If it weren’t so important, I’d let it go. You know how I feel about inflammation.
There is a great farce in the healthcare world that needs more exposure. It’s a terrible problem because it gets in the way of me taking care of you. It inhibits humanism in the practice of Medicine. It inflames me immensely. And I’m tired of quietly toeing the line.
It’s the idea that current-day electronic medical records improve the quality or cost of healthcare. Promoted by cubicle-doctors and wonks in think tanks, this fantasy was held up as the solution to the healthcare crisis. What a mistake!
First a couple caveats: I don’t use the word farce lightly. I looked up the definition and found this phrase: ludicrously improbable situation. No three words better describe the morass created by the forced acceptance of proprietary EMR systems. Second, I am a fan of computers and harbor no doubt that if done right, computers will enhance medical care.
Real doctors, those who actually see patients for a living, not as a hobby, have been writing about problems with EMR systems for years. We write about it because things that inhibit patient care get to the core of our self-esteem.
A review of the current situation is in order. A few notables on current-day EMR:
- EMRs interface poorly with users—doctors. Completing a medical record on an encounter for a common heart rhythm ailment requires me to click more than 25 times. (Fact: All doctors forced to use EMR either decrease the number of patients they see or they spend less face time with each patient.)
- EMRs don’t talk to each other—and in their current form, never will.
- There is not a shred of evidence that they improve real outcomes.
- EMRs function more as a billing invoice than a useful medical record.
- EMR systems are software behemoths that come with such high initial capital costs, that once purchased, a buyer cannot afford to change.
- Doctors are the end-users but not the customers of EMR companies. So our feedback carries little weight. There is no need to offer customer service. Why would there be? An Economics 101 student understands the concept. I get faster service from my cable company.
- EMR companies effectively answer to no one.
- And like many other government-created oligopolies, they have become immensely profitable. Even the NY Times took notice.
In writing these words, I hope to increase awareness of how a good idea has had dreadful results in the real world.
The lack of mainstream media attention to this farce has been surprising. Why would the public sit still and let a few companies get rich with a product that only makes it harder to get humanistic medical care? Why is that when doctors write about intrusive EMR systems, we are seen as greedy gadflies that should just get back to work? Why do my fellow doctors just fall in line and let themselves become data entry clerks?
As an optimist, I hope that a public conversation might help this dire situation. Perhaps recent attempts—by an EMR company–at intimidation of doctors who dare speak out might help spark a useful debate. When a multimillion dollar EMR company intimidates one of the good guys of Medicine, others notice. Influential medical blogger, Doctor Wes Fisher asks us to consider the ethical implications of this muzzling action? “What might a big multi-million dollar EMR company be hiding?” Another influential voice of physicians, Dr Bryan Vartebedian wonders whether “patients have a right to see and understand the EMR that their doctors are using to facilitate their care?” Dr V calls for “a very contagious public conversation” surrounding EHR. He wonders what would happen if influential patient advocates walked clicked in our shoes.
Perhaps it will be hubris–the great mistake of many of the influential–that exposes this farce.
Patients need to understand this is not about doctors. It is about their medical care.
Speak up. Make some noise. Get doctors off the white screen and back to the business of doctoring. Now that would be meaningful.
JMM
Ken Grauer, MD says
February 24, 2013 at 12:24 pmHi John – GREAT column in which you (as usual) speak the plain simple truth. When I was contemplating whether or not to retire from my academic & patient care position 3 years ago – one of the developments that convinced me beyond doubt I was making the right decision for me by retiring was ongoing implementation of our system-wide out-patient EHR product. I type very fast – I love computers – and I was saavy at time-saving charting. But despite that, EHR added a minimum of several hours to each patient care day. It literally took me at least an hour to “abstract” each of my regular patients before I’d see them the first time (to convert their previous paper chart into EHR charting). I’d cringe if I had 10 new patients scheduled in a day or two from now. Rather than quick dictation as one goes along after seeing each patient (with result that my charting used to be DONE after I was done seeing patients that day) – I found myself having to make notes in the room – and then after the day was “over” find a time of peace and quiet to contemplate what the visit entailed in order to summarize what transpired and what I’d do next visit – thereby adding hours to my day even when seeing patients who had been “abstracted” into the system. I realize others didn’t do this – but I did because I otherwise would not remember the details that transpired which are typically not amenable to the check boxes in EHR.
As mentioned – there was less eye-to-eye contact during the patient visit. I kept some eye contact (because I can type fast without looking at the keyboard) – but it was very different from days past … My impressions from speaking to friends who have been patients is that nowadays they rarely get the doctor’s undivided attention because of doctor focus on the computer …. How sad … How counterproductive …
Bottom Line (I fear) in our system – was that by eliminating transcriptionist fees – a lot of money was saved by administration. It didn’t matter that extra time was added to the physician’s day to put it all in the chart …. I didn’t feel my voice had any impact on how EHR evolved …
I’m sure if some patients respond to this post that their perspective will support your premise that patients like EHR even less than most doctors do …
P.S. I would bet that in the RIGHT healthcare system – small office (rather than large group practice) – just starting out in practice (so that hours wouldn’t have to be spent “abstracting” = translating paper to electronic charting) – and with the right EHR system that can be tailored to individual needs – that EHR has the potential to be a powerful tool. It wasn’t for me for the 9-month “snapshot look” I got of having to use EHR in my setting …
Dr John says
February 25, 2013 at 6:18 amAs always Ken, your comments add much to my posts. For this, on behalf of my readers and myself, I thank you. Please keep it up.
wcw says
February 24, 2013 at 12:41 pmInteresting reading your column. I just had a eye exam and it had been 5 yrs since my last one. I was surprised at how fast the doctor was typing and said to him “wow, you type fast” and he said i have to or i would be here all day. I don’t remember him ever typing the last time and now understand why he had to. Keep spreading your message so more of us understand what these “idiotologs” are doing to all of us.
BillH says
February 24, 2013 at 4:15 pm“Doctors are the end-users but not the customers of EMR companies.” Similar dichotomy between doctor/patient/insurance co/insurance buyer.
Eugene Chung says
February 24, 2013 at 6:17 pmI agree with most of the points made and also think it is extremely important for EMR systems to receive a “reset”. Couple of points to make. First, I don’t agree that ALL doctors are slowed down by EMR. That depends on how bad the pre existing paper system was. Don’t forget how ridiculous the paper charts were. Secondly for a busy inpatient service, I find the EMR indispensable. I used to spend significant time daily looking for charts. Yes there are problems w inpatient EMR but I gotta admit I could never go back.
Dr John says
February 25, 2013 at 6:16 amThanks for the comment EC. You make good points. About 6 years ago, my old practice had an EMR that wasn’t as bad as the current iterations. My hospital is trying to deploy an EMR for its entire network of doctors. This is tough because the needs of each group are so different. The inpatient arena makes for different challenges, but I still hold that unless doctors get help with interfaces and usability, they, like nurse, will spend less face time with the patient.
Allison says
February 24, 2013 at 8:40 pmDo you read Musings of a Distractible Mind? Here is his report on his EMR system. He’s been a user for 16 years and he just can’t stand the new one. It seems to be endemic.
http://more-distractible.org/2013/02/17/progress-report/
I am sorry your field is falling victim to the forces of people who are not experts but are more than willing to tell you how to do your job. I experienced them in my previous career which led to early retirement. It just was not worth it anymore.
Dr John says
February 25, 2013 at 6:11 amThanks for the link. Yes, I am a huge fan of Dr Rob.
Rob says
February 24, 2013 at 11:33 pmJust wrote another piece about my loss of faith in the EMR cause. EMR had the chance to simplify difficult things, but never reached that potential. I really feel like they could have made care better, but they have now been turned into data-generators. It’s sad. I am glad I can hop off of that train now.
Diane Wills says
February 25, 2013 at 9:50 amI read your post and the referenced posts as well. I’m a patient (and very much enjoy reading your blog).
I have an idea: Why can’t the medical transcriptionists be kept and trained to take your dictation and use it to enter the data into the EMR? Does the current health care law require the laying off of the transcriptionists? It’s sad that they are laying off low-wage employees and giving much higher-paid doctors hours of additional tasks instead, so they have less time for patients.
MJ says
February 25, 2013 at 12:32 pmDiane,
I am a transcriptionist whose livelihood has been strongly affected by EMRs. However, another nasty thing most patients and doctors don’t know about is that there is a lean toward voice recognition and offshoring transcription. We jokingly call it “voice wreck” because the theory is that a computer will recognize what a doctor says and type it. The transcriptionist has now transitioned to becoming an editor. We are then supposed to edit what a physician says. However, rather than paying us for our skill and knowledge, we are expected to take a 1/2 to sometimes as much as 2/3 paycut to unscramble gibberish. While voice rec sounds good in theory, it is horrid in execution.
Secondly, there is offshoring. That is where the transcription (yes, even into an EMR) is sent to a foreign country to be transcribed by non-English-speaking individuals. It is then sent back to the US where a former transcriptionist now medical editor is again expected to decipher the gibberish that these transcriptionists have turned out. Again for a 1/2 to 2/3 pay cut.
Unfortunately, doctors and hospitals are getting what they pay for. I’ve been dong this for around 25 years and was trained that we are on the front line for assuring appropriate documentation of patient care. Now it doesn’t matter if it’s in accurate. As long as it’s cheap. It’s literally horrifying to see what is being churned out for some of these EMRs. If I were a physician, I would not want to hang my license, degree, or integrity upon such a poor system. I truly feel for their situation.
Finally, there is one more item that no one talks about: The potential for a monopoly to form in the processing software development of EMRs. Of course the systems don’t talk to each other or integrate well. Why would they? It means that one business who is willing to market, deploy, and maintain an EMR stands to be the front runner and could potentially squeeze other EMR providers out of the market. Nasty but true.
Thomas Runyan says
February 25, 2013 at 11:15 amDoc, I went to the Mayo clinic becasue I could not find answers locally. Every doctor I saw locally I had to drag along piles of documents and re-explain every bit of information to every doc that I was referred to. At the Mayo clinic which is completely computerized I saw several different docs and each one knew who I was, what my issues were and were able to read the results of all of test. I think the biggest issue with medical care these days is lack of collaboration between docs especially if you have anything beyond a simple issue. The Mayo clinic convinced me that the use of computers work if implements properly. The days of having paper files in seven different offices with seven different docs who refuse to communicate with each other should end.
Teresa Clark, MT (and proud of being an MT, NOT an English Language Specialist!) says
February 25, 2013 at 11:52 amDear Dr. John,
A HUGE HUGE THANK YOU!! I am a medical transcriptionist in Ohio and it is a pleasure to read your column. FINALLY, the physicians are speaking out about this “farce”. It truly IS about the patient’s medical record and it’s so refreshing to see a physician finally speaking out about THAT. Again, thank you a million times and NEVER let anyone muzzle you. I will not be silenced until things change.
A. Bailey says
February 26, 2013 at 7:18 pmNothing will be done about this situation because it is the brainchild of the Obama administration, and substantive criticisms of the Obama administration are found only in the English or Russian press, or Fox News. Only fascists watch Fox News anyway.
MJ says
February 26, 2013 at 8:18 pmA. Bailey, that is incorrect. It is the brainchild of George W. Bush, set forth in a 2004 mandate that every American should have an electronic health record by 2014.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2274790/
A. Bailey says
February 27, 2013 at 7:24 amW. may have planted the seed, but it was Obama who threw billions of borrowed dollars in the guise of “stimulus” at this situation. Perhaps you are not familiar with the details of his program. Google “meaningful use”.
Ken Grauer, MD says
February 27, 2013 at 7:39 amTo A. Bailey – I don’t think Dr. John intended for the purpose of this post or his excellent web site to become a political battleground. I have been through these discussions – and they are without end (and without hope of changing the other’s viewpoint).
Andy Bailey says
March 1, 2013 at 9:21 pmThe disease will not be cured until the root cause is identified and dealt with.
Dr John says
February 27, 2013 at 7:47 amThanks Ken.
Come on you all. Let’s not get inflamed over politics. Namaste.
MJ says
February 27, 2013 at 9:44 amDr. John, have you ever heard of open-source electronic medical records, either entity controlled and/or controlled by patients? There is a push for open-source HL7 interface compatible records that will remove the profit-seeking portion of the program and instead put the control of healthcare back into the hands of patients and their physicians.
Brick Rigden says
February 28, 2013 at 10:18 pmJohn,
Just found your website. Very nice column. You are absolutely right. EMR’s are a billing tool not a clinically useful medical record. A good tool for data-mining. As you point out their major impact is less doctor-patient face time and/or fewer patients seen.
Dr John says
March 1, 2013 at 6:45 amHello friend. It’s been a long time. For readers, Brick and I learned electrophysiology together at IU. Thanks for your support of the EMR column.