doesn't work. In this day and age, it is unacceptable to not be able to read someone's hand written note and need to call them to find out what they said, only to find out that they aren't 'on' anymore, so you need to talk to their partner, who doesn't know what they wrote, who then needs to call them directly to get the story etc etc.

We paid north of half a billion dollars for Epic. It still amazes me at some of it's limitations and its seemingly boneheaded interface. Trying to make any changes in it is like pulling teeth. But, to blanket say that EMRs aren't beneficial going forward is a bit silly. It is a little like saying that we shouldn't have smart phones because flip phones can make a call faster.

Well said. Before I start school I did some clinical informatics consulting for one of the biggest health systems in my state (Nearly 10k providers). We were rolling out an ePrescribe software, and eventually will move to a full blown EMR, to all of the hospitals, ambulatory care centers, etc. While we got a lot of push back in the beginning, especially from old timers whose only computer in the whole office was running windows 98 at the registration desk, in the long run it is going to be extremely beneficial. Moving towards everything electronic is going to allow for more data and more optimal treatment for patients. Some states are leveraging the electronic prescriptions and creating a database so all of a patients physician can access their history. Allowing physicians to monitor for prescription abuse, see what is being prescribed by other Docs which helps minimizes record errors. The age of EMRs and Clinical Informatics is still in its infancy and it's biggest downsides, which is the work flow and ease of use for the end user, are all things that will work itself out as we progress. Imagine a world where all of your patients notes and records are stored on a cloud that you can access with a PIN, and not have to rely on a fax machine or another office sending it over to you.

 

[ForHumors]

Epic already has the capability to share patient files with other institutions electronically. Trivially easy to do between hospitals that both have Epic. They also claim to be able to send the file to other systems, but most other systems aren't capable of accepting them.

Glad to hear they're making efforts towards communication between systems at least. How helpful do you think it would be clinically?

 

[22031 Alum]

They're switching to epic =o

I like Epic. Used it in residency and would sacrifice an ovary to have it replace the system at my current job. I remember thinking Star Panel was fine, but that was using it as a student. Who knows what I would think of it now.

 

[Psai]

Because the government makes the law, not physicians. They see numbers and making numbers look good is their job description

Emrs are terrible because they don't talk to each other and they are full of crap. It's too easy to fill up a note with useless garbage that no one reads. Or having crap like bipap settings be classified as physician notes. They are just completely disorganized and cumbersome

 

[mimelim]

Glad to hear they're making efforts towards communication between systems at least. How helpful do you think it would be clinically?

It will be useful/helpful because when I need medical records from the hospital across the street from me, I just need to put in a request in my EMR and someone on the otherside just needs to click a button and it immediately transfers exactly what I asked for. No need to fax a form, wait for someone to check their faxes, then get 170 pages of nursing notes via fax that I need to sift through. It will make a process that is time consuming and painful, 50% more bearable.

Because the government makes the law, not physicians. They see numbers and making numbers look good is their job description

Emrs are terrible because they don't talk to each other and they are full of crap. It's too easy to fill up a note with useless garbage that no one reads. Or having crap like bipap settings be classified as physician notes. They are just completely disorganized and cumbersome

The reason they are full of crap is because physicians (like all people) are lazy. Notes are what you put in. If you put in trash, you get trash out. People like to complain about the overabundance of crap in EMR notes, but if you look at the alternative, it is no better and often worse. For starters, paper charts are illegible. Second, the content is often abbreviated and incomplete. Third, they are located in only one location and unless you go to that patient's nurse's station, you can't read them at all. This is not the government's fault. This isn't the hospital's fault. This is the physicians' fault. Why? Because we don't teach our people how to document. How many H&Ps do we coach people on? SOAP notes? How many lessons in how to communicate through written form do you get in your training? How many residents get yelled at for having too much crap in their notes? None. The notes are crap because the people using it are copying and pasting their notes from the day before or someone else's notes without putting time/effort into it. If you don't want your notes to be crap, don't make crappy notes.

An argument can be made against the utility of documentation. A silly one, but one can be made. But, once that is settled, I don't think that you can argue that anything besides an EMR is appropriate. In experienced hands, it can be made efficient and far more functional than anything else. It doesn't take long to create a workflow that creates very usable and useful notes/other documentation. But, it takes investment of time and energy to establish, something that physicians on a whole expect to not have to give except "to take care of patients". For example, we had to build the order sets for our half a billion dollar EMR for all the physicians. We asked the 150+ ophthalmologists with privileges at our hospitals to sit down with us or webex with us on the order sets (that were copy/pasted from the old EMR). You know how many responded or helped? Zero. Not a single even replied. Every single one was "too busy" over a 2 month period to spare an hour or two. Guess what happens when they show up to training? When we log into the production software and they look at their order sets, with out exception they are upset that the order set is crap. Is anyone surprised?

EMRs are tools. Some of them are pieces of ****. On the other hand, some are actually pretty smart/well designed. Far from perfect and clearly not originally designed by a physician. But, they need more than to be simply purchased. They need to be customized and adapted to specific group's workflows. That takes time and energy investment that few physicians are actually willing to do. They would rather bitch about how the government, insurance companies and hospitals are screwing them and how much better things were in the good old days.

 

[Stagg737]

I am in a large hospital system (7+ hospitals, 50k+ employees) and we have switched/are switching to Epic from a hybrid paper chart/other EMR. You will not find a single physician under the age of 35 who is not a 100% advocate of switching over. I have been working for Epic the last several months to help teach their physician classes. (They offered to pay several of the residents the equivalent of moonlighting money to help with the classes and since I'm on research, it is easy money). I have worked with probably ~200 physicians ranging from interns up to 80 year old, still practicing surgeons and heard every comment possible. I also do work and research in informatics, so obviously I come from a slightly different angle, but frankly, EMRs are a necessary step forward. Now, an easy argument can be made that many of them are poorly rolled out and have major issues. But, those are technical things that should be fixed. The problem that people forget is that what is being replaced was far from perfect as well.

Physicians are people. They feel entitled (like everyone). They worked long and hard through a decade of training in order to take care of people. They expect to show up, do what they want to do and then leave. Many older physicians were able to setup their practices in this fashion. As one senior surgeon said maybe 6 times during his class, "Why would I learn this module? I pay people to do all of this." It is a fair point, after all, he is a fantastic surgeon with a fantastic system and gets fantastic outcomes. But, when trying to administer healthcare on the scale of an entire hospital system or state or country, it just doesn't work. In this day and age, it is unacceptable to not be able to read someone's hand written note and need to call them to find out what they said, only to find out that they aren't 'on' anymore, so you need to talk to their partner, who doesn't know what they wrote, who then needs to call them directly to get the story etc etc.

We paid north of half a billion dollars for Epic. It still amazes me at some of it's limitations and its seemingly boneheaded interface. Trying to make any changes in it is like pulling teeth. But, to blanket say that EMRs aren't beneficial going forward is a bit silly. It is a little like saying that we shouldn't have smart phones because flip phones can make a call faster.

I think an issue that a lot of people are forgetting is the constant updates and changes made to many EMR systems. I had a professor that used to work for Cerner and his biggest complaint from every area of staff was that as soon everyone got used to one interface and setup, an update would come out and people would have to relearn the new interface, where random check boxes were located, how to submit orders and test results, etc. Same goes for a classmate that was a manager for epics admins before starting med school. Fixing problems and expanding on the limitations can absolutely be beneficial, but it kills efficiency and probably increases errors when the entire staff has to get used to new, often drastic, updates every 2 months.

 

[Pacna]

Why did physicians allow these to become mandated?

Why isn't there more pushback against them?

If they were resigned to using an EMR, why not create ones that are more user friendly?

Or am I way off base here, and a lot of people secretly love them?

These more are nuanced than implied by your question.

Regarding making them mandatory: This is probably the most valid question. They're certainly superior in just about every way to paper charts, but mandatory implementation is a challenge for me as well. I see no reason to penalize some small practice in the boonies for using paper charts. People just like mandates these days.

Why isn't there more resistance? If balk was a liquid, it would be oozing out of every hospital in the US. There's plenty of resistance.

From a technical standpoint (speaking as a supernerd here), EMRs have the software equivalent of PDAs. Vaguely modern, but woefully behind current capabilities. Nobody's wondering if EMRs are going to support DirectX 12. 😛 There are a number of reasons for this, but I think the #1 driver is intellectual property (IP) as a concept. Above, someone reported that their hospital paid $500 million+ for an EMR. That's for an archaic platform compared to consumer software! How could it cost so much?

I'll give a quick example of what I mean by archaic: Service-wide resets to "update" is a relic. Notice that none of the other software you use does that? When Windows updates, does everyone have to wait simultaneously for a few hours? Certainly each client may have to restart, but they can do it at their convenience. That's just 1 example of the sort of innovation that has happened in the tech industry in the last 10 years, and EMRs have not adapted.​

As EMRs exist, they are unacceptable at a cost/benefit level compared to what they could do. Once the next generation of docs phases out the ones who are learning to send emails, we'll see pressure be put on the industry to modernize, and a small number of coders will be unable to continue meeting the demand. Until then, IP is the main factor restricting our ability to seek cheaper alternatives.

 

[WingedOx]

Seeing a not yet in med school poster actually asking why we use electronic charts instead of paper is a great point about why potential students need to take what they hear from older physicians with a grain of salt large enough to fill Lake Superior with enough sodium to make it unsafe to drink.

...though it is amusing that programs like Cerner require just as steep a learning curve as old dinosaurs like CPRS.

 

[Cytarabine]

I like Epic. Used it in residency and would sacrifice an ovary to have it replace the system at my current job. I remember thinking Star Panel was fine, but that was using it as a student. Who knows what I would think of it now.

I think I've used all the big EMRs at this point. I think epics the best if you're willing to put time in to customize it/ template it out and learn it well. Cerner's easier to jump into and be reasonably adept at. Starpanel somewhere between the two but the UI is awful imo. I like epic too. Just surprised they're switching. Seemed like they had a lot of pride in starpanel

 

[WingedOx]

I think I've used all the big EMRs at this point. I think epics the best if you're willing to put time in to customize it/ template it out and learn it well. Cerner's easier to jump into and be reasonably adept at. Starpanel somewhere between the two but the UI is awful imo. I like epic too. Just surprised they're switching. Seemed like they had a lot of pride in starpanel

As a student (or resident in the type of crappy program that doesn't teach you how to bill), Cerner is actually nice to use. The problem is once I have to bill with it, everything goes to hell. The interface is insanely clunky, you have to navigate through way too many windows and menus, and if your hospitals servers are having a slow day, clicking the various boxes takes way way too long.

 

[Cytarabine]

It will be useful/helpful because when I need medical records from the hospital across the street from me, I just need to put in a request in my EMR and someone on the otherside just needs to click a button and it immediately transfers exactly what I asked for. No need to fax a form, wait for someone to check their faxes, then get 170 pages of nursing notes via fax that I need to sift through. It will make a process that is time consuming and painful, 50% more bearable.



The reason they are full of crap is because physicians (like all people) are lazy. Notes are what you put in. If you put in trash, you get trash out. People like to complain about the overabundance of crap in EMR notes, but if you look at the alternative, it is no better and often worse. For starters, paper charts are illegible. Second, the content is often abbreviated and incomplete. Third, they are located in only one location and unless you go to that patient's nurse's station, you can't read them at all. This is not the government's fault. This isn't the hospital's fault. This is the physicians' fault. Why? Because we don't teach our people how to document. How many H&Ps do we coach people on? SOAP notes? How many lessons in how to communicate through written form do you get in your training? How many residents get yelled at for having too much crap in their notes? None. The notes are crap because the people using it are copying and pasting their notes from the day before or someone else's notes without putting time/effort into it. If you don't want your notes to be crap, don't make crappy notes.

An argument can be made against the utility of documentation. A silly one, but one can be made. But, once that is settled, I don't think that you can argue that anything besides an EMR is appropriate. In experienced hands, it can be made efficient and far more functional than anything else. It doesn't take long to create a workflow that creates very usable and useful notes/other documentation. But, it takes investment of time and energy to establish, something that physicians on a whole expect to not have to give except "to take care of patients". For example, we had to build the order sets for our half a billion dollar EMR for all the physicians. We asked the 150+ ophthalmologists with privileges at our hospitals to sit down with us or webex with us on the order sets (that were copy/pasted from the old EMR). You know how many responded or helped? Zero. Not a single even replied. Every single one was "too busy" over a 2 month period to spare an hour or two. Guess what happens when they show up to training? When we log into the production software and they look at their order sets, with out exception they are upset that the order set is crap. Is anyone surprised?

EMRs are tools. Some of them are pieces of ****. On the other hand, some are actually pretty smart/well designed. Far from perfect and clearly not originally designed by a physician. But, they need more than to be simply purchased. They need to be customized and adapted to specific group's workflows. That takes time and energy investment that few physicians are actually willing to do. They would rather bitch about how the government, insurance companies and hospitals are screwing them and how much better things were in the good old days.

A pro-EMR surgeon , please no more posting, I can only get so erect

 

[Cytarabine]

As a student (or resident in the type of crappy program that doesn't teach you how to bill), Cerner is actually nice to use. The problem is once I have to bill with it, everything goes to hell. The interface is insanely clunky, you have to navigate through way too many windows and menus, and if your hospitals servers are having a slow day, clicking the various boxes takes way way too long.

I have no experience to speak of in the billing department obviously, so I'll take you at face value there. Really no idea what goes into it

 

[Stagg737]

I think I've used all the big EMRs at this point. I think epics the best if you're willing to put time in to customize it/ template it out and learn it well. Cerner's easier to jump into and be reasonably adept at. Starpanel somewhere between the two but the UI is awful imo. I like epic too. Just surprised they're switching. Seemed like they had a lot of pride in starpanel

I've heard a lot of smaller practices/groups like epic because of that customization, but a lot of bigger hospitals/programs like Cerner because it's easier to learn/use. Any truth to that? Thoughts?

 

[pkwraith]

Paper charts are terrible for everything except convenience of barebones documentation. It's a national passtime to complaining about things. Some configurations/programs suck and it's great to complain about them (including me), but they're still 1000x better than reviewing a patient's paper charts.

Nothing worse than receiving a stack of paper charts from OSH and trying to figure out what the **** is going on (oh great, no way to filter out nursing notes and LDA assessments). Going up to a patient's room 4 floors away to put an order in their chart. Looking at a paper chart of a visit 5 days ago that has literally 6 things written on it, or not being able to find the chart at all, or someone else is using it or left it somewhere in of the 6 nursing stations so you have to do a scavenger hunt just to put in a single order.

Is it easier to scribble ten words on a chart, and circle 5 things, and call it a chart? Most definitely. Is that useful for anything else except billing? No

 

[WingedOx]

I have no experience to speak of in the billing department obviously, so I'll take you at face value there. Really no idea what goes into it

Lots of f-cking buttons to click. At least here at the VA we use CPRS which is now 20 years old and essentially meant to work on 20 year old technology. You can pull a tower from the closet that's covered in cobwebs and the damn program will run fine. When I need to the equivilent to coding/meaningful use type things, it's "click, click, click, click, done"

With cerner it's "open window... hourglass, click...hourglass, click, click, new window, ...hourglass.... still hourglass.... click....."

 

[VA Hopeful Dr]

Epic already has the capability to share patient files with other institutions electronically. Trivially easy to do between hospitals that both have Epic. They also claim to be able to send the file to other systems, but most other systems aren't capable of accepting them.

I've had several Epic reps tell me that but have yet to actually see it happen. Hell, I worked for a large multi-state corporation and they couldn't even get Epic to share data across the health system itself much less other systems.

 

[Cytarabine]

I've heard a lot of smaller practices/groups like epic because of that customization, but a lot of bigger hospitals/programs like Cerner because it's easier to learn/use. Any truth to that? Thoughts?

Mimelim might be able to give you some insight, my experience is limited to using them. If i had to guess, far and away the number one factor behind why any hospital without strong physician leadership picks an EMR is $$$. If costs are comparable then maybe people's preferences come into play more. More to the point of your question though, EMR's are customizable on an individual user level, the extent to which they are is variable. Epic seems like the most flexible of the ones Ive seen, though as a student I didn't bother putting in a ton of effort making high yield templates. Plan to as a resident though

 

[Cytarabine]

I've had several Epic reps tell me that but have yet to actually see it happen. Hell, I worked for a large multi-state corporation and they couldn't even get Epic to share data across the health system itself much less other systems.

Duke and UNC are connected afaik, though that's about as straightforward as you can get with being half an hour apart from one another

 

[Cytarabine]

Lots of f-cking buttons to click. At least here at the VA we use CPRS which is now 20 years old and essentially meant to work on 20 year old technology. You can pull a tower from the closet that's covered in cobwebs and the damn program will run fine. When I need to the equivilent to coding/meaningful use type things, it's "click, click, click, click, done"

With cerner it's "open window... hourglass, click...hourglass, click, click, new window, ...hourglass.... still hourglass.... click....."

No better way to find out someone's true temper than have them work under constant hourglasses on the comp =)

 

[mimelim]

I've heard a lot of smaller practices/groups like epic because of that customization, but a lot of bigger hospitals/programs like Cerner because it's easier to learn/use. Any truth to that? Thoughts?

I've only worked a limited bit with Cerner, and can't pretend to know how hospital administrations think, but... I don't think that you can easily make those types of broad generalizations. There are benefits to both, but I doubt that most users would be able to really tell the difference, especially once they are used to it.

I've had several Epic reps tell me that but have yet to actually see it happen. Hell, I worked for a large multi-state corporation and they couldn't even get Epic to share data across the health system itself much less other systems.

What I have found with Epic is that they don't do very well integrating their older versions with their newer ones. For example, when an entire hospital network switches over to Epic together at the same time, things tend to be seamless. I have used the records request functionality and it is about as trivial as you can make it. I can only speak to the newer versions (I think they are 2012 and 2015), but I have yet to see it be as easy as they advertise. But, I wouldn't be surprised if there are issues integrating between systems that rolled out at different times. Internally, consistent, but getting newer/older versions to talk to one another and work together, I've seen some headaches (outpatient/inpatient stuff not lining up properly).

 

[WingedOx]

I have heard form many a Wisconsin-based computer science graduate that working for Epic is like being shoved into the depths of hell.

...take that however you'd like.

 

[mcloaf]

Assuming you have a basic level of computer literacy you'd be ****ing crazy to prefer paper charts if you're doing any sort of inpatient work IMO.

 

[CherryRedDracul]

Assuming you have a basic level of computer literacy you'd be ****ing crazy to prefer paper charts if you're doing any sort of inpatient work IMO.

I remember having through thumb through numerous paper charts to come up with a grand rounds presentation coming up in a few hours. I was ****ting bricks and on the verge of a mental breakdown because 80% of the time was spent figuring out what the **** I was reading. I hate cursive.

 

[mcloaf]

I remember having through thumb through numerous paper charts to come up with a grand rounds presentation coming up in a few hours. I was ****ting bricks and on the verge of a mental breakdown because 80% of the time was spent figuring out what the **** I was reading. I hate cursive.

It only took me about 15 minutes trying to preround on a surgery service with paper charts before I realized that was a no go. Maybe it's different for old school attendings who aren't spending their time keeping track of orders and vitals all day, but paper charts suck for doing the little things that actually keep the hospital running efficiently.

 

[Stagg737]

I have heard form many a Wisconsin-based computer science graduate that working for Epic is like being shoved into the depths of hell.

...take that however you'd like.

I believe the classmate from a previously mentioned post said the same. Great for getting some early experience and learning about the system, but wouldn't have been able to stay much longer than she did.

 

[Brahnold Bloodaxe]

What about the notion that EMRs are destroying the viability of small private practice due to their cost? Whenever I read an article on the death of private practice EMR requirements almost always feature prominently. Is this an exaggeration coming from docs with poor business sense looking for a scapegoat, or a real issue? Cause if EMRs really are a major factor driving the corporatization of medicine (turning us all into corporate slaves) then that on its own is reason enough to view them as the very Devil.

 

[Tenk]

EMRs are great if you know a decent amount about computers and scripts. The people who complain are typically older and not computer savvy.

I use EMR + dragon everywhere I work and I chart ridiculously fast thanks to macros. The only thing that takes any time at all is proofreading for medical legality.

 

[Mr Roboto]

... From a technical standpoint (speaking as a supernerd here), EMRs have the software equivalent of PDAs. Vaguely modern, but woefully behind current capabilities. Nobody's wondering if EMRs are going to support DirectX 12. 😛 There are a number of reasons for this, but I think the #1 driver is intellectual property (IP) as a concept. Above, someone reported that their hospital paid $500 million+ for an EMR. That's for an archaic platform compared to consumer software! How could it cost so much?

I'll give a quick example of what I mean by archaic: Service-wide resets to "update" is a relic. Notice that none of the other software you use does that? When Windows updates, does everyone have to wait simultaneously for a few hours? Certainly each client may have to restart, but they can do it at their convenience. That's just 1 example of the sort of innovation that has happened in the tech industry in the last 10 years, and EMRs have not adapted.​

As EMRs exist, they are unacceptable at a cost/benefit level compared to what they could do. Once the next generation of docs phases out the ones who are learning to send emails, we'll see pressure be put on the industry to modernize, and a small number of coders will be unable to continue meeting the demand. Until then, IP is the main factor restricting our ability to seek cheaper alternatives.

This is really curious. Why hasn't anyone exploited the huge market gap? A more affordable EMR (the administration will love it!) that is also easy to use and modern (the staff will love it!). Seems like it's a market ripe for disruption and exploitation.

 

[Pacna]

This is really curious. Why hasn't anyone exploited the huge market gap? A more affordable EMR (the administration will love it!) that is also easy to use and modern (the staff will love it!). Seems like it's a market ripe for disruption and exploitation.

It would be indeed, but IP injects a huge amount of inertia.

 

[pkwraith]

This is really curious. Why hasn't anyone exploited the huge market gap? A more affordable EMR (the administration will love it!) that is also easy to use and modern (the staff will love it!). Seems like it's a market ripe for disruption and exploitation.

Most of the costs are not from the EMR (licenses, development fees). The majority of the costs are in the implementation process with consultant fees and IT staff, hardware costs (servers, PCs), initial loss of productivity (need for overstaffing), and then the maintenance in perpetuity. Example, for the millionaire dollar Epic installs, about a quarter to a third of the money comes from software costs.

There's plenty of cheap personal EMRs for small clinics.

 

[Psai]

As I go through this unpaid online emr training by people who can't even pronounce or spell pruritus or metoprolol, I feel a part of me dying. Meaningful use aka wasting time clicking buttons. This is the dumbest thing ever.