My EHR Tells Me I’m a Bad Doctor.

I’ve written before about our EHR and all the the things that I really like about it. Add to that list the fact that we can now get incentive payments from Medicare (or Medicaid) for buying and using an EHR (we were early adopters of the technology before the current incentives came out). But in order to qualify as an electronic health record in the government’s eyes, the federal government determined that everyone’s systems must meet certain minimum functionality requirements, what they call “meaningful use”. This is where things are getting tricky. . . because my beloved EHR is telling me that my medical records are are not meaningfully useful, and in fact are meaninglessly useful, or meaningfully useless, one or the other, or perhaps both.
As if that was not enough of a slap in the face after all the love and adoration I’ve showered upon the system, there’s this bitter morsel. I’m being told that the manner in which I’ve been deficient is in the department of documentation of smoking. Can you believe that? Smoking! Me! The super-anti-smoking guy! The one who wrote this article. And then the other one. Plus, remember that other one? Seriously?
Could I truly be deficient in my smoking documentation? Refusing to believe such blasphemy, I delved into the medical records. No, see, there it is? Right there.  Under HPI, “patient has no history of smoke exposure”. And there again, in the next chart, more extensive smoking data meticulously typed into the history. I knew that I was documenting this stuff. What could the problem possibly be?
I spoke with our office’s biller. In order to figure out what the problem was, we delved into the various rigamarole of documentation requirements. Poring through the various reporting requirements and how Megatron (that is what I’ve named our EHR since this incident) reports on them, we identified the source of the problem. As it turns out, it was stupid. Like really stupid.
Ya see, our Megatron has a check box section under social history where smoking can be documented. Even if I type in my own more extensive social history, Megatron does not recognize it.
He wants me to take a specific set of actions every time. In order to illustrate this for you I’ve taken a few edited screen shots from an imaginary patient encounter. Below is our allscripts EHR opened into a patient encounter session. On the upper section there are searchable terms such as cough, abdominal pain, etc. . . If I were to  click on one of these, I would be taken to a check-box system of questions. Since I can type well enough on my own, I prefer to type in the initial complaint history in the field below it, as the person relays it to me. There is where I would normally type in what a person tells me about their smoking habits. However, instead of typing in something like, “The patient has no history of smoke exposure”, I need to click on “History” in the column on the left.

After clicking on that box on the left, I’m taken to another screen. A new column opens that gives options of entering data on different aspects of the medical history such as social, family, medication history, etc. . .

In this new screen, I need to click on “Social” in the second column, which then opens up the social history field. Under the social history field in the third column, clicking on “Tobacco Use” then takes me to another pop-up screen of check boxes (not shown) which must then be checked. Only if I complete these series of actions will I be considered as a physician who asks people about smoking, and hence using my EHR in a “meaningful” manner.

As you might imagine, I came away from this experience feeling very frustrated. Unless I clicked in the check-boxes, as far as Megatron is concerned, I did not ask about smoking. I felt like I was on a weird Seinfeld episode.
Me: But Megatron, I typed a social history with much more detail that you include in your check-boxes, and I can type it faster than I can click the check-boxes.
Megatron: No soup for you!

I went back to my biller/computer person/assistant office manager/scheduler. “Isn’t there any way we get the computer to just recognize my smoking history if I type it in?”
Her reply: “Dude, you type too much. Just click the damn boxes and quit bothering me.”
Damn, you, Megatron, Damn you!

Related articles:  Snow Birds and EHR;   Where Medical Reports Go to Die.

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  • http://twitter.com/IMWHorvitz Dr Steven Horvitz

    MU is a meaningless waste of your time that is better dedicated to patient care. You have allowed yourself to be labeled by a computer data program with requirements given by a govt more into control of budgets than patient care.
    You know who you are and should go back to only being labeled by the patients you care for.

    • http://www.caduceusblog.com/ Deep Ramachandran

      You make a good point, MU makes it so that more and more the EHR is designed about fulfilling billing goals than patient care. It’s making it quite cumbersome.

  • http://www.facebook.com/kwkeirstead Karl Walter Keirstead

    When you buy an EHR program from any vendor, the most fundamental question you need to ask yourself is “my workflows or theirs?”

    Most organizations spend years developing internal best practices. This is what gives them a competitive advantage.

    Cookie-cutter approaches take away that competitive advantage.or prevent you from developing one.

    Chances are the people imposing their workflows on you have never run a healthcare facility.

    When you put YOUR workflows in line, all complaints re too much data or too little data or data being collected at the wrong time go away (aside from mandated data collection). If too much, cut back, if too little add more, if the timing is wrong change it. None of this requires expensive “programming”.

    My take on MU is that it is not so much for billing but rather for cross-patient long term outcomes improvement.

    I don’t see much of a focus at all on wellness, disease prevention or disease management at the individual patient level.

    Why is healthcare moving away from patient-centricity when the rest of the world is moving toward patient centricity?

  • ken keirsey

    This is just another example of non-doctors in Washington, D.C. telling doctors how to doctor. Why not? They are mostly non-businessmen (and women) telling businessmen how to do business, and mostly non-military telling military how to conduct military operations. This is why an engineer needs to work with a mechanic, an architect with a builder, a computer programmer with a real user, etc….but common sense, as they say, is an oxymoron…..especially in Washington, D.C.