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Mark A. Wolgin, MD, Orthopaedic Surgeon

Specialist (Fellowship Trained) in Spinal and Foot/Ankle Surgery, Albany, GA, Office Phone 229-883-4707

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Allscripts EMR

ALLSCRIPTS Electronic Medical Record System

 

Our practice purchased this system, and my thoughts are below for anyone who might be interested:

 

The following letter was submitted to the executive team (to Lisa Zvonik, assistant to president Paul Black) at Allscripts headquarters September 2013, and none of the problems addressed below have been corrected or changed.  As my frustration level has continued to rise with my use of Allscripts, and promises from the company go unfulfilled that changes might be made (and their promises to make improvements become less credible), I decided to post this fairly long review for any other medical practices who might be considering incorporating the Allscripts EMR system into their practice.

 

Bottom line:  If you are considering Allscripts, think twice.  My opinion:  don't do it.

 

Although the amount of information noted here is likely more than anyone would have the tolerance to read in full, I am noting many of my opinions in case any interested party wants to drill down to understand the problems and inefficiencies that I and my partners have experienced. 

 

I cannot recommend the Allscripts system.  Maybe all electronic medical records systems are poorly designed, inefficient, and are not able to be customized to the style of a particular practice like Allscripts, but a reader here can make their own assessment of the issues I outline below.

 

 

 

Lisa,
 
I had mentioned to you that I am an orthopedic surgeon, and our group has been using your system since January '13, and that I was and am a dissatisfied customer.  I mentioned that I had been working on this document for months to record the frustrations and problems I have had with your system.  I am finally taking the time to hit the "send" button so that you, and hopefully other high level executives in your company, will find my comments of interest.  Since I have been working on this email draft for months, you may note that some points are mentioned more than once, and each time they are mentioned, please assume a high frustration level and feel free to picture a head exploding.
 
Up until speaking with Natalia (a rep from Allscripts who tried to help, but no problems were solved) this past week, I have had nothing but frustration both using the Allscripts system, and through our training process.  In training, any question I raised, or any inefficiency I mentioned, or any aspect that didn't make sense, was met with a number of responses, the gist of which really amounted to "go pound sand."  The responses were usually one of these: 
--we are not doctors so cannot discuss any aspects relating to medical issues (like what are the elements of an office note or history and physical)
--the system was designed by doctors, and works fine for them
--the items I was suggesting or changes I was requesting could not be done.
Natalia mentioned that at least some of the elements we discussed this past week could be changed.  This idea is news to me.
 
As you read my screed below, you will note that I left in much of the anger, sarcasm, and frustration, as these aspects reflect my experience as an Allscripts user.  Also, while I recognize you very likely have a different opinion in this regard, I am left wondering what kind of discrepancy there was between how your sales people represented the ease of use and efficiency of your system to our office administrators to allow them to choose to go with Allscripts, versus the reality of using your system.  I can tell you that if the sales presentation was anywhere even close to the reality of the experience of using Allscripts, no sane person would choose this system.  Unfortunately for us, once a practice goes down the Venus flytrap of entering their data with an EMR system, the process of extrication is expensive and painful.  Therefore, I can see a high incentive for your sales team to say whatever they have to to get the deal, as once a practice signs up, they most likely can't escape.  Your company continues to charge high fees after delivering a product that I certainly regret buying, and yet we are prisoners.  As I reviewed the purchase agreement, your lawyers certainly did a good job of indicating in all capital letters all the ways your product has damaged us, and for which you take no liability.  Good for you, bad for us.  If the roles were reversed, would you be angry?  I suspect the answer would be yes.
 
As another data point, after we started using Allscripts, I went to visit another orthopedist in our town who had been using Allscripts for two years before us.  I went to see what types of efficiencies or suggestions or tricks they had, and to see what their assessment was of the Allscripts system.  As it turns out, a big part of their documentation included making photocopies of the doctor's handwritten notes, as they too had so many problems with the multiple clicks involved to record any data.  At the end of my visit with them, as I was standing at their work station with two physicians, a PA, and a medical assistant, I asked them if, after having used the system for two years, they've gotten used to it and if they actually like it, they replied in unison, almost like a scene from a movie, "we hate it!"
 
I know other physicians who have not had the visceral reaction to other EMR systems that I have had to Allscripts, but I can say that in our practice, to a person, nobody likes it.
 
Hopefully, you all can dissect out from my anger below some useful points whereby your system can be improved.  Until yesterday, and I have yet to see if Natalia can actually make any changes, the only feedback or assistance or indication that improvements can be made that I have heard back from Allscripts is....nothing.  
 
As you read through, and frankly, I wonder how much of my writing here you can tolerate, please be aware that once the assessment of your system reached the level of unacceptable and even ridiculous, the continued problems I and other members of this practice have had with your system have only served to cause more frustration and anger.  These feelings are reflected below.   
 
Mark Wolgin, MD
 


To Whom It May Concern,
 
I am writing this letter in case you might be interested in customer feedback.  
 
I have a negative impression of both your system and the training process, and I have experienced an indescribable amount of frustration and anger associated with the attempts to integrate your system into our practice.  I have been working on this letter over the last several months and have not sent it earlier for three discrete reasons:  
1) after implementing your system, I have chronically run behind in all my clinical duties and have been less productive, 
2) on nearly a daily basis, new problems and limitations of your system are identified, but there are less entries noted below as I have been trained to expect inefficiencies and disappointments, and 
3) every time I would try to finish up this letter, I would become even more angry and have to walk away from the task of trying to complete it.  
 
This document has been a running testament to an indescribable dissatisfaction with a product that has been so integral to the practice of medicine, and yet so poorly designed, and so inefficient that there had to have been deception if the process of selling this product to our practice.  If this product were a car, I would certainly have asked for my money back, but since the system had so little congruence with the realities of recording medical information, it would be like selling a car and asking the buyer to build their own engine. Totally unacceptable.
I am quite sure that whoever at Allscripts might be reading this letter, sitting comfortably in their corporate headquarters, will easily disregard the opinions below (as have the trainers when they were training us).  I will also assume that you regard your own review of the Allscripts EMR an excellent product.  Part of the reason for my delay in sending this letter is that I have no indication that your company is interested in feedback from the people to whom they sell their product.  As an illustration, our office admininstrator Cheryl Boyles received an email link to give feedback to Allscripts, however it was a dead link.  Along the lines of, if you don't want to find a fever, don't take a temperature, Allscripts as a company has shown no interest, as far as anyone in our practice can tell, about any feedback about problems or suggestions for improvement.
There is significant anger and dissatisfaction in the text below, and I have left these sentiments in since your company earned it.  If the recipient of this letter is not interested in this type of feedback, then read no further.  I am not sure what kind of response I might expect from your company, but at this point, after sending this letter, assuming that your response to me will be as underwhelming as your interest in customer feedback, please know that I will likely make it one of my missions in life to communicate through through my professional associations that no other physician or practice will have to subject themselves to the problems I have experienced by using the Allscripts system.
As mentioned, my editorial opinions are included in the comments below.  By including these reactions with my observations, I understand I may risk a potential reader of this letter choosing to discard it out of hand, but I chose to leave it in as I feel it is important for anyone in your company to know the feelings of at least this user.  
 
Like the adjectives pregnant, or unique, one either is or isn't.  The same characterization applies to the descriptors "acceptable" or "unacceptable," and your system is clearly the latter.  There really aren't gradations, but if there were, Allscripts would be so over the line into unacceptable territory, I find myself at a loss for words in this regard.  If the user experience could get more ridiculous with each additional error, it would, but it can't.  While I feel that a review can't get lower than "unacceptable," the multiple problems with your system just add to the frustrations.  Also, my opinions are shared to one degree or another by every person in our practice on both the clinical and the practice management (PM) sides.   
 
 
For the record, when I shared my opinions with the trainers your company sent, not only was there was no interest in any feedback, they were clearly resistant to any suggestions or to consider the possibility of any changes being made.  Instead, they simultaneously defended their system as being excellent, while also taking no responsibility for its design because they aren't doctors, and failing to acknowledge that Allscripts has any errors or inefficiencies.  Interestingly, there is language right in your contract/purchase agreement, in all capital letters, (paragraph numbered 13.3) which notes that Allscripts, not being engaged in the practice of medicine, is providing only an informational tool, as if this disclaimer would be a valid excuse for providing a dysfunctional product.  Imagine how well that excuse would go over with someone who bought a big ticket item, like a car, to find buried in the small print that the car company is in the business of designing cars, and makes no warranty that the car will actually run.  I wonder how long that company would be in business.  The difference here is that while a person can always get another car, once we start down the path with an EMR system, the divorce process would be exceedingly cumbersome and expensive.  I would think, therefore, in the sales presentations, there is a strong incentive to not give a complete presentation where the inefficiencies and potential problems of the system would be outlined.  Certainly, the sales people would not outline how the EMR system being delivered is incomplete, nor how much work would be required for building of templates and protocols.  If we happen to be the first orthopedic practice to whom you have ever sold your product, that fact should have been disclosed, as we should have had some discount for being the first ones on which you are trying your system.  Or, if you have sold your system to other orthopedic practices, there should be already embedded some templates, even if fairly boilerplate, with normal exams for various orthopedic body parts, off of which we could fine tune the details to fit our preferences.  Instead, to continue with the car analogy, you sold us an unfinished car, and have graciously allowed us to do the remainder of the work to make the car capable of being driven.  And, you charged us a lot of money so that we could have the privilege of finishing your product.  
I can see that from your perspective, once you sign up another practice, it's like an annuity for your company, regardless of the satisfaction of the customer.   As much as I would like to conclude otherwise, I have the firm impression that the people who made the sales presentation are guilty of the sin of omission, which is a form of deception, failing to reveal the problems with your system.  While I wish I had done more due diligence on my end, I unfortunately cannot roll back the clock.  However, since the cash from our practice is flowing into your coffers, I could see how you really would have no reason to be interested in my thoughts on your system.
 
From the outset, the trainers said we would get used to the system.  To a degree, their statement is true.  However, the same would apply to having your leg amputated:  you get used to it, but there is still not a day that goes by with some significant frustration involved.
 

EMR Background issues:
The following points are listed just so we're starting from some similar facts:
 
-The government is providing a series of incentives and disincentives to persuade all health care providers to use some sort of electronic medical records system.
-There are a number of criteria that have to be met to meet the qualifications for "meaningful use" so that funds can be returned to health care providers from the government to help defray the costs involved with the purchase and implementation of an electronic medical record system.  
-The medical record is integral to the doctor-patient interaction/relationship and must be a credible, quality document created in an efficient manner.
-As with any transition process, there would be a certain number of "speedbumps" that might be expected along the way.
-A medical practice would choose an EMR system based on the information presented during the sales process, and one would hope that there would be at least some correlation between the representations made in the sales pitch and the actual truth, since the creation and management of medical records are integral to the practice of medicine.   

We have implemented the Allscripts system in roughly mid January '13, and the frustrations have been present from the outset and still continue, examples of which will be documented below.  Even the word "frustration" is inadequate to describe the reactions to how my practice, almost on a daily basis at least for the first several months, was stopped dead in its tracks due to some feature of the Allscripts system.   Probably, "sabotage" would be a better word.  Although there has been some improvement that we learned in the first few months after becoming more familiar with, and working around the limitations of the system, patients still have to routinely wait longer, and our practice is less efficient.  I also believe that the transition process was made unnecessarily painful.  
 
I am documenting my troubles here for two reasons:  
 
1)  in case someone in your organization might be interested and probably more importantly, depending on the response I get, and 
2) to share my experience with any medical person contemplating the purchase of an EMR system so I can hopefully prevent them from going through what I have experienced implementing your product.  If I can save even one doctor from having to go through what I have experienced, the effort will be worth it.
 
My main points:  The Allscripts EMR system is 
 
--not intuitive, and not user friendly (e.g.: whereas everywhere else in the world of computers, you double click on an item to open it, with Allscripts some places you click once, and in some you click twice)
--not efficient (many mouse clicks needed for what should be simple tasks)
--the training was inadequate, and only reaffirmed all the features not available with this system
--there are many embedded errors in the system, with the excuse frequently offered that Allscripts is a computer company ("we're not doctors")...completely ignoring the fact that they're selling a medical records system, a system which has errors that would get a first year medical assistant fired.
--the company motto for any improvements, modifications, or suggestions for a system that was supposed to be customizable apparently is "just say no."
--although I was not present for the sales presentations, the representations clearly had to have been false and misleading, as a proper description would have disclosed the many problems that have been the hallmark of our transition to the Allscripts EMR system, and nobody would have seriously considered this system if an accurate description were given.

Although I am generally prone in the theme of "less is more" to communicate my issues without hyperbole, there have been many instances of frustration levels with Allscripts where the only appropriate descriptor what that I was, on an almost daily basis, livid.  I have lost sleep on many occasions as a result.   Your product has damaged our practice, and has jeopardized our relationship with patients, increased waiting time, and markedly increased physician frustration.  Some of these sentiments have been perceived by our patients as they have commented that we all have seemed stressed for the first few months.  Probably most importantly, due to Allscripts-related inefficiencies, the high cost of the Allscripts system, and our being handicapped to perform billable activities, the financial viability of our practice has been threatened.  I have found it a significant challenge to control the extreme anger I have felt at being sold the bill of goods that is Allscripts.
Since the medical record is such an important part of the doctor patient interaction, and since that process has been so corrupted by your system's implementation into our practice, I find it a challenge to express how much Allscripts has disrupted our practice.  I have had to rewrite this letter many times to remove the emotion and the expletives that seem to be the only way to express the feelings that continue to be generated on a daily basis by running into the roadblocks and design flaws noted with your system.  I can say that on a scale of 1-10, with 1 being poor and 10 being excellent, that giving a rating of 1 does not do justice to characterize the inefficiencies and frustrations that go along with using Allscripts.  While at this point, I have gotten used to it to some degree, the same could be said about having your arm cut off:  it's a terrible situation, it's irreversible, it's not your choice, your life is worse, and eventually you have no choice but to get used to it.  The final grade is "unacceptable, would not recommend."   Every day I use the system, I wish I could tell you all that you're fired.  And although I was not at the sales presentations, I also have to think there would likely be some subsequent prosecution for negligent misrepresentation or even fraud for the disconnect between how you probably described the system and the reality.
 
If I weren't so busy with all the extra time required trying simply to get my records done, I would have sent this letter sooner, and I would probably have made it my life's work to go on every online MD chatroom, and confer with every colleague I can find, and to share what I am documenting here and below, to save them from the bad experience I have had with your system, with the only solace being that maybe I can dissuade another healthcare provider from becoming an Allscripts customer/victim, and to hopefully save them from the same misery.  
 
While my description might appear to violate the "less is more" manner of expression, I actually could make the point stronger, but I don't know how receptive the reader of this letter will be to my feedback.  If Allscripts can offer a system so riddled with errors and hide behind the "we're not doctors" excuse, and still sleep at night, then the people at Allscripts and I come from different planets.  Additionally, given that my resentment at being sold your system with its design flaws and the accompanying poor training is so deep, I would question if this situation is even repairable.  Or rather, it seems to me that we're married now, and the only options are to either live in unhappiness or go through an expensive divorce.  
 
My points below are listed first from a general standpoint, and then with many examples.  As I will detail below, there have been new problems with your system that still occur practically every day.  And the only days when I don't have frustrations related to the Allscripts system are the days when I don't use the Allscripts system.

 
 
First, as a baseline, we can review what functions might one expect from an EMR system.  We could start by looking at the name (although it would seem absurd to start the definition here, as will be detailed below, Allscripts falls insultingly short for each of these important characteristics).
 
E = electronic, implying computers, with an expectation of better work flow, with improved efficiency, and less paper.  However, with Allscripts we're less efficient, and probably use more paper.
M = medical, like with doctors and patients.  However, the Allscripts system is a blockade to the doctor-patient interaction.
R = records, like the charts that doctors would keep for their patients.  However, Allscripts changes the way the data is organized in a manner that is different from, less personalized, and less intuitive than I had learned in medical training and in over two decades of practice.
 
We can detail what might be some reasonable expectations for an EMR system.

IMPORTANCE OF THE MEDICAL RECORD
 
As you may, or may not, be aware, next to the actual face to face time a doctor spends with his/her patient, the medical record is probably equally or possibly more important.  The medical record, which needs to be made in an efficient manner, is critical to the business of medicine for a number of reasons:
-it documents the provider/patient interaction as well as data collected, analysis of the situation, decision making process, and recommendations to the patient
-it communicates to any other providers, present or future, the salient health related details for that patient
-it stands as the receipt to the third party payor about the level of service that was provided
-it stands to defend the provider against any potential malpractice action
-it is important for quality measure reporting and to meet regulatory demands 

 
IMPORTANCE OF TRAINING FOR A NEW RECORD SYSTEM
Given the above importance of the medical record, it would seem essential that before the system were implemented, that the training would be at a point where the driver of the system would be comfortable, and demonstrate competence before the training wheels were taken off.  A person learning to drive a car, or fly a plane, would have many hours of supervised training to be sure that they do not crash.  They would not be given a 4-8 hr course and then be given the keys the vehicle.  They would have to demonstrate ability to perform all aspects of operation of their vehicle in a supervised fashion before the trainers would certify that they could operate on their own.  Although I understand that the likely company response would be that after the 4-8 hours of training that the trainers stayed for the following week, their role was essentially to continue out outline all the functions of what the system cannot do.

 
IMPORTANCE OF EFFICIENCY
Any business can survive only if revenue exceeds expenses.  In a service business, the revenue is generated by performing the service.  If a change to the business model were to occur where the service could not be performed with the same efficiency, the survival of that business would be in jeopardy.  
 
If a medical practice were reliant on a certain volume of business/patient flow, and a new system were implemented, that system would not be seriously considered unless the flow of patients and the volume of business could be the same or possibly more.  If a new system were to be implemented with the knowledge on the front end that the volume/productivity would suffer, but yet there were severe penalties for not implementing that system, an assessment could be made about which is the lesser of two evils (penalities vs. the drop in productivity) so an educated decision could be made.  I would expect/hope that this choice would have been clearly mapped out by any self respecting sales person.

 
GENERAL IMPRESSIONS:
 
The fact is that the transition to Allscripts EMR has been less than optimal in every regard.
 
My opinion, and that of all of my fellow practitioners within Orthopaedic Associates, is that Allscripts has made our lives worse in the above three categories.  While I was not part of the group that received the sales presentation, unless the presentation outlined the issues we have confronted, and until proven otherwise, I will assume that it was not, I suspect that a less than complete picture was presented to our office administrators in the presentation of this system.  Clearly, your company has a significant incentive to get a practice to sign up, as once we're in, our data is in, our billing and financial information is in, and the extrication process is extremely distasteful, cumbersome, and expensive.  With such high hurdles to a customer to potentially change companies, and with the potential to lock in a future income stream from the client, and since most businesses compensate their sales staff based on productivity (commission based reimbursement to the sales team), I suspect strongly that if we rewound the video of how this system was presented to our practice, there would be more of an impression of an incomplete representation.  I can't help thinking that what occurred here is either some form of negligent misrepresentation or some pitch that bordered on bait and switch.  However, I suspect the sales process was more the former, as the Allscripts system has had problems from our first encounters with it.  While I regret that I was not more involved in the decision making process, unfortunately I cannot undo that step.   
 
Your system has changed the medical record so that it is either harder to complete or is incomplete and makes it hard to decipher the thoughts and intentions of the provider, substituting important patient information instead for boilerplate.  There are aspects of your system that are user unfriendly and non-intuitive, or more specifically, just plain stupid, that make using this EMR system irritating and inefficient.  And the training was poor making the transition unnecessarily painful.  It would have been helpful if, on the front end of the training process, the representation started out noting: "you are going to hate this system, it can't do what you want it to do, it will take more time, you will be less productive, but you have no choice."  At least, expectations would have been more honest and realistic.
 
In the early stages of implementation of your system, with my feelings of frustration mounting, I sought out other practitioners in our community to see how they handled some of the problems I was encountering.  One doctor to whom I spoke is a very busy orthopedist in our community, who has been using your system for about two years.  I spent an afternoon with him and his assistant, the one who is the main person who navigates the system and does data input, hoping to get some of their tricks of the trade.  While they had some ideas, most of our discussions focused on the inefficiency of the Allscripts system.  The doctor had relied to a great degree on his handwritten notes, copies of which are scanned in, to survive an audit to justify his level of medical services provided.  They too found Allscripts to be too cumbersome and inefficient to try to negotiate an audit with the information recorded solely by using the drop down menu items within the EMR system.  Aside from his low tech suggestions (scanning his handwritten note), and after observing how this practice of two years was navigating your system, I finally asked, since they've been using it for so long, whether they were used to it and if they even sort of liked it?  Their response, in unison, "We hate it!"
 
Even the process of "seeing" patients has been corrupted.  The amount of time I have for face to face contact has been supplanted by patients now looking at the back of my head, as they watch me type and click in entries while I try to appear that I'm still listening to them, and each encounter takes much longer.  And this interaction occurs after I apologize for their waiting so long, since, unless it's the first patient or two of the day, they have waited significantly more than an acceptable time to see me (significantly more than they did before Allscripts) due to the inefficiency of the system.  We have been using the system for about a few months now, and at the outset, the trainers recommended that we see a lighter load in the transition period.  That information might seem fine to them, but if you think about it for two seconds, it's ridiculous.  As an example, think about what happens when you crimp a hose:  the pressure just builds up.  Currently, just to play catch up, with my current patients, at the expense of slots to see new patients, I am both working significantly longer (routinely now missing lunch and working hours overtime every clinic day), and seeing fewer new patients as I have to spend more time taking care of those I already am handling.  This change, among the multitudes to be outlined below, gives Allscripts a FAIL rating.
Clearly, I don't run your company, but I would think that for your business to be viable, even though it is so painful to extricate ourselves from an EMR system, I would think there would have to be at least some interest in maintaining a happy customer base.  The evidence, however is to the contrary.  Most likely, your company plans to focus only on short term profits, with efforts to garner more sales, and then hope to cash in by selling the company.  However, I wonder if there is some small place within your organization where customer satisfaction is important.  If so, please direct this letter to that part.  
 
Unfortunately, I feel that the experience of using the Allscripts system has been so oustandingly bad that I am unsure how or if this relationship can be repaired.  To present with a straight face such a terrible system introduced with insufficient training is, simply put, bad faith.  If I assume that there is that small part of your business model that wants to stay in business and get other customers from positive referrals (instead of people like me who will make it a mission to help others avoid this misery), and that there is someone within your organization that has a humanistic attitude that they would want to treat others as they'd want to be treated (which isn't like this), then I will outline below more information about problems I/we have had and how the experience has been so objectionable.  Then again, if your plan is to generate sales, get some cash, and get out of Dodge, you can again stop reading here.
 

OBJECTIONABLE ASPECTS OF ALLSCRIPTS SYSTEM:
TRAINING
First, the amount of training was entirely inadequate.  On 1/14/13, we went live with your system after the preliminary training provided by your company.  This training was represented as a week of training, but in fact was two 4 hr sessions for the main users, and less time spent for many others in the office.  To a person, nobody in our practice felt comfortable with the system after the training provided before going live.  As mentioned above the analogy would be like giving a non-driver a brochure and some lecture time, and then giving them the keys to the car:  on no planet would that be acceptable or appropriate.  Although our trainer, Jennifer Easter, would often end each session both not answering questions ("We'll get to that later," or "you'll see how that works when we go live," or would offer other evasive answers), she would end each session by saying "you guys are doing great!" when in fact we'd look at each other with no sense of understanding of how the EMR works, and no confidence in our ability to drive it.  Probably she was taking to herself, referencing her own review of her own teaching capabilities.  With no person in our practice feeling comfortable, we were essentially thrown into the deep end with our going live the following week.  However, as we were trying to learn the hard way in the live setting, more often than not, for any particular aspect of the system we might question, the trainer response was usually that the system cannot do what we want.  The particular function that we wanted the system to do was not possible within Allscripts.  After a while when the answer to the question is consistently "no," one learns to stop asking.
It is difficult to describe how inappropriate it is to take an element that is so essential to a medical practice, the medical record, and also the process of entering charges for the services, and to throw a practice into it without adequate training.  Not a single person in our practice felt adequately trained, and the trainers who were with us should have, again, prefaced their interaction with the disclaimer:  "our system is terrible, you can't do what you want to do, it will take more time, but you have no choice," so the expectations could have been more consistent with reality.  
We were given a brochure about a piece of heavy equipment, a few hours of computer training, and without having real competence, were given the keys.  Ridiculous.
 
With other physicians to whom I have spoken, there was significantly more training.  Either that, or their systems were more intuitive.  Other colleagues have had training that actually was a week, not eight hours (four hours for other employees who also had to use the system) spread over the course of a week.  These physician colleagues also described going over many different patient scenarios through the entire course of a patient visit, from the different perspectives of the different office people, so that the employees and doctors were comfortable with the process.  Nobody in our office was comfortable at the conclusion of our week of training.  While I understand that we had a training patient, and while I am sure Jennifer would disagree with this assertion, we never went all the way from "check in" to "check out" to see how the whole system works.  Aside from the overview aspects that were outlined for us during our eight hour training, actually working the system is a different experience.  Before going live, we never printed a prescription, nor saw how the drop down menus fit so poorly with the actual stories that a patient might tell us, nor appreciate how clumsy it is to modify the physical exam entries in real time.  All of these experiences were new when we were seeing actual patients.  If it were really true that, as Jennifer repeatedly noted to us, we were doing great, there would not have been so many speedbumps and near fatal crashes as will be detailed below, in the process of implementing the Allscripts EMR.  As time as shown, we were not doing great.  Her assessment was inaccurate.  The user experience was the opposite of great.
And, as an aside note, while Jennifer is clearly a bright person and understands the system thoroughly, she needs to keep in mind that her understanding does not translate to our understanding just by our being in the same room with her and breathing the same air as she does.  Not everyone knows it as well as she does.  Additionally, from my point of view, and this opinion has been shared by many in our office, if she wants to continue teaching, she should probably be aware that when she starts her answer with "as I've told you," or "as we've already discussed," that there is an implied "you idiot" at the end.  If she thinks that adding those phrases makes me/us learn better, she is mistaken.  
 
When asked about aspects of the system that make no sense from a medical standpoint, like where and why various elements are positioned in the medical record, Jennifer would often retreat one of a few responses:  
 
-that she's not a doctor (so can't address any issue...despite the fact that she is the trainer for a medical records system)
-that the system was designed by doctors (so, does that make everything alright?).  
 
In other words, she had an "out" for any question I might ask about system design whereby she'd simultaneously disavow any responsibility for the system design with regard to setting up a medical record system in a way that makes no sense, and yet still be able to defend the system about which one second ago she professes to know nothing.  In other words, she did not solve my problem.  She just said in so many words "can't help you."  
 
Just to be clear, regarding all the roadblocks Jennifer and her team would present to me for my questions, there should have been one of two responses:
--either I am unreasonable and have unrealistic expectations (which was what was reflected back to me), or
--she should have taken ownership of correcting the issues I was raising, and if needed, keep a list, and kick it up to a higher level.
As you can likely infer, I did not get any solutions for the problems I was pointing out.
 
Since an Electronic Medical Record system has the words "medical record" right in the name, I don't think it would be unreasonable for the person who is teaching the medical record system be versed in at least the kindergarden level understanding of what elements go where in a medical record.  These days, with so much information available at our fingertips with a click of a mouse, medical students, and even medical assistants, can learn the elements of a history and physical and the order in which they belong.  These issues are not complex, and I was not asking Jennifer for a medical opinion, such as what treatment she'd recommend for a certain condition.  I think the appropriate response would be for the trainer to either know the answer, or take ownership of the question, write it down, and then get back with an answer when one is found from her supervisors, as opposed to dispensing with the question with one of her two canned responses noted above.  To be more blunt, to have the trainer of a medical record system not know what goes into a medical record is inappropriate and unacceptable.  For our group to pay for training, and have a trainer who is not oriented to basical medical record keeping, is also insulting.  Maybe Allscripts thought we wouldn't notice.  Well, for our info, we did.  So, to Allscripts:  once again, you're fired.  Jennifer's responses were inappropriate and unacceptable.
 
As a corollary to the complaint noted above whereby Jennifer would not engage any questions about the system design, other issues arose with regard to the billing process which also in a function inherent to the workings of a medical records and practice management system (that is what you are selling, isn't it?).  Allscripts has modifiers built in to the billing screen, but any question about this aspect was met with the response that "this is not an Allscripts issue."  Given that the entire foundation of a medical practice, aside from the face to face interaction with the patients, is the medical record, and that the financial viability of a practice revolves around correct documentation for correct billing, I would think that any of these questions are indeed Allscripts issues, thus making her responses again both inappropriate and insulting.  I would think it would be the minimal requirement of competence of your training staff to know information about which they are doing the system training.  Then again, if your sales team disclosed that your company would be sending unqualified trainers, and we signed the contract, then I guess it's our bad.    
I believe that, to a large part, the inefficiencies, practice slowdowns associated with the transition, and the high levels of frustration could have been mitigated or avoided by better or at least adequate training.
 

SYSTEM DESIGN
 
There are many issues, which will be detailed below with daily anecdotes, about how the system would lose patients, classify information incorrectly, prolong times needed for simple tasks, and provide for non-intuitive and idiosyncratic modes of achieving certain ends.  As the weeks have passed with continued use of your system, I am still finding significant problems.
 
While Jennifer has noted that many doctors use the Allscripts system, there are aspects of the way the program is run that go clearly against that assertion.  The system has many errors and incomplete lists to leave the impression that either Allscripts has never been used with an orthopedic practice, or whoever was the final judge of what is to be included where is either not a doctor (which is not a valid excuse) or simply wrong.  Simple examples that come to mind include having an entire section of subjective data entries (pain) in the objective (physical exam) section.  
Just to elaborate here, as if I were explaining this issue to a young child, a medical record note, which is often referred to as a history and physical, is structured using the mnemonic of the SOAP note, where these letters stand for (and I can't believe I have to outline this for a medical records documentation company):
 
S:  subjective, what the patient feels ("I feel pain with overhead activity", or "I feel pain with walking" and represent things the patient would express to the doctor)
O:  objective, listing observations made by the practitioner about the patient (they have tenderness when the medial joint line of the knee is palpated), and also includes other information, like lab results or xray impressions
A:  assessment, what is the opinion of the situation after looking at all the data?
P:  plan, or what are we going to do about the problems we have just identified?
 
Seems simple enough, but in your physical exam section, which is objective, because we are examining the patient, there are entries for subjective data, like pain modifying factors.  Seriously, if you can't tell the difference between subjective and objective, you are, again, fired.  Jennifer offered that other doctors wanted this information.  If what she says is true, her answer is still not a defense for doing something wrong.  Also, from a company standpoint, I would allow that you could modify the electronic record for that particular doctor, and you can put their subjective information in the objective section, if he or she wants it that way, but to offer that same product to other customers who happened to have actually learned the difference between subjective and objective is, again, ridiculous.  Did the Allscripts team do their homework to see what goes into a history and physical note?  If a medical student presented their data in this type of fashion, they would certainly get a bad grade, if not worse.
Here are some objections about the organization of data in the Past Medical History:  the normal order of items is
Illnesses/Conditions (so we can see at a glance what other conditions might affect the patient's treatment, like the big picture other conditions:  is the patient a diabetic? cancer? asthma?)
Medications
Surgeries
Allergies
then Family Hx, Social Hx, Review of Systems (ROS)
 
Seems simple enough, but on your EMR, the first thing that we would normally look for, which is the illnesses/conditions section where there would be a list of the patient's significant medical problems, is the last item listed, under Other Past History.  Can you site for me the medical books that you used where it says to put the patient's most salient other conditions under a heading called "other past history" and how you should list it at the end of the section?  The way Allscripts has the information organized is that the major illnesses come after information that is irrelevant, like Pregnancy, and Travel and Immunization history.  Not only is this list organized poorly, but for you to deliver this EMR product in such a fashion, and have the trainers defend it and the hide behind the "we're not doctors" defense, is, again, ridiculous.  If you buy a product and find it is poorly designed, what kind of confidence does that give you in the competence of the designers?  Of their interest in customer satisfaction?   I don't know which doctors are your consultants, but like before 9/11, one would never have imagined that jet planes would be used as bombs, I would never imagine that I would be presented a system with so many errors. 
 
Other examples of gross errors, that are documented below:  
"Elbow reflex":  There is a biceps and triceps reflex.  I could see calling it an elbow reflex if you had no medical training, but can you cite the medical text that referred to this reflex using this adjective?  I could see that sentence being used by someone in kindergarden, but not by a medical professional.
Cervical effusion:  There is a listing in the cervical spine section of cervical effusion.  An effusion usually refers to a joint filling up with fluid, but what structure will fill up with fluid in the cervical spine?  What medical text did you consult to include that descriptor?  With which spine surgeon did you consult?
Tinel's sign in the shoulder region?  Does anyone there even know what a Tinel's sign is?  There is no evidence to support that they do, as this entry is nonsense.
 
When your company offers for sale a product with these types of ridiculous errors, how do you expect that your customers have confidence that you know what you are selling?  Even to use the excuse that "we are not doctor" is inappropriate, as these types of details are integral to the quality of your product.  
 
Another example of a gross error in organization of data within the history and physical is the manner of recording results for imaging (Xray, MRI, etc.) studies and labs, both of which are still considered objective data.  I am thankful that I don't very often need to look at lab data, as still after 8 months using your system I still have no idea where to put or look for lab data within your EMR system.  However, we, do interpret and record information about Xrays and other imaging study all the time. 
 
The location of X-ray results in the history and physical is incorrect (goes before the "assessment" section), and the manner of entering the data is not intuitive.  X-rays in our office are ordered on the day of the encounter by putting the X-ray under the appropriate diagnosis in the Assessment and Plan section on the desktop.  After the X-ray is done, if I double click on that X-ray in the Assessment and Plan section, the results wold not be able to be seen in the history and physical (how presumptious of me!  Why would I want my impressions to be recorded in the medical record, especially one that might get printed out and sent to the hospital or another doctor??)  If I enter results in this manner, they'd be as a comment, and would not show up on the printed version of the history and physical.  Or, I can note my impression by clicking on the Procedure results section in the left hand column, and then enter my review*, and then that information is still not on the history and physical that is on the computer screen, but can be seen on the History and Physical screen in the contact menu by clicking on it...under another tab.  Why does the X-ray information have to listed under another tab?  Again, for an aspect of a medical record that at least for orthopedics is used for almost every patient and at every visit, to have so many clicks required to see results or to enter X-ray impressions is both unacceptable, poorly designed, and ridiculous.  How many times can I fire you?  And, on top of that, to harken back to our kindergarden version of a lesson on what exactly is a SOAP note, X-rays are considered objective data and would be in the objective section of the SOAP note.  In that regard, they are typically part of the information that is listed before the Assessment and Plan section.  On the history and physical printed out with the Allscripts system, X-ray information is inserted within the Assessment and Plan section (should be before it), which is again incorrect.  Again, for such a fundamental aspect of how a medical record is organized, your system shows yet another example of poor design by programmers who leave me wonder what they were thinking.
 
One other cherry of a detail:  after I enter my review/reading of the X-ray, I have to click on the button on the top that says "Review" to show that I reviewed the X-ray reading that I just read/reviewed!  Great! Additional clicks!  Love it!  You guys are awesome!!
 
I have lots of objections about the organization of data in the Physical Exam section, many of which will be detailed below:  one of the first broad categories of the physical exam for any body part is Inspection. The word "inspection" (for the designers of the program who don't know what that word means) implies visually examining the body part in question.  On the Inspection category for spine, there is nowhere to list anything that might actually be perceived by looking, like for scars or marks, except by free texting. The data entry system with all your dropdown menus are so impersonal, inefficient, cumbersome, and in many cases irrelevant, that they are of little value.  There are so many areas where I would have to click, even after formulation of various types of physical exam templates, that the process is not made quicker. Perhaps your other customers have patients that fit into cookie cutter molds, but in our practice, they do not.  Each patient is different, and I find that I have to use free text in some manner on every patient. Then again, according to Jennifer, we should minimize our free texting, as the E&M calculator cannot read the text, and cannot assist in determining level of service for coding.  This particular functionality of your system, the E&M calculator, is therefore sabotaged and made worthless by your own system design.  So, did we get a discount off our system price since this feature is, with the amount of free-texting required for every encounter, essentially worthless?  Oh, wait, we didn't.    
 
In the physical exam section, the word "gait" refers to how a patient might walk.  One of the most common ways a person might walk would be favoring one side due to pain, which is called antalgic gait. If I search your system, I can find antalgic gait under either the spine section or the lower extremity section, but if I search "gait," under many of your sections, General, Neurologic, and others, there is no listing for this most common adjective of how a person might walk.  The General section has the word "limping," but that term is more of a layperson term and is non specific.  Poor design.
 
I understand that part of Stage 2 meaningful use focuses on exchange of standardized data to improve care and performance and introduce the idea of measuring process improvement.  However, your templates for entering physical exam data are so inefficient and poorly designed that I have had to use mostly free text in certain fields in order to produce a medical record that a) reflects reality and b) doesn't take forever to produce.  I have only been able to use your drop down boxes to a limited extent.  The more I learn about the meaningful use issues, the more I have the impression that this free text data will not be able to be integrated in a standardized fashion to meet these criteria, thus making your system not only inefficient, but guiding me down the wrong path to potentially not meet the government instituted meangful use parameters.
The way your system records range of motion also is ridiculous.  First, the category in Allscripts is called "ROJM."  I asked Jennifer what the "J" stands for, and she responded "joint."  I have to think I'm not the smartest guy out there, and even lay people get this, but if you're measuring motion, what else, besides joints, move?  Is the letter J there so we don't get confused with Range of Pancreas Motion?   Additionally, the geniuses at Allscripts have put a dash in front of the range of motion number, so at first glance, it looks like a negative number.  And, just for your information, since you all are confessedly not doctors, there can be a negative number on range of motion, like with a contracted joint or hypermobile joint, but your notations allow for, at no extra cost I presume, an additional level of confusion.
There are also many objectionable elements of your system in the Assessment and Plan sections and elsewhere.
When I prescribe a drug for a patient for which the system detects a possible interaction, I am asked for a reason for override.  I can provide the reason, but next month when the patient calls for a refill, I am asked to again provide a reason for override for a drug that the patient is already taking, without problems, and for which I have already provided a reason.  This type of repeat questioning of my decision, for a question I have already answered, not only is inefficient use of my time, but it even borders on harassment.
 
When I get a refill request, I understand that I can either approve, approve with changes, or reject the request, but the request comes from somebody to me.  When I make my decision about what to do and type in my response, I have the option of clicking send, to send my response back to that somebody who sent me the message, but with the current defaults of the system, I would be sending that response back to...wait for it...myself!!  Right on!!  Or, I can use the drop down menu to find from whom the message was sent, and put their name in the field for whom to send the message, and then send the response back to them.  Frankly, this type of inefficiency is simply poor design.  If we think about it, when you get a message from someone, and we want to send a reply, and have the message not come back to ourselves, the programmers could have a default be to send the message back to the sender.  This type of functionality could be incorporated into your system, just like it is for...oh, yeah, every email program in the world.  A proper design would have already figured out that the message will come from me, and go back to that somebody.  If there is a way around it, some way to change the options to correct this problem, nobody in the office can figure it out, and this issue is another example of Allscripts being inefficient and non-intuitive.
Since all surgeons have a procedural related practice, not just orthopedics, it is mind boggling to me how the system can be missing a global period calculator or indicator.  In case the reader of this document doesn't know (surprise!!), when a significant procedure is done, like a surgery, no other office billing can be made regarding that problem for the global period afterwards.  Usually, that period is 90 days, but for some procedures, it is 10 days.  There should be somewhere that can be prominently displayed the dates of most recent procedures, and the end of the global period.  I understand that computers can do this type of thing...although apparently, yours can't.  This finding is another common sense utility that is missing.  And again, I would disregard this complaint if, in your sales pitch to our practice, you disclosed that our practice was to be the first practice with doctors who do surgery to have the chance to try out the Allscripts EMR system.  However, I am getting the impression that that representation did not occur.
 
We still have continued trouble with having the system electronically send fax copies of an office note to a referring physician, with many idiosyncrasies about how to enter the number, whether to include parentheses or not around the area code, or whether to have a dash between the numbers, and how the system can save the number after it's entered, so that this aspect remains essentially worthless.  We still need to pay an individual to print out and send faxes, a salary that should have been eliminated had the function of sending fax copies to other doctors actually worked.  So, do we get another rebate for this feature that doesn't work?
 
When I search for a diagnosis, some aspects of the listings are incomplete.  For example, if I search "biceps tendonitis," there is an entry for Biceps Tendonitis, and Biceps Tendonitis on Left...but not on right.  How hard would it be to add right?  Did your doctor consultant say that this condition never occurs on the right?
 

In many places on the physical exam section, the system lacks pertinent negatives, like being able to indicate "no spasm."  Instead, only a positive can be indicated.  The system is not easily customizable.  I suspect you'd make the changes for us, but at additional cost of course, even if it is to correct mistakes in the product you sold us.

 

In the lumbar spine, under the "tenderness" section of "inspection and palpation," there are boxes to check only for "medial low back" and "over spinal column," but what are these?  I have never heard these terms.  If you are going to offer a product that might be used by an orthopedist, wouldn't you maybe consult with someone who actually practices on that particular body part, to at least get the terminology right?  A term like "over spinal column" is one that might be used by a lay person or a child, or maybe a non MD, like a chiropractor, but do you have spinal surgeons who use terms like this?  How about "midline," "paraspinous muscles," "posterior buttock"?  I understand that Jennifer said we have to build our own system, but for the amounts you charge, my opinion is that your sales pitch was clearly omitting the number of hours that would be required to either improve the system or make our practice slower and less efficient.  The sin of omission is still in my mind a form of fraud.  Can we get a rebate for the time we have had to spend to build out this partially finished product you have sold us?  How about for the countless hours of frustration?  How about the the time to work on this letter?

 

There should be a field, especially for new patients, that is part of the H&P:  how the patient came to the practice, to be reminded in case we want to keep that doctor in the loop.  There should be a section with a listing noting:  referred by....

 

There should be an easy way to insert a photo in the chart, especially for wounds.  

 

Reminding myself about the details of a particular patient when checking a chart to answer a message is also ridiculous.  When I check a patient related message in your system, and it's on a patient that I don't remember, I pull a chart.  The act of clicking on the icon to pull the chart brings up a dialogue box that asks me if I want to delete the message, which, if you think about it for two seconds, is completely stupid.  If I don't remember enough about the patient that I have to pull the chart, and I have to navigate through the chart to find the answer, and during the process I will probably forget the question being asked in the first place, why would I want to delete the message (that I have to answer!) before looking at the chart?  And once I find what I'm looking for in the chart...oh, wait, I just deleted the message!  Are you serious?  Again, this feature is ridiculous and you're fired.  Similarly, when I'm writing the response to the message and need to again refer to the chart, there is an option to "save draft."  I can click on that, but then if I pull up the message again, the saved draft is not saved there.  Although I know I clicked on "save draft," I still, despite clicking on every possible entry within the patient's chart, cannot find the draft, so I have to write my message again. My draft may be tucked somewhere in your system, but it's not intuitive, I cannot find the draft, and again, Allscripts is enraging and poorly designed.  Clearly your team has no regard for the experience of the end user.  But, do you care?  I don't know why I even ask that question.
When I write a note in the Assessment and Plan section and want to copy some of that text for pasting on a work note, even though about every computer in the world has cut and paste functions, with Allscripts I have to copy the text to the scratch pad, and then copy it from there to paste in the work note. This additional step is not only inefficient, it inspires in me the belief that your company has no regard for the time of their clients.  
 
When we get a note from our physical therapy department, it comes as a procedure result that requires a physician comment.  This procedure result needs physician input which I will enter, and then after I just typed it in, I have to click another box to note that I reviewed what I just entered (which is still beyond me), but when I type the first letter, I am stopped by a dialogue box that pops up with the heading "Reason for Change."  There are two choices for me, either "initial entry" or "error entry."  This feature is obstructive and irritating.  This same roadblock/obstruction happens when I attempt to type in any other field, like the Physicians Report Continue/Discharge section, or the Comments section.  Ridiculous.  Now you're just insulting us by offering this clearly terrible product.
 
Your system cannot produce a patient information handout that includes any illustrations.
 
I look at my list of procedure results to review, and there are patients whom I have never seen, on my list to review their results.  Makes no sense.  Apparently, the results to be reviewed are note segregated by physician, so if another doc orders an xray, and if I look at the patient and see the result is to be reviewed, I have to take the extra steps to see who saw the patient on the day that study was ordered so see whether or not it was ordered by me.  This additional step could be avoided if the physician ordering the test were indicated...but it's not.
 
There are warnings that come up, like "this patient has unresolved recommendations," that we just learn to ignore.  I get a dialogue box warning me about drug interactions every time I prescribe a drug, even though I have already prescribed the medicine and provided a reason for override.  More inefficiency.
 
We can't put in a patient's nickname without adding that information to the PM side, a change that could potentially jeopardize insurance filing since their nickname may not be on their insurance card, or without adding a reminder to come up every visit, like an important item to be flagged every visit and to be cancelled every time the chart is opened.  Maybe you all have never been to a doctor, but if the doctor remembers something special about you, you feel more cared for.  An example of that "something special" might be...wait, let me think a minute...oh yeah...how about THEIR NAME!  Additionally, without adding the pop up alert to every visit, there is no way to indicate on the top line if there would be a name alert, for when there is more than one patient with the same name.  For your information, I have had the situation where in one clinic day, I had two patients both named John Williams.  It would be helpful to know to double check the birthday and other identifiying information for multiple patients sharing the same name.
 
For work comp patients, they are approved only for certain body parts.  There should be somewhere easily accessible for each visit that the approved body parts are listed.  There should also be a feature to add a note, like which adjuster approved that body part and when.  Similarly, there should be a place to list the name of the referring physician without having to enter the PM side of the system.
On some parts of the desktop screen, to open the field, like for messages or appointments (the items in the columns on left or right) you click once.  To open items in the center of the screen, you click twice. This feature is not intuitive, and since every one else in the world opens items by double clicking, if for a moment I revert to the "what is normal elsewhere in the computer/internet world" setting and I double click to open the field to see how many messages I have, the double click opens and closes the window instantly, resulting in more frustration and more time spent learning and re-learning the idiosyncrasies of this system.  
 
When we open a document that has been scanned in, the icon that would normally be the arrow on the screen, moved by the mouse, defaults to the hand, which is not very useful because a) the printing is small as the whole document is fit to the small screen and b) since it fits the whole screen, there is nothing for the hand to move.  Additional clicks are required to open the magnify feature, and even then, I can't scroll up and down on the document by using the wheel on the mouse (again, like everywhere else in the world) without moving the mouse to the thin area on the right side to grab the scroll bar to move the magnified document up and down...another inefficiency.
 
If I bought a car with this many design flaws, I would want my money back.  Based on how many customer surveys I have received (hint:  it's zero), you clearly don't care about the customer experience, and from that, I would infer that you don't care about any problems a customer might have.  We'll see if you even have made it to this far in this document.  Don't worry though, I am sure I will find other readers who might be interested.  Hopefully you will be able to sell the company before any potential buyers find out the truth about your product.

 

 

 

SYSTEM EFFICIENCY
 
Allscripts has, at least for me, made the practice of medicine inefficient.  Although we have been advised to construct templates, and although I have done so, not every patient fits a template.  The time required to click on certain data points to use your entries has made me revert to significant amounts of typing. On our "go-live" week, one of your trainers even noted that with the amount of typing I was doing, that "your practice has purchased a very expensive word processor and printing system."  I would concur with his opinion.
 
One suggestion made by the trainers was that I use the Dragon dictation system I had been using before changing to Allscripts.  However, with Dragon, I am dictating to a non standard window, so the features of Dragon don't work, including simple features like starting the first word of a new sentence with a capital letter, and typing all the words I actually say (a feature which works great if I am dictating into a Word document).  One trainer offered that I could open another text box, dictate into that box, then copy that box, and paste that info into the field where I want the text.  This suggestion is so ridiculously inefficient that I am amazed that the trainer could even offer it with a straight face.  Then again, the trainer gets a paycheck from your company, so they're not likely to agree to anything that would imply your system isn't the best.
Your sales people suggested that we buy many ipads to carry around the office with us for portability as we input information during our interviews and exams with patients.  Perhaps your company didn't check on the products you recommended, as the Kensington Folio keyboard which we purchased at your suggestion connects to the ipad by bluetooth, and although most of the keystrokes are recorded, the key word here is "most."   Not all keystrokes are.  In other words, you can type using this keyboard, but you have to check very carefully to find the missing letters that are noted not infrequently, so extra time is required to check what we just typed.  To consider using the touch keypad on the ipad is simply unworkable.  And again, your ipad app, the Wand program, is not intuitive and at best has limited applicability.  The format on Wand is very different from the format on the desktop, so you are offering us not one but TWO confusing and only semi-workable EMR systems, neither of which is even approaching satisfactory.  Having watched every video instructional I could find by searching both your website and the internet widely for the key words "Allscripts Wand," I can say that there are certain functions that are available on the desktop, but not available on Wand.  Also, with my experimenting with the Wand on a ipad, I cannot figure out how I could see the same encounter on both the ipad (Wand) and the desktop (note, since initially typing this letter, Natalia has shown me how to be on the same encounter on both the Wand and the desktop, but I certainly couldn't figure it out on my own).  If I have to enter data on the ipad and then save the encounter as historical summary only, that information and work to create is is not billable, and I cannot incorporate it into the current active billable encounter.  Although I am open to learn about how to better use Wand, and as the physician here most interested in computers and making this all work, I have to say the use of the ipad at least at this point would be graded with another "F," although I guess you can't get a lower grade.  As I was reviewing the instructional material on the internet for how to enter physical exam details on Wand, the example they use for dermatology condition (http://www.youtube.com/watch?v=e924J07_Zgw) carries the check boxes to a final diagnosis.  Again, since nobody there in your company has ever done a history and physical exam, and apparently either doesn't know how this information has been organized for decades before Allscripts came along, the actual diagnosis goes in the ASSESSMENT section, not in the physical exam section.  However, your program lists the diagnosis in the physical exam section.  Apparently, either Allscripts is changing how a history and physical is arranged, and what information goes where, or I just didn't get the memo about how the paradigm has changed for how to do a history and physical.
Does Wand have auto replace text?  I can't see how to use this function. (I have since learned from Natalie how to do ipad shortcuts, but without her special additional advice, I could not figure it out from the training materials I saw).
 
I am left wondering how much more we get charged for the Wand feature, as, at this point, I am the only one even trying to use it.
 
The different fields for your information organization makes your system unworkable and inefficient. While we can scan in documents from before going to EMR, or outside documents, we cannot look at a scanned record and toggle back and forth between that record and the patient chart to where we would enter some of the data from that scanned record.  Multiple inefficient mouse clicks are required to go between looking at a scanned note and the data entry fields at a cost of significantly more time and frustration.  Even though the system should allow us to use less paper, we instead have to do more printing, or have old charts available, even though they have been scanned, to avoid the extra time for this toggling.  We are left to choose to spend our manpower time to either click back and forth multiple times between windows, or have our medical records clerk scan the charts, and then still have to deliver the charts for our review.
 
In the physical exam section, the provider should be able to add notes to each subsection.  For example, in the Upper Extremity section, like for Clavicle, or Scapula, or Shoulder, there should be a section at the top to add a note, but there is none.  There is only a hammer icon, which is useless, unless we want to hammer in another template to this area.  A note section would be helpful to organize the data, especially since your system is so cumbersome and inefficient.
 
Since the system is essentially a very expensive word processing program, the fact that Dragon doesn't work in your fields is additionally frustrating.


 
TRANSITION PROCESS
 
Although it was represented that it will take several months to transition to full use of EMR to get the active charts entered, aspects of your system make the transition harder than it has to be.  As mentioned above, looking at the scanned documents is an inefficient process.  Continuing to hunt down charts (since it is more time efficient to look at the old chart, instead of either toggling back and forth between scanned copies, or printing out copies of the scanned documents) also adds more time for that duplicate work.
 
The system was delivered with numerous errors, no basic templates, and many aspects of the system that were essentially non-functional, such as the E&M calculator (doesn't read free text, which is the format I have to use), or the ability to include a patient's photo (this capability was added a few months after I wrote this, the it wasn't available for a few months), or even list the primary care physician at the top.  The system is customizable only to a point, so instead of allowing physicians to tailor their record to how they like to view and add to it, we have to learn to paint within the Allscripts lines.  Therefore, aside from learning a new system, we also have to learn where we can strategically place bits of data so we can find them because the way Allscripts manages the data is not inuitive.  The transition therefore is made more difficult by the design of the system.
To my understanding, part of the utility of having an EMR system is also to provide remote access.  When I'm on call and a patient calls in with a question, I should be able to access their chart from anywhere with a computer.  That function, after about six months using this system, is not even close to functioning.  I am sure the executives at Allscripts will say that this feature not being set up is somehow our fault.
 

YOU HAVE CAUSED DAMAGE 
 
(but don't worry Allscripts, as will be noted below in your purchase agreement, none of this is your fault!! Yay for you!!)
 
I can tell you that my schedule has been less than full because of the inefficiencies of your system, and as a result, we are not able to bill and collect due to the inefficiencies of your system.  Additionally, each week, even though I am operating as quickly as I can, there are one or two patients who, even with my lightened schedule, leave as a result of the prolonged waiting times.  When a patient feels disrespected enough, and has waited long enough, to walk out, what do you think is the chance of their coming back? What do you think they are going to tell their friends about how our practice treated them?  Again, don't worry, they won't even know your name, nor will they care.  
 
I often have felt during the first few months of the transition that I would like to put a sign on the front door:  "Notice to Patients:  Thanks to Allscripts, Orthopaedic Associates will now be closing.  The bank will be repossessing the building.  Have a good day and a good life.  Oh, and about your orthopedic problem, walk it off."
Although I was not present at the contract signing, the trainers clearly outlined during our "training" that we will have to build our own system, and reinvent the wheel from a documentation standpoint, an endeavor which will take weeks or months.  With this situation being the case, it is beyond me how a product can be offered with a straight face to a group of doctors, with an implementation process that goes live with minimal training, and with incomplete documentation, not to mention the dysfunctional and inefficient aspects built into your system.  Was it somewhere noted in the contract that we were informed that from the first day we can expect to have massive inefficiency?  Was it specified in the contracts that you will be slowing down our business, jeopardizing our financial viability, that we will see half the patient load in twice the time, and we will still pay you for that privilege?  Was it specified that, thanks to Allscripts (but probably you would blame us for being slow learners) we should be prepared to suffer in our relationships with patients due to prolonged waiting times?  Actually, as noted below, you were prepared for that type of complaint, and for the damage your company has and will cause, and we have to absolve you of all liability!  Sweet!  
 
Mandy and Brandy, our in house Allscripts experts, were hustling at 110% to answer the multitudes of questions and get us through the speedbumps, inefficiencies, and non-intuitive steps involved with getting your EMR to work.  Was the need for two full time employees to be pulled away from their regular jobs for weeks on end outlined in your proposal to our practice?  Wait, again, another score for Allscripts...no liability for increased employee hours per the purchase agreement!!


 
REVIEW OF PURCHASE AGREEMENT
 
Having not previously purchased an EMR system, I cannot comment on whether your prices are either fair or appropriate, but I can say how your agreement both misrepresents the experience for the end user and is clearly one sided, as opposed to a partnership/supportive type of relationship.
 
Your agreement outlines an estimate of provided training hours, which on paper might seem like a lot, but wasn't anywhere near adequate.  Additionally, there is an implication or assumption that the training will be of a certain level of quality, as opposed to having questions answered with "we'll get to that later," or "you'll get it when the system is up and running," or "that change can't be made," or "this is not an Allscripts issue," or some other version of a non-answer.  In fact, in the purchase agreement, there was no indication of what recourse we have when the training is inadequate or substandard, nor was there any indication that the client would be satisfied.  I personally had a total of about 8 hrs between two half day sessions, but much of the training was cursory, and questions were not answered, and the training did not result in my being competent to run the system.  To an individual, every other employee in this practice had the same feeling about the training being inadequate.  We never followed the progress of a training patient from check in to check out during training with different patient scenarios like those we might actually encounter, with actual patient questions,to review issues like global periods and modifiers, and procedure codes, etc.  
 
Also, I note in the purchase agreement how the liability to Allscripts includes no liability being taken whatesoever for:
 
-special, indirect, consequential, exemplary, or incidental damages or any damages whatsoever resulting from unauthorized access to the system (okay, fair enough), but then they go on:
-loss of use of data (there have been times when I have been paralyzed in the office, system locked, and I can't do anything for an hour, all while patients wait for their problems to be addressed):  no liability
-loss of profits (Allscripts makes me unable to see the same patient load):  no liability
-loss of goodwill (patients wait now 3-4 hours, and many have left in disgust feeling disrespected):  no liability
-additional employee hours (clearly more hours were required, and our main two in house experts also will attest to a high level of frustration with your company, and we lose their productivity for their previous jobs):  no liability
-loss of anticipated savings:  no liability
 
Too bad for you, suckers!!  Great news for Allscripts!!
 

SUMMARY
 
I don't know how the system was represented in the sales process, but based on how much frustration I have felt with its implementation, either your system has way too many problems to be represented as fully functional (like you sold us a lemon of a car), or as you might be concluding at this point, I just have a bad attitude.  Either way, my subjective impression is that, as with many sales representations these days, the trend is to overpromise and underdeliver.  Unfortunately for us, the entry process into an EMR system is like going into a Venus fly trap:  easy to enter, but hard to get out.  In the meantime, I remain highly unsatisfied and don't know what, if anything, you all can or might even suggest to remedy this situation.  Clearly, your response (or lack thereof) will be shared with any colleagues interested in choosing an EMR system, or possibly to as many as I can find with whom to share this screed.
 
Maybe I'm unrealistic, but given that I spend a good part of my day trying to do the right thing for patients, and given that the only proof of this work is the medical record, and that this record speaks to insurance companies, medical reviewers, sometimes to attorneys, and to other doctors, the past, present, and future of that particular patient's condition, and that the record is exquisitely important, the poor training, and the design flaws, inefficiencies, errors, and other problems with the Allscripts system are maddening and make the Allscripts system as a choice for EMR completely unacceptable.  
 
Also, it appears that I am not alone in my dissatisfaction.  According to this recent article,  http://www.amednews.com/article/20130408/business/130409959/4/, EMR satisfaction has dropped from 39% in 2010 to 27% in 2012.  Maybe the new rules, which nobody exactly explained, is that this new system is coming and it's terrible, and you have no choice.  I certainly don't recall anyone from your staff presenting your system in that light.
 
I normally would write this letter with an eye towards making some sort of constructive move forward, but I don't really see how this situation can get better.  The Allscripts EMR system has moved the practice of medicine a quantum leap in the direction of being more unpleasant, and I struggle to see how these recent trends of making medical practice more unworkable can be sustained.
I would have submitted this letter sooner except for two issues:
 
1) I continue to find, on a daily basis, more problems with the system, and
 
2) I have had no time to write it since I have been so inefficient in my practice by using this system, chronically running behind 2-3 hours.  
 
Given the inefficiency of the system, the recommendation make by the Allscripts trainers of making a lighter schedule during the adjustment period really was not much help, as it just kicked the current patient load further down the road, which is only a temporary delay, for which I would have to either compensate later by making up the deficiency, or losing those patients.  I mentioned this analogy before, but if the patient flow is thought of as water flowing through a garden hose, what happens to the pressure when you kink off the hose?  (hint:  it goes up.)  What were the trainers thinking with this type of suggestion?  For several months, I was having to see more than my normal load just to keep up with current patients.  Since working the Allscripts system is like pedaling a bike through sand, I still have a hard time potentially finding more spots for new patients, since it is not uncommon for an encounter to take a certain time for the exam and recommendations, but another 10-15 minutes to get the information in the computer, arrange their prescriptions, and any other medical record related work.  To this day, even with the templates and all the tricks I have learned, my delivery of care is still less efficient than before we used your system
By the way, although I was not part of the discussions on the sales side, and I can only speak for myself and not the entire practice, but, what exactly is your policy for unsatisfied or unhappy customers?
I suspect it can be summarized as follow:    
 
(sound of crickets....) 
 
 

 

:(