EMR Customization Not Always Achievable
Unhappy Camper (Vol. 1, Issue 6)
In my EMR system there is a checkbox for “History Verified.” This seems well enough, and it’s probably a good procedure to ensure that you have recorded the pertinent past history of your patient. If there is a note here that contains some past history, all is fine and the history is presented properly. But in pediatrics, it is more often the case where there is no pertinent past history to record. Alas, in these instances when you enter the check into the box, the EMR automatically enters the statement, “No Medical History documented.” It does not clarify as to whether one did not bother to document a history at all, as opposed to there being no pertinent past history to record. It's vague and too open to misinterpretation.
It makes much better sense to rephrase it to “Past Medical History: Noncontributory” or “Pertinent Past History: Negative”. But we can’t change it. In cases where there is no pertinent past history to acknowledge, our practice has adopted the policy of deliberately NOT checking the box at all so as to avoid the Catch-22 positive testament that we never took any documentation of the patient’s medical history. Is this good documentation? Most definitely not. But with my darling EMR it appears impossible to do otherwise.
I put in a support request and talked to my EMR vendor support staff on this issue. Ultimately, my support tech instead suggested that I add my complaint to the list of recommendations in the user group ideas forum, which I also promptly did. But it does seem that my particular EMR vendor may be redirecting a lot of such customization requests to the ideas forum where they’ll pay attention to it only if it gets enough positive votes from fellow users. In the forum I discovered there that one other user had previously pointed out the lame phraseology used. Unfortunately, my idea has only 7 positive votes as of the time of this writing, and I doubt there will be much notice taken of the issue by those people in the dark rooms where computer code is written. So for those 'physician champions' that endlessly tout the ability to customize the EMR to every need, I say, that's a bunch of baloney!
Oh, Oh! And if you already have an EMR, you just HAVE to go to this web site for the latest and greatest EMR product! www.extormity(dot)com The direct link won't work from this web site, of course, but you can type in the url yourself.
you raise a good point and describe an all too common scenario for anyone using an EHR or any new technology. We need to be aware of what needs improvement in EHRs, but let's not ignore the value of an EHR in its current state. I've used 5+ EHRs over my clinical career and they all had major flaws...but each one was light years ahead of the paper alternatives. I don't understand why my current EHR won't easily accommodate two doses of the same med (i.e., alternating doses of levothyroxine on alternating days), but many of the check list functions are very good and enable me to provide better care for my patients. Similarly, my new smartphone doesn't integrate seemlessly with my email/calendar system used by my employer...but overall it's the best smart phone I've ever used and saves me tons of time and effort every week.
Regarding your specific issue--your approach is logical. Notify the vendor of your suggestion and find a work-around that enables you to care for your patients.
disclosure--Jonathan Leviss, MD, is editor of HIT or Miss (AHIMA, 2009), a book of case studies of HIT failures with discussions of lessons learned.
Using an EHR? Yes - eClinicalWorks
Disclosure: Director, Clinical Solutions, Microsoft Health Solutions Group
Thank you for your comments Dr. Ejnes. I agree that we should focus on the issues, both negative and positive, in a constructive, collegial manner. Having been involved with EMR implementation, customization, beta testing, reporting, and working with developers to improve the functionality of our EMR, I have been frustrated at times. I have also been very involved with a user forum for my EMR, in which some will voice significant frustration dealing with errors, limitations, lack of response by the vendor regarding small as well as big/critical issues. Thankfully our vendor makes great strides to listen to the users' needs and keep its eye on where things are headed nationally so we have a product that will sustain over time. I think it is important for anyone involved with electronic systems to realize that there will be limitations. I try to look at the EMR as a tool. If the tool provides the means to create efficiency in the practice, embrace those aspects, learn/develop them to get the most out of it. At the same time you will identify deficiencies/errors, the best thing to do is recognize the limitations, report them so the vendor can work on them, find ways to work around the limitations, and move on. If anyone knows of the perfect system that would work for all users' needs, be affordable, and adapt to all the future requirements - meaningful use, reporting, etc, I would love to hear about it.
That being said, I would like to comment further on the topic regarding EMR customization. I was instrumental in customizing our product five years ago. We were able to customize most of the working features of the product, which has clearly improved efficiency and professional satisfaction. There are certainly many different areas of the EMR that are not able to be customized, that require the vendor to develop fixes/changes. We continue to work with the user forum and vendor "ideas" site so the vendor can compile the user input, identify the needs, and make advances for us.
I hope that those that have not yet taken the dive into the electronic world will not be discouraged by problems they read about. In our experience, the EMR experience has been 95% positive and 5% negative (certainly not a scientific estimation, but most in my practice would probably support my estimate). Pursuing an EMR and getting your practice organized with an efficient, electronic system will pay off (financially and professionally) if you research it well and approach it in a sensible fashion.
Using an EHR? Yes - eClinicalWorks
Disclosure: Owner/practicing partner of Aquidneck Medical Associates, Inc. Contracted as the Case Management Physician Advisor at Newport Hospital (a Lifespan affiliate) and as an advisor for BCBS of RI to help facilitate HIT integration in community practices
If I can't find a checkbox that will do what I do, or can't get one that sort of does what I want to do to do it better, I find a place where I can enter the free text and be done with it. So, in the example that you describe, I go to a window in the HPI or ROS and enter what I want it to say, in this case "PMH noncontributory." Not an elegant solution, but much faster than trying to get the software changed, though I agree that the vendors need to be more responsive.
I do have to comment on your complaint regarding censorship, Dr. Concannon. I'll first disclose that I'm Vice Chair of the RIQI Board of Directors but I am not involved with DocEHRtalk.org any more than the other physicians who've registered and post occasionally on this site. I do not know what was edited out of your original comment, but if the staff did such a thing, I'm certain it was done reluctantly and with good reason. What is abundantly clear to me is that they are not censoring negative comments, because if that were the case, all of your posts would have been edited, if not completely removed.
The mission of this website is to create a community for physicians to learn about EHRs, both the good and the bad. Just as the feds expect EHR use to be meaningful, physicians who use this website as a resource for EHR adoption and use deserve that this website be meaningful, and that is best achieved if all points of view and experiences are shared in a constructive and collegial manner. That's how a community works.
Using an EHR? Yes - eClinicalWorks
Disclosure: Shareholder of Coastal Medical, Inc.
I think what you may have been 'offended' by was my making a simile between the phrases of "No Medical History Documented" as presented in the eHR and "Have you stopped beating your wife?" I was not making light of domestic violence in any way, which would be offensive. But, as it turns out, that specific phrase was taught to me in logic class as THE prototypical example of a loaded question. And it still is. As examples, see http://en.wikipedia.org/wiki/Loaded_question or see http://www.fallacyfiles.org/loadques.html (scroll to Exposition). Both of these sites, and indeed most sources, reference the wife-beating phrase as THE exemplary phrase to explain a loaded question.
Using an EHR? Yes
We certainly value and encourage free thought- both positive and negative. The Messageboard is a place for conversation about all aspects—the good and the problematic—of Health IT issues. The content removed in this case was perceived as personally offensive by others. We reserve the right to remove such content in this rare situation.
This is a forum where one provider can learn from others’ experiences and we are glad that we are able to offer it as a resource for RI’s providers.
Using an EHR?
Please note that the article as presented above has been highly edited by RIQI from the original as submitted on September 3rd, 2010. The original article referred to hypothetical legal scenarios and to conversations I had with the support team of my EHR wherein it was difficult for them to understand why I wanted the wording changed. It is apparent to me that RIQI will not allow postings that do not reflect EMR in anything but a positive light. BE VERY AWARE THAT THE FORUM AT DOCEHRTALK.ORG IS NOT OPEN TO FREE THOUGHT ON THIS SUBJECT.
Using an EHR? Yes