“The Tragedy of Electronic Medical Records”

Yves here. We’ve written about the pitfalls of electronic health records in the past. One of the surprising reactions is the “dazzled by technology” response of some readers. While there are problems with relying on paper-based records, and electronic records could in fact remedy many of them, a large swathe of the public seems unwilling to hear that what is good in theory may not turn out well in practice.

The sorry fact is that electronic health records, which in theory should reduce errors and allow for more consistent delivery of medical services, were instead designed only with patient billing and control over doctors in mind. As a result, they are if anything worsening medical outcomes. One indicator: as we reported, the latest ECRI Institute puts health care information technology as the top risk in its 2014 Patient Safety Concerns for Large Health Care Organizations report. Note that this ranking is based on the collection and analysis of over 300,000 events since 2009.

This is another example of crapification. Electronic medical records have been implemented, with apparent success, in other economics. For instance, when I lived in Australia from 2002 to 2004, it was normal for doctors to make use of them during patient visits, making entries into the system, and I never got the impression they found it onerous. Here, in New York City, I still see doctors making considerable use of paper records. As the article indicates below, the reason is the US systems are costly, lower productivity, and make doctors less likely to review patient information.

By Informatics MD, a medical doctor, and medical informatics professional via NIH-sponsored postdoctoral fellowship at Yale School of Medicine. Expertise in clinical IT design, implementation, refinement to meet clinician needs, and remediation of HIT projects in difficulty in both hospitals and the pharmaceutical industry. Former Director of Scientific Information Resources and The Merck Index (of chemicals, drugs, and biologicals) at Merck Research Labs. Faculty, Drexel University, College of Information Science and Technology, Philadelphia, PA.. Originally published at Health Care Renewal

The Indianapolis Business Journal has published this article, citing former head of Indiana University’s Regenstrief Institute, a world leader in EHR research, Dr. Clem McDonald:

The tragedy of electronic medical records
October 23, 2014
J.K. Wall

It wasn’t supposed to work out this way.

Digitizing medical records was supposed to transform health care—improving the quality of care and the service provided to patients while helping cut out unnecessary costs. Just like IT revolutionized all other industries.

Perhaps they still will. But lately, electronic medical record systems are getting nothing but votes of no-confidence from physicians, hospitals, insurers and IT experts.

Dr. Clem McDonald, who did more than anyone to advance electronic medical records during his 35 years at the Indianapolis-based Regenstrief Institute, called the 5-year, $27 billion push to roll out electronic medical records “disappointing” and even a “tragedy” last month during a talk with health care reporters (including me) at the National Institutes of Health in Bethesda, Maryland.

I agree with those sentiments.  The botched industry approach to clinical information technology has set back the cause of good health IT severely, largely through clinician disenfranchisement.  That dissatisfaction and disappointment will not be easy to reverse – and never should have needed to have been reversed.

… “It’s sort of a tragedy because everybody’s well-intentioned,” said McDonald, who spearheaded one of the nation’s first electronic medical record systems at Regenstrief and what is now Eskenazi Health. McDonald’s work in Indianapolis on the electronic exchange of medical records put patients here at least a decade ahead of those in most of the country in benefiting from the technology.

I’m not so sure that perverse behaviors such as willful blindness to the risks, profiteering, and indifference to harms caused by these systems, as I’ve documented at this blog and elsewhere count as “well-intentioned” (e.g., “FDA on health IT risk:  “We don’t know the magnitude of the risk, and what we do know is the tip of the iceberg, but health IT is of ‘sufficiently low risk’ that we don’t need to regulate it” (http://hcrenewal.blogspot.com/2014/04/fda-on-health-it-risk-reckless-or.html).

… McDonald now has a nationally influential post to promote electronic medical records, as the director of the Lister Hill Center for Biomedical Communications, a part of the National Library of Medicine, which is one of the National Institutes of Health.

During his talk, McDonald released his latest research survey, which found that electronic medical records “steal” 48 minutes per day in free time from primary care physicians.

That may be true regarding data entry time.  I’d say the amount is likely more when accounting for confusion and communications difficulties that bad health IT causes.

… One-third of physicians surveyed said it took longer to find and review medical record data. One-third also said it was slower to read other clinicians’ notes.

Some docs don’t even read reports any more. This is a perverse side effect,” McDonald said, noting that the electronic reports have so much information in them, that they become “endless and mindless.”

I have used the term “perverse” in the past regarding commercial health IT; this is the first time I recall seeing the term from one of the EHR pioneers.

… More bad news about electronic health records came out this week in a new research study. It found that physicians using electronic medical records spend an extra 16 minutes per day, on average, doing administrative tasks than their peers who still use only paper.

The study relied on data from 2008—which when compared with McDonald’s study suggests EMRs are now consuming more of doctors’ time than they were before the federal push to expand their use.

“Although proponents of electronic medical records have long promised a reduction in doctors’ paperwork, we found the reverse is true,” wrote study authors Steffie Woolhandler and David Himmelstein.

Yet we still hear promises about “increased efficiency” and reduction of clinicians’ administrative tasks and paperwork due to health IT.  When will that canard be put to rest, one might wonder?

In my view, the experiment of making clinicians perform EHR clerical work has been a failure.

And it was, in fact, an experiment in the full sense of the word.  It was done with little clue as to the true effects on patient care.

From the article:

… So with so many so upset with electronic health records, why is McDonald still optimistic?

He thinks the problems folks are having aren’t inherent to the technology itself, but are instead caused by overly restrictive rules coming both from the federal government and from hospital systems.

Hospital systems, knowing that more information can be recorded now that it’s electronic, have insisted that doctors do more documenting. McDonald cited one research study that found that documentation requirements have doubled in the past decade.

“I think they’ve got to ask less,” McDonald said of hospital administrators. “Nobody has any idea of the time-cost of one more data entry.”

I don’t share that optimism or a belief physicians will be asked to “do less” with EHRs, since physicians have essentially abrogated their professional independence and autonomy, and are increasingly becoming servants of their business-degree masters – and of bad technology.

At least nurses are fighting back, e.g., per National Nurses United (see query link http://hcrenewal.blogspot.com/search/label/National%20Nurses%20United).

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  1. fatmoron

    The meat of this article is, sadly, entirely on point.

    I was employed in a hospital during their switchover to EHR. The results for the care-giving staff were largely disastrous — while there was a welcome huzzah for complete clarity in doctor’s prescriptions (the old cliche about their handwriting is all too true), the overall ability of nurses and doctors to best perform their jobs seemed to markedly decline. The move from paper to the computer program forced a standardization of orders — excellent for billing purposes (which now tallied exact doses of medicines given, procedures done, wasted meds, etc.), but terrible for patient care.

    I was trained how to use the program, and my job was to help the staff square their medical knowledge with how this system worked. In my experience doing this job, several things became apparent. One, this switch-over was motivated, in part, to push older clinicians into retirement. We had several members who had literally never touched a computer before in their lives, and were now expected to perform complex computer commands on a daily basis. In addition, the move created administrative issues across different departments of the hospital — inevitable IT issues came up, as doctors either didn’t enter an order properly, or a simple system glitch prevented their order from going where it needed to — and then you’d have the lab or some other component refusing to do their job because “it’s not in the computer right.” I witnessed several nurses flip out because their patient’s health was deteriorating, and important diagnostic functions were held up due to IT issues.

    But perhaps the biggest change that I noticed from paper to the electronic method was the standardization of orders. The hospital where I worked paid a company to modify their program to be more suited to the hospital’s specific needs — so medicine doses defaulted to the most common items in stock, and while a doctor did have the ability to change that dose in most circumstances, doing so was often a tremendous pain in the ass. The result, all too commonly, was that doctors would just prescribe the default dose of a given medicine regardless of that patient’s personal needs. One doctor I worked with, who was often regarded among staff as one of the best doctors working in the entire region, was floored by this change — with the paper charts, he had no problem saying, “X milligrams of this for a day, then Y milligrams thereafter,” but the program the hospital used made those sorts of inputs incredibly difficult — and being put in correctly, it was equally difficult for the prescribing nurse to administer for the same reasons.

    There were some things to like about the change — clear prescriptions, much better accountability among staff — but the overall picture definitely showed that best returns from the move to electronic records occurred on the billing side of the equation.

    1. mikkel

      The sad thing is that physician and especially nurse focused IT is dramatically better than the paper system.

      I worked with a physician who is very interested in medical sociology and she recorded it took about 60-75 minutes to do rounds on her unit with paper. Once switched to the standard EHR that you describe, that went up to 120 minutes and errors increased dramatically.

      However, she worked with the local University’s computer science department to develop an interface specifically designed for her unit and the length of the rounds went down to 20-30 minutes, with errors falling dramatically (something like 80-90% lower than the baseline paper state).

      This is in a neurointensive care unit where many patients had tramautic brain injury with generalized internal brain swelling — when they start stroking or have excessive pressure, diagnosis and interventions must be made within seconds, and the proper diagnosis requires several non-standard information streams.

      This dramatic success was accomplished with about $30k of grant money and a couple of programming grad students; it’s hardly difficult to create when you have the medical people themselves (instead of insurance) as the primary power holders.

      1. vlade

        In my experience, developing systems like these is best done in two steps. First, a small “system”, which makes everyone hate it because it doesn’t work as they expect it to work (people tend to expect miracles). Then spending some money on personalization (or should I say making it fit for that particular use). There are still problems – the system in the first place must have the flexibility that allows the personalization, and the initial roll-out can’t be too damaging to the trust in the system – there still has to be someone who wants to make it work (on both the user and maintenance side).

        The initial problem stems from the fact that a) people who are going to use it don’t have time to specify it well (and often would be unable to do so even if they did have time and wrote piles of specification docs…) b) when it finally hits them, they don’t have time (or feel so) to spend on getting it useable c) if they actually manage to get past b and want to make it useable, it may well cost too much (or at least be perceived to cost too much).

        As someone who has been on both sides of this (although not in healthcare), users expect too much and invest too little (by invest I don’t mean necessarily money, but more importantly time), developers promise too much and listen not enough

      2. reslez

        Sad that this doctor and her department resorted to paying grad students what was undoubtedly below market wages to customize their system. If only her hospital had invested in a proper system to begin with. Thank goodness for the cost savings of starving, debt burdened grad students.

  2. vlade

    You know, it could be potentially very simple. Basically, all you need is that you give everyone a USB stick (or an equivalant personal data holding device, or put a chip on a driving license that can hold it…..), on which there’s a single document that a doctor (or anyone who has the right private key, signed by the right authority) can update with fully trackable and digitally signed changes. If someone came with an easy way how to get it also countersigned by the patient, then the doctor could update the original and keep a copy… No need for central databases, specialised software etc.. And if patient doesn’t want it, the doctor can still use paper (or word doc as a paper equivalent).

    1. Paul P

      When Taiwan introduced a single payer system, they employed something like that. I don’t know whether it was exactly as you described or envision, but people have a card like a credit card that contains their medical records. One of the elements of the system is for people to be able to rapidly replace their medical records card, if lost. So, the records had to have been cloud stored as well.

    2. reslez

      If patients had sole access to their medical records, health industry vultures wouldn’t be able to sell off their personal health information to every Tom, Dick and Harry. The market demands a multitude of incompatible, error-rife and uncorrectable databases overseen by unaccountable oligopolists.

      At any rate this sort of thing would require strong data standardisation regulations. But of course regulation is scary and bad.

  3. chicagogal

    From a patient perspective, my healthcare access went down while my doctor’s office was transitioning to their system. What used to take one phone call to the nurse became an exercise in frustration because she was on their transition team stationed at a different location 15 miles away and I would have to leave several voice mails over several days before getting a response. I was already dissatisfied with some of their administrative changes and heavy reliance on nursing temps, so this was the final reason why I transferred to a different doctor. However, the new doctor’s reliance on computerization meant that he stood across the room behind his keyboard rarely looking at me was no improvement and helped to create an antagonistic atmosphere. It’s also made getting copies of my records difficult because they only provide the electronic summaries and nothing that was paper-based, even when the paper records were specifically requested. Overall, something that I thought could only better my care has turned out to be detrimental, and at times harmful, instead.

  4. Dave

    Healthcare has become so fraudulent, clueless, irrelevant and parasitical that for most things I’d rather drop dead than see a doctor. Given my family pays over $15,000.00 a year for insurance, maybe non-use is the desired outcome, except for doctors. Who wants to have records kept when they mostly record ignorance and fraud, just to create the furtherance of ignorance and fraud. Well, almost all doctors are ignorant and fraudulent, so just more of the same.

  5. Faye Carr

    My husband is onne of only 4 IT guys at a huge group medical practice. He’s been at this nightmare for over 20 years. Including some of the most innovative medical programs out there. . I have heard him (yes at home) after 10 at night walking a doctor through the most elementary computer commands while the poor doc tries to figure something out.

    He claims a large part of the failure of the EMR concept is the stubborn unwillingness of the corporation’s leaders to adequately fund the hardware upgrades the new programs require.

    I can”t even tell you about the huge information security gaps.
    Last tidbit – and no surprise – the insurance industry is driving all of it.

    1. Alfred

      “the insurance industry is driving all of it”

      I would have to disagree with that statement. The VA was one of the successful early adopters of electronic health records. Insurance industry not involved.

  6. armchair

    I love the point about making the clinician do copious clerical work. From the unholy alliance of MBA’s and programmers we get software designed to cut staff positions and to achieve business minded goals. The point of the software is to run handsome reports for the MBA administrators and to give them the opportunity to fire more staff. We all know that staff reductions equal fat bonuses. It is obvious that the medical industry could benefit from more digitization, but when the process is overseen by the greedy-MBA-creeps, you get sickening results.

  7. Lawrence Rupp

    Yesterday I came home from a 3 day stay at New London NH Hospital, after treatment (12 -15 strong IVs) for a bad case of Cellulitis, from a cat bite on my left hand:

    When Cats Bite: 1 in 3 Patients Bitten in Hand Hospitalized, Infections Common

    Middle-aged women were most common cat bite victims

    Rochester, Minn. — Feb. 5, 2014 — Dogs aren’t the only pets who sometimes bite the hands that feed them. Cats do too, and when they strike a hand, can inject bacteria deep into joints and tissue, perfect breeding grounds for infection. Cat bites to the hand are so dangerous, 1 in 3 patients with such wounds had to be hospitalized, a Mayo Clinic study covering three years showed. Two-third of those hospitalized needed surgery. Middle-aged women were the most common bite victims, according to the research, published in the Journal of Hand Surgery.

    Journalists: sound bites with Dr. Carlsen are available in the downloads.

    Why are cat bites to the hand so dangerous? It’s not that their mouths have more germs than dogs’ mouths — or people’s, for that matter. Actually, it’s all in the fangs.

    “The dogs’ teeth are blunter, so they don’t tend to penetrate as deeply and they tend to leave a larger wound after they bite. The cats’ teeth are sharp and they can penetrate very deeply, they can seed bacteria in the joint and tendon sheaths,” says senior author Brian Carlsen, M.D., a Mayo Clinic plastic surgeon and orthopedic hand surgeon.

    “It can be just a pinpoint bite mark that can cause a real problem, because the bacteria get into the tendon sheath or into the joint where they can grow with relative protection from the blood and immune system,” Dr. Carlsen adds.

    The bacteria injected by a cat bite can include a strain common in animals and particularly hard to fight with antibiotics, he says.

    New London Hospital has been declared the Most Wired in NH. My experience with it over past year, or two,
    has be excellent. And it keeps getting better! And Staff seem to thin it is excellent.

    Larry in NH

  8. Garrett Pace

    It’s not just an interface issue. Medical organizations struggle mightily with their IT setups, databases, everything electronic. I have a buddy that works for a health care consultancy, and the “baby’s first database” they implement for their clients is treated as the second coming.

  9. ac

    Another little consideration: thanks to federally mandated computerization of records and the rest of the ACA , when you speak to a doctor or nurse taking your history, asking you seemingly innocuous and incidental questions about yourself, you are talking directly to the government at the same time. As this fact gradually impresses itself on the public’s awareness, the doctor patient relationship and patient outcomes will suffer, not improve.

  10. Jack Heape

    Personal experience anecdote. I am a veteran who receives my health care from the VA. The VA is 100% fully computerized and it is a wonderful system. I can even go online from my PC at home and download my complete medical file, and I mean complete. Appointments, lab results, physician notes, test results, etc. In the VA system you can even secure message your Doctors, which I do frequently. And yes, many times the Doctors personally respond. Sure, the VA has received some recent criticism, but I believe these are isolated incidents. Overall the VA delivers quality care, and believe it or not, at less cost than even medicare. Why do I say quality care? I can vouch for my own personal care, but there have been several studies done as well. For instance, in 2003 the New England Journal of Medicine published a study “published a study that compared veterans health facilities on 11 measures of quality with fee-for-service Medicare. On all 11 measures, the quality of care in veterans facilities proved to be “significantly better.” The Annals of Internal Medicine recently published a study that compared veterans health facilities with commercial managed-care systems in their treatment of diabetes patients. In seven out of seven measures of quality, the VA provided better care. The National Committee for Quality Assurance today ranks health-care plans on 17 different performance measures. These include how well the plans manage high blood pressure or how precisely they adhere to standard protocols of evidence-based medicine such as prescribing beta blockers for patients recovering from a heart attack. Winning NCQA’s seal of approval is the gold standard in the health-care industry. And who do you suppose the 2005 winner was: Johns Hopkins? Mayo Clinic? Massachusetts General? Nope. In every single category, the VA system outperforms the highest rated non-VHA hospitals.
    The VA is a quality health care system that uses 100% electronic records. So it can be done.

    1. Lambert Strether

      VA is single payer, though for veterans only, and uses (IIRC) a language called MUMPS, purpose-built for medical data (very robust). Gawd knows what the newer systems are using….

      1. OIFVet

        Speaking as a VA patient, their electronic record system is top notch indeed. But why? As Yves stated in her write-up:

        The sorry fact is that electronic health records, which in theory should reduce errors and allow for more consistent delivery of medical services, were instead designed only with patient billing and control over doctors in mind

        . Gee, whatever happened to the for-profit industries’ supposed efficiency driving down costs?

    2. Alfred

      I agree 100% with this comment concerning health care at the VA.

      Personal access to my health records allows the knowledgable interaction with my physicians that lowers the stress level for the physician as well as myself the patient. Being able to interact intelligently and knowledgeably with my physician is tantamount for the best care.

  11. liberal

    IMHO a big piece of the puzzle is that software firms do not appear to do any usability testing (for anything, not just EHR).

    And like a lot of sectors in a late-stage capitalist economy, there’s no apparent competition/economic incentive to do so.

    1. DavidS

      Mostly, the software is just bad, often terrible, and not just the UIs, which are generally incredibly poor. The broader issue is that few large organizations outside of the Bay Area possess the know-how to make good software.

      Sooner or later, Google or someone like them, will put these clowns out of business.

      1. DavidS

        Also, software engineers are in such demand that they can basically name their price and their company of choice, and are not going to be willing to work for a bunch of suits who have never written a single line of code before.

        So unless it’s for their own startup, professional software engineers and interaction designers won’t want to work in this indusry.

  12. impermanence

    Eventually, EMS will be a wonderful thing. At the moment it is like attempting to institute universal driver-less cars with the autobody shops in charge of coordinating the efforts.

    As long as you have the government/insurance companies doing the planning, you will have a dys-functional system designed to make the insurance companies billions while satisfying those in government that they can do things better.

    Seeing that practically nobody in the U.S. is willing to take responsibility for their own health, a single-payer national health care system, with EMR’s designed by providers in each specialty, is the only sane way to move forward. Funding to be spent into the economy by the federal government.

  13. LAS

    Re EHR Output: What should happen is that these health records automatically print patient safety checklists for the patient’s conditions so doctors/care givers don’t have to search for the information. They should automatically create transition reports when the patient is transferred to rehab or sent home. They should automatically report adverse health events to the CDC or the state public health departments. They should automatically provide information about medications. These would be productivity gains.

    Re EHR Input: Robotic surgeons should automatically report to the EHR. Pump infusers should automatically report what the heck they just dispensed to the EHR. Fancy imaging, lab reports should automatically report. So on and so forth. OK, this is asking for more than EHR; it is also asking for smart health care tools. But I don’t see why we can’t work toward this.

    Theoretically, productivity and safety should have been primary, not the billing. It could be.

    BTW, disappointment with the current generation of EHR systems were mentioned by several experts giving testimony on patient safety at a Congressional hearing July 17, 2014. Some safety experts appealed to Congress to mandate more safety features be built into the software and systems. I hate to say it but the hospital systems’ fundamental problem is they don’t think patient safety first. Making a culture shift to safety first would probably do a lot toward improving the EHR productivity deficit. When their revenues truly depend on quality care (as opposed to hyped up marketing) they will do what’s necessary.

  14. BE

    Sounds great, until you realize how bad the security is on these systems. Best case, we all know exactly what the British Royals got treated for and with every time they’re in the hospital. Worst case, murders and assassinations could be done via hospital hacking.

    The danger with EHRs already, as I have seen as a patient and family-member-of-patients, is that they can lead to incorrect care.

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