See what happens when you give a doctor a user-friendly EMR?

I’ve finally found my groove with our EMR. Maybe I’m even starting to like it.

A few weeks ago I got a new iPad, this time a Mini, which lets me type with two thumbs the way some people text on a smartphone, and the voice transcription is good enough as long as you avoid fancy jargon and unusual generic drug names. Yesterday as I sat next to a patient and dictated her history, she added to it and her words transcribed perfectly into my office note, unintended but very elegantly.

Even the size difference from my personal iPad which I had been using, horse barn scented leather cover and all, made a difference because on the mini I can type faster with only my thumbs. Years ago I had a pen tablet computer that wasn’t bad, but I find that the smaller my device gets, the more unobtrusive it seems.

The iPad version of my EMR is growing on me. Its interface was obviously designed from the ground up, so while it looks different from the desktop version, once you’ve worked with it for a while, it is twice as fast.

The software can graph, instantly, any historical lab values and vital signs, which is extremely helpful when I sit next to a patient and want to show them their improving hemoglobin A1c or variable blood pressures. When I first started using the iPad, I saw a couple of patients who had subtly but steadily falling hematocrits and turned out to have erosive gastritis in one case and colon cancer in another. Without seeing the trend in a graph, it would have been harder to spot.

Reading reports, I can enlarge them by spreading two fingers and I can move around by dragging them left to right, whereas on the desktop I have to enlarge the window, click “view,” then choose a percentage enlargement and then use the scroll bar to move left to right in order to see each line completely, which is ridiculously cumbersome.

During today’s 7 hour Saturday clinic I saw 27 patients, one of them brand new to the practice, and I did 90 percent of my documentation on my Mini in the room with each patient. Twenty minutes after closing, I walked out the door and drove home in the sparkling afternoon light, down winding roads flanked by the peaking fall foliage and the royal blue waters.

I felt like I hadn’t even worked today, that’s how easy my day was with my user-friendly app and my new Mini.

EMR ROI depends on workflow improvements

Some of the toughest obstacles to EMR are the physician doubters.

These people say, “My charts are going to be on a computer. So what? All I know for sure is that it will take longer for me to finish my charts every day and we will have another component in fixed overhead. Why this is a good idea?”

The concerns are valid. When my practice chose to get EMR 6 years ago we made a decision of faith and vision, not from an ROI analysis. But for most practices, faith and vision are not good enough. We need a return on investment (ROI) rationale that justifies EMR adoption to the Doubters. The IT experts talk in vague terms about workflow and re-designing your practice to take advantage of EMR, but these arguments are not concrete or specific enough. Yet after 5 years of EMR no one in our group has ever suggested that our EMR investment was unwise. I am convinced the ROI argument exists. My next few posts will attempt to make the case.

Let’s start with an unusual example. Your car needs new tires. You live in a beautiful rural area but there is only one car shop, staffed by a single mechanic. He is glad to put on new tires but the job will take all day.

Why so long? How many steps does it take to put on new tires?Any interruptions such as other cars needing work, a phone call, emergency, etc. will make the job take longer because these events interrupt the work on your car.

1. Remove the first wheel from the car
2. Take the old tire off the wheel
3. Put the new tire on
4. Balance the wheel
5. Put the wheel back on
6. Repeat the above with other 3 wheels, one at a time.

Our solo auto mechanic must operate by sequential processing – defined as one operation at a time.

Now consider the other extreme. You are an Indy racecar driver going 180 miles per hour around the track. You need new tires fast. You pull into the pits and the pit crew changes all 4 tires at the same time. You also get mechanical adjustments, a full tank of gas, and the windshield cleaned. A pit stop that takes more than 8 seconds is considered a failure. This is parallel processing – defined as multiple operations taking place simultaneously. Thanks to parallel processing the Indy pit crew can do in 6 1/2 seconds what takes the solo mechanic all day.

Now go to the doctor’s office. The physician sees a patient with a suspicious nodule in his thyroid gland that needs surgery. How many steps does it take to get that patient to the operating room?

1. Create a chart note that supports the need for surgery
2. Schedule the operation with the surgical facility
3. Preoperative labs, imaging, EKG
4. Specialist clearance (i.e., cardiology)
5. Pre-certification with insurance
6. Generate and complete documents
a. Surgical consent
b. History and Physical
c. Preop and Postop orders
7. Communication with the referring physician
8. Handle the unexpected – patient calls with questions, abnormal lab values, scheduling conflicts, etc.

How does the paper chart office handle these tasks? In all but the smallest practices these tasks are each handled by different individuals. Every step requires access to the paper chart, which can only be in one place at a time. The chart won’t be available to anyone for at least 24 hours until the transcription comes back and is filed. The paper chart office must therefore accept the slowness and inefficiency of sequential processing. Workflow is defined by stacks of paper charts – stacks waiting for transcription, stacks waiting for labs, waiting for scheduling, etc. And if the patient scheduled for surgery calls with a question…what stack is the chart in? Will the chart find its way back to the right stack after the phone call is handled? Everyone competes with each other for access to the chart. Not only is the process slow and inefficient, it carries a high risk of workflow failure.

How is the same process handled in a doctor’s office that has EMR? With the power of parallel processing:

1. The chart note, including the diagnosis codes, is immediately available to support preoperative workflow.
2. The chart note is paperless faxed to the referring physician the same day, sometimes before the patient leaves the office.
3. The staff is immediately notified of the new workflow via the EMR system
4. Consent, history and physical, and orders are all generated with a single button click
5. All workflows are performed simultaneously, greatly improving speed and efficiency and reducing the risk of a workflow failure.

With parallel processing there are no stacks of charts and no competition among staff for access to the chart. Copying and faxing charts within the practice is eliminated. The chart is everywhere, all at once. Any phone call regarding a patient is easily handled without having to search for a paper chart and without the risk of killing a workflow because the chart was not put back in the right stack.

So where is the ROI? The same work gets done with fewer people, fewer resources and less space. These initial benefits happen without having to “re-engineer the practice” or change anything else about how things get done. After electronic documenting becomes second nature it will be time to employ the concepts of remote access, computerized provider order entry, workflow design/automation and “e-patient” functions like secure e-mail and patient portals to really get things cooking.