On the AAPF Family Medicine

On the AAPF Family Medicine EMR listserv this week .. a quote that I think speaks volumes about why electronic medical recrords are hard to use: 

"Most templates created by EMR companies are useless because they are designed backwards.  They base the template on diagnosis instead of chief complaint.  This doesn't work because you often don't have the diagnosis until the end of the visit unless it is for follow ups or routine.  You'd think the companies would have figured this out by now, but they haven't."

Electronic Medical records

Things have been awfully busy the past few weeks — so busy that it's been hard to post here.  We've been building an integrated mini-electronic medical record in the office, and it's been a challenging yet satisfying experience.  A bit of an overview:

Our 3-person family practice is one of 17 primary care offices in the area that is part of a medium-sized primary care group.  We are the only site using the Mysis EMR.  It's a weak EMR .. and woefully slow.  But it's better than paper ..

When physicians think about an EMR, they often think FIRST of the progress notes.  But this is actually one of the last components that should be implemented.  The best systems are built to capture data in the course of daily activity.  Wrte a prescription electronically instead of on paper .. and you create a record of the prescription AND do the work.   Order lab work.  Send a referral letter.   Write a message to the office manager about a paitent.  Take a phone message from a patient.

The Mysis product focuses on the progress notes, and while it enables prescription writing … it doesn't do this well.  We also have been struggling with how to manage the paper that continues to come in to the office.  Letters, old records, etc.  When we started the practice last summer, we signed an agreement with Smart Copropration.  Smart put a scanner in our office.  We scanned images in .. and their (human) indexers in Idiana would read the images and associate each image with a patient in a database.  All images were then available through their "EMRWEB" system.  The user interface of EMRweb stinks.  It was slow to use, and the indexers wouldn't always check the database to see if a patient already existed .. so we end up with 3 Bob Smiths with the same date of birth .. rather than one.

So we got out of EMRweb.  Extracting the data was technically straightforward, but politically challenging.  It took them about 4 months and 40 or so e-mails.  I think the guy probably made a new "spam" filter for my e-mail address since I pestered them so much to do it. 

Then we built our own application.  The commercial products .. and even the "Misys Document Manager" are slow and expensive.  Our solution had to be FAST and easy to use on the scanning end .. and fast and easy to use on the lookup end.

What we built:

  • A Scanning application using Microsoft .net C# and LeadTools TWAIN API.  Tis got one screen and only a few buttons.  Easy and fast.  We bought an expensive (fast) Fujitsu scanner. .. and will likely buy a few more. 
  • A patient "face-sheet" viewing application where one can very quickly view a patient's medications, medical problems, allergies, and scanned images.  We just bought a digital camera .. so we'll add a "face shot" of patients as well.  Images of lesions could be added without much trouble.  The viewing application is developed in ColdFusion MX, and does some lookups via ODBC to the Informix database that the Mysis EMR is built on.
  • A messaging system that replaces all of those little pink message notes.  Each messages is tied to a patient's record, so the phone numbers and medications etc are clearly visible to the message sender and the message receiver.  We now know that EVERY phone message has a resolution .. and the resolution is dpocumented.

The key for all of this is that the software is fast and easy to use.  a patient lookup in the native Mysis EMR takes ~10 seconds.  A lookup in ours is usually doneless than one second.  Multiply this by several hundred .. and you've got significant cost savings on the basis of physician time alone.

There remain a few bugs to work out .. and some features to add .. but we're happy so far with how this has come, and we think that it will enable us to provide better service to our patients.  We've not replaced the Mysis EMR.  Rather, we use this system as an adjunct to provide the core functions that the Mysis system cannot deliver in an efficient manner.