After 5 successful years with electronic medical records (EMR), I am convinced that the promise of EMR to improve physician practices and to improve the health care system is real.

If that is true, why is adoption of EMR currently limited to only 5-10% of medical practices?  Why is there so much resistance?  As folks who work in heath care IT so often ask, why don’t doctors “get it?”  I don’t mind the question but I do object to some of the sinister explanations that are offered.  Physician resistance to EMR is legitimate.

This post will explore one of the reasons for doctor resistance to EMR.

A few years ago one of our best referring physicians came to see me as a patient.  After we took care of his medical issues, I asked him how he liked our new EMR and the notes we were sending him through it.  His answer floored me: “I hate it.”  That is not what you want to hear from one of your best referring physicians.  After a moment of drop-dead silence he added, “nothing personal.  I hate all the EMRs out there, including the one our practice just bought.”

He went on:  “Notes that come from an EMR have so much extra stuffing in them that it takes me forever to figure out what you guys really had to say about the patient I referred to you.  I have to wade through lines and lines of empty verbiage to finally find a meaningful sentence or two that tells me what I need to know.  Our own EMR notes are no better.  But there’s nothing we can do about it, we just have to accept it.”

Except for that last part, he is absolutely right.  Why did things get so bad?

Doctors used to document their work with concise handwritten notes.  Then came CPT codes, which brought elaborate documentation requirements that medical records must fulfill in order to receive payment from the insurance provider.  These requirements measure the documentation, not the care itself.   Fear of documentation errors often force providers to code and bill at a lower level than their work truly deserves.  Physician revenues are thus limited not by the amount of real work performed, but by the sheer number of words one must write to properly document that work.  As long as chart notes had to be handwritten or manually dictated and transcribed, CPT effectively limited physician billing.  Providers became as much servants to documentation as they were caregivers.

This situation inspired the first marketing efforts by EMR vendors to physicians.  Recognizing the need, vendors promised improved, automated documentation and monitoring of charts for CPT compliance.  Doctors could finally bill safely at the appropriate CPT level.  With just a few mouse clicks the chart note can fulfill all the requirements to be CPT-compliant.  Now the physician can concentrate on the patient again.  In my experience this has worked well.

But sometimes it’s the side effects that kill.

EMR shows us what fully CPT-compliant documentation looks like. And it’s awful. The folly of carrying CPT documentation requirements into the information age has been exposed. The relevant data are buried in a sea of white noise — patient demographics, irrelevant historical data, normal physical findings, and diagnosis / billing codes.  Each mouse click generates a bland, repetitive phrase in order to hit a CPT-mandated “bullet point.”  The result is a multipage, single-spaced, small font monster of a chart note with very little substance relative to its size.   This obsession with documentation is distracting both EMR vendors and users from pursuing the real benefits of EMR — automation of workflow, rapid data exchange, reduced costs and improved efficiency.

Want a real incentive for docs to get EMR?  Forget HITECH.  Few doctors I know believe those incentive payments will ever happen.  All but the largest practices and major institutions will be defeated by “meaningful use” criteria.  Instead offer EMR users freedom from CPT documentation requirements.  Replace CPT with a system that is appropriate for the information age.  Leverage the power of EMR and create a system that rewards quality of care rather than volume of documentation.

Easier said than done.  But recognizing the problem is the first step.

Mike Koriwchak is an otolaryngologist who blogs at The Wired Practice.

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