Electronic medical records (EMRs) are the way of the future. And, for most practices, that future is today, whether we like it or not. The federal Center for Medicare Services is paying doctors a financial incentive to switch from paper to electronic charts, and the first checks have already been cut.
It’s notable that the government has chosen to bribe doctors to switch to electronic records, when no one had to pay us (or you) to use Google or Facebook or Twitter. Maybe it’s because EMRs don’t run like Google, Facebook, or Twitter. Despite the tremendous potential benefits of EMRs, they remain clunky, distracting, and non-intuitive. In their current form, their benefits are clearly limited to administrators, third-party payers, and others who are more interested in data than in the quality of care provided. But what do I know, I’m just a doctor, and no one ever asked me.
Anyway, in the last 18 months, I’ve had the opportunity to use two different EMRs, one called Patient Care Manager by Prime Clinical (about which I can’t find much positive to say, so I’ll keep my mouth shut), and another, Practice Fusion. I must admit I’ve been rather impressed by Practice Fusion, a free “cloud-based” EMR system with many user-customizable features and a surprisingly simple interface.
Alas, for several hours yesterday—right in the middle of a busy Monday—Practice Fusion went down. As in: totally unavailable. Couldn’t log on, couldn’t view any charts, lab reports, patient correspondence, or the daily schedule. Couldn’t even look at patient demographics. It was as if the entire chart rooms of hundreds of doctors’ offices across America were closed for the day.
In a conventional practice with paper charts, this sort of thing is unacceptable. To be sure, things get lost every once in a while, but to lose access to an entire chart room—and schedule—without any idea of when it will return, is a potentially very serious problem. Doctors have been severely disciplined for losing or missing data (even in individual cases), and clinics have been penalized with significant fines for shoddy recordkeeping.
Fortunately, Practice Fusion came back up late in the day, but not until hundreds of practices across the country struggled for 5-6 hours without vital information, making for a very difficult Monday.
I should point out that (when it works) Practice Fusion is unique. More so than any other EMR I’ve used, PF is extremely user-friendly, offering informative (and sometimes humorous and irreverent) YouTube videos, live online chat, and an attentive support team. They even allow comments on their public Facebook page. You might expect it to be a place for doctors to vent their outrage on a day like yesterday. To the contrary, most of the comments were quite sympathetic. Some direct quotes:
“I feel like I’m deaf and blind… could not pull labs or test results…. I know it happens. It could happen even to the best. But hey! It’s not the end of the world! True, it’s very inconvenient since I’ll be spending most of my evening trying to catch up charting. But still… Love you guys! Keep up the good work!”
“I love Practice Fusion no matter what happened today… Good job guys!!!”
“We are thankful for PF, even with the RARE problem…. Thanks to you and the team for providing us a reliable and FREE EMR.”
“If it’s going to stay this fast [after the outage] I can get over being down today though it was quite stressful! Thank you PF staff. You were probably stressed too.”
It’s a surprising commentary when a very significant glitch in a widely used EMR system—which, in a conventional practice situation, might have resulted in disciplinary action or heavy fines, and which most certainly resulted yesterday in lost income for a number of docs and probably more than a few adverse patient outcomes—was accepted with such grace.
Maybe I’m old-fashioned, but EMRs are not like any other piece of software. When Netflix goes down, I can’t watch a streaming movie. But when Practice Fusion goes down, I can’t access vital information which may make a significant impact on the well-being of the patients in my office. It’s a very slippery slope when we “permit” EMRs to be buggy, and even worse when we providers simply “accept” it (and even give the companies a free pass) when they go down.
But then again, the future is today. We need to get used to it.
Thought Broadcast 
One reason my patients and I didn’t suffer too much from the PF downtime was that I use another cloud based service for scheduling, and Google Apps for almost everything else. Best not to put all your eggs in one basket. But this should serve as a reminder that records are just records, and the patient-physician relationship remains where the medical rubber meets the road.
Is Google Apps HIPAA-compliant and CCHIT-certified? 🙂
I agree with the eggs-in-basket comment. BTW, does the “medical rubber” include such practices as sporking?
(That’s sporkiatry.)
If you’re N.a.C.E (Not a Covered Entity) you don’t have to worry about HIPAA compliance, but it’s best to not include info that identifies the pt or identifies the person AS a pt. just to be safe. What is CCHIT?
CCHIT is yet another way to “certify” EMR implementation: here’s a link (PDF) on the certification process.
I’m glad you like your EMR, but the problem is the cloud-basis. I was warned off internet-based EMR when I went shopping for precisely this reason.
As for “meaningful use”, I guess I’m glad the government is willing to give me money for a decision I made 9 years ago. I just worried this is more than a bribe. When are they gonna come back looking for the vig?
I’m thinking that some of those “We love you, guys!” comments on Facebook were written by PF staffers trying to control the tone, and tamp down on complaints. There surely weren’t m/any patients giving out High 5s.
But on this topic, we’re all patients. When it’s our records — or our kids’ records — that go “phhht” and the doctor is essentially winging it, that’s just a disaster waiting to happen. And I said “doctor” and not “psychiatrist” because this applies to all specialties and primary care physicians.
In our capacity as patients, it would be a good idea to find out what recourse, if any, we have in the event that we are ever injured by an EMR shutting down. And as patients, are we just supposed to stay for an appointment — and have it billed to us — when we know that our records aren’t available to the doctor? I’m guessing that PF and the other providers of EMRs don’t want us thinking about things like that.
Jackie,
Just curious what you mean by “find out what recourse…we have”?
We are all patients, customers, clients, whenever we are looking for service. If you go to a service provider (Doctor, whatever) and learn that your prior records are not available to them, do you automatically think recourse?
Just curious.
Hi geezer,
No, I don’t automatically think recourse, I think “how am I going to be impacted today by the fact that my doctor can’t access my medical records?”
Based on my assessment, I would decide whether or not I wanted to proceed with the medical appointment.
If I was there for something that didn’t require background information — like having a cut stitched up — I would have the treatment. If it was something that I felt did require my medical history — say, a change of medications when I have a complicated history involving more than one doctor and take a cocktail of pills — then I would want to reschedule the appointment.
So, who would pay for that “cancelled” appointment? It’s not my fault that I’m rescheduling — from my perspective the doctor wasn’t “ready to go” with all the information at hand to give me the best healthcare. It’s not the doctor’s fault either — s/he fully intended to provide the care but wasn’t able to consult my file.
So, what to do? Have the venture capitalists who currently own PF set funds aside to take care of the problems caused by service interruptions? Or are they expecting patients/insurance companies/Medicare/doctors to eat these costs?
And that’s just a simple problem, based on the above post. What happens when there’s an actual injury to a patient from using these EMRs? It’s all well and good for investors to sign up doctors, and hope for a successful IPO down the road. But where do the patients fit into this grand scheme? I don’t know the answer to that, and I don’t like not knowing.
I hope that answers your question. If not, let me know!
First I’ve heard the notion that a doc has some kind of duty to provide records at the time of a visit. If anyone ever successfully challenges their fee for that reason, all docs would probably just add a disclaimer to the treatment contract. Maybe the patient has some responsibility for keeping records, too. Or maybe like criminals are entitled to a fair trial, but not a perfect one, patients pay for a good enuf doctor visit, not a perfect one. I hasten to add that not having immediate access to complete — or legible — records did not start with EMR’s.
Moviedoc, I would think that a doctor would want to have the patient’s records on hand so as to avoid malpractice. If there’s a note in the file that a patient is taking a certain medication and a doctor prescribes something that has a serious drug-drug interaction with that, or that the patient has an allergy or takes St. John’s Wort, then the doctor who doesn’t take those things into account could be facing a potential lawsuit in the event of an injury. And I know that the pharmacy would probably catch that kind of thing, we’d all hope, but even then the appointment would have been a waste of time.
For me, I would weigh whether I wanted to get into that situation at all or whether it was safer for me to wait until the records were available. I guess I’m coming from the position that a doctor does/should consult the patient’s prior records before prescribing a medication, especially if that patient has a complicated history. And then, as I said previously, in simple scenarios the records being unavailable might not be an issue.
It’s not that the doctor would have a duty to provide records, in my opinion, but that s/he should consult records. And I agree with you that the problem didn’t arise with EMRs, but the EMRs can go down in an instant — with paper records, I would imagine that it would be known more in advance that they had gone missing/been misfiled and contingency plans made.
Now, while I believe what I wrote above, would it happen to me in practice? Probably not because I do keep records and I take them along with me to appointments. With a complicated history, I figure that’s in my best interest. It also helps the doctor — If s/he has a “why did we change that medication?” or “when did Dr. X order up that lab?” type of question, then I can supply the answer and we can proceed from there. If the records I bring aren’t required, then they stay in my bag.
Sometimes, a good enuf doctor visit ain’t good enough! And believe me, although I understand your point, I don’t think I’m paying “for a good enuf doctor visit” — ever.
I try hard to “pass for normal” and don’t disclose my mental problems in the community. I know it is a matter of time before my data gets hacked and the medical company won’t pay the ransom, and my data is all over the internet. It is no solace to me that everyone else’s dirty laundry will also be out there.
My social worker doesn’t even have an alpha numeric password on her new laptop which she is now required to use. When we talk, now there is this laptop between us, a barrier.
I guess now I ought to write up some neat summary charts for myself and my husband, and especially for my father, who has heart failure and on so many meds. I love to use computers, but they have not simplified my life!
Jackie, your example proves my point: “If there’s a note in the file that a patient is taking a certain medication and a doctor prescribes something that has a serious drug-drug interaction with that, or that the patient has an allergy or takes St. John’s Wort”
The doc would likely have to read the entire file on every visit to catch an old note about medication or allergic reaction in a paper record. Not going to happen. Before prescribing any new med a doc should ASK the patient if she has ever taken it before and what was her experience as well as all drugs she is taking now, including herbals and snake oil. I can’t imagine a scenario where it would make sense to postpone the appointment because the records was not available.
This is where the benefits of EMR outweigh the risks.
Moviedoc, here’s a scenario where I would postpone: A friend just had a prostate biopsy and an appointment was made to discuss the results, and treatment options. If he turned up and the Gleason score numbers and the full-color prostate shots were unavailable temporarily because of a glitch, then he could not make an informed decision about his health.
Same thing with lab reports — X rays, blood tests, etc. If that day’s appointment is about the results of those reports and you can’t access them, then the patient should reschedule — and should not be billed for the cancelled appointment.
I would also go back to the meds: Sometimes patients can’t remember what they’ve taken in the past, especially if they’ve been on different polypharmacy cocktails. Depending on the circumstances, it may be wise to postpone there, too.
So that’s what I think — and thanks for not shouting at me!
Lab/imaging result examples are most convincing, but often you can get those from the lab or other provider. Reminds me tho, that usually the appointment will not be a complete waste, and will not require a later appointment, just maybe a phone call. In my experience if a patient can’t remember the good or bad response to a drug it’s probably OK to give it another try.
I think if I knew a critical piece of info might not be accessible I would want to call the pt and offer to reschedule. I don’t require advance notice of cancellation anyway.
Dr Balt,
Thank you so much for your fair feedback. I can only imagine the type of inconvenience that an outage would cause to a busy practice. Here’s a note from our VP of Engineering, Matthew Douglass, on EXACTLY what happened.
Over the weekend, our engineering team worked to upgrade our data center to an entirely new platform designed to bring you faster access and more reliability with your EHR account as we continue to grow.
In preparation, the team conducted exhaustive testing for the past few months with a simulated daily load of users. While the testing was extensive, we experienced some unexpected events when a full scale load of live users logged into the new system on Monday morning. This led to some users intermittently not being able to login to the EHR account as well as some system slowness in the morning and afternoon.
Our engineering team worked quickly to repair the system and bring it back online. We know that having access to your EHR is critical to both your practice and your patients and we are confident in our continuing 99.9% Service Level Agreement.
The good news: Our new data center is performing well and is now providing the speed enhancements we were looking for. You should see a noticeable improvement in performance when you next login.
On a personal note: Your support throughout the day meant the world to us. We received calls and Facebook posts saying you were still dedicated fans of our free, web-based system. To hear this on our worst day, in the midst of a crisis, was powerful.
Thank you again for your patience. We appreciate your support during this difficult enhancement. As always, you can access real-time updates and get answers to your questions at http://www.facebook.com/practicefusion.
Best,
Helen Phung
Media Relations Specialist
Practice Fusion
helen@practicefusion.com
And PS for Jackie: They were all real Practice Fusion users, posting with their own Facebook profiles. You can visit our facebook page at http://www.facebook.com/practicefusion to see for yourself. We were amazed at the support of our community during this very rare disruption.
I didn’t see any support from the “patient community.”
Still, if your product is good, I’ll check out the IPO that is surely in the works.
Dr. Balt,
I’m very concerned with electronic medical records pertaining to psychiatric treatment. I’m not sure they are of much benefit frankly… They simply tell of how someone was functioning in the past, but nothing of how they might have recovered… in many cases, fully-recovered.
I find it frightening that these records would be kept electronically… And that an ER or other facility would have access to them, especially if someone has done their best to move beyond their past, and into living a full and meaningful life today.
Also, the DSM is hardly scientific… The labels that get placed on people are harmful.
Another article by Marcia Angell, M.D. – on the DSM –
http://www.nybooks.com/articles/archives/2011/jul/14/illusions-of-psychiatry/?page=1
Duane Sherry
Duane, a person can be “living a full and meaningful life today” with a mental illness. They are not mutually exclusive.
And about those labels you keep talking about, you may be showing your age (and I can say that, because you’re the same age as I am!). The young people I know don’t care about labels put on them by other people — they define themselves.
Now, is there a privacy issue with EMRs? Yes, but that applies for all of us, not just psychiatric patients.
Jackie,
I think it’s sad that kids are given these labels. I an think it may bother them more than we adults know.
I’m all for people defining themselves, even people our age!
I like some of the points your making about medicine at-large; you’re not alone in your frustration…
Medicine is highly political, and money-driven… for instance, cancer treatment… where people keep “racing for the cure”… where the American Cancer Society brings in money hand-over-fist (supposedly, non-profit)…
These “non-profits” are beholdent to drug makers also… Meanwhile, the mortality rate for cancers has not changed in 95% of cancer. With a few exceptions, specific types of cancer, there’s been very little progress.
IMO, if you want something done right, you sometimes have to do it yourself –
http://www.doctoryourself.com
Duane
I don’t much like the sound of doctoring myself, Duane. In fact, I’m scared to even look at the link!
Jackie,
One more quick-comment about labels.
The kids who are given these psychiatric labels don’t fully realize what they’re up against later in life.
A young person who has ever been diagnosed with ADHD cannot fly an airplane. Ever.
A young person who has been given the label of “bipolar disorder” or “schizophrenia” faces all kinds of issues later in life… Difficulty purchasing health insurance, life insurance, joining the military… restrictions on such things (depending on the state) as getting a hunting license, driving a commercial vehicle… A few years ago, Virginia was looking at passing a law that would prevent people who had been diagnosed with a “severe mental illness” such as “bipolar disorder” or “schizophrenia” from voting.
Labels cause lots of harm.
And they’re based on nothing of any substance, science… and in my opinion, dignity.
Duane
Duane, a young person who has bipolar or schizophrenia does indeed face issues now and later in life, because they have a serious illness.
It’s not the label, or diagnosis, that causes the problem, it’s the illness. Now, as I said earlier, the young people I know don’t care about the label and are accepting of those with the illness. Kids who have gone to public school with inclusive classrooms realize that their friend with a mental illness or their friend with a physical disability is just that — their friend.
My son doesn’t hide his illness, and he has a wide circle of friends at college. And why not, he’s a great guy.
Now, it may take time for the rest of society to catch up. It’s starting to happen — you can’t discriminate on health insurance, you certainly couldn’t deny voting rights, the military and the airlines now allow antidepressant use, and so on. Will there be parity in everything? No, because maybe it’s really not a good idea to accept someone with schizophrenia into the military. At least, not now.
Remember the olden days, when people with eyeglasses couldn’t get certain types of jobs, like police officer? That changed and this will change, too. And I don’t think the changes will take too long, either.
Jackie,
I think it’s very sad when I hear that a young person has learned to “accept” their “illness”… especially, if they’ve been taught that their “illness” is similar to diabetes, and they “need to take their drugs, like a diabetic takes insulin.”
It’s sad.
That’s all I can say, and all I’m going to say.
Duane
Somehow I suspect that’s not all you’re going to say!
yep
that’s it
I would rather pay than compromise my patient’s privacy. http://www.forbes.com/sites/kashmirhill/2013/10/24/practice-fusion-reviews-whoops/
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