How Electronic Health Records Degrade Care and Endanger Patients

Yves here. We’ve featured posts from the Health Care Renewal site that regularly warn about how electronic health care records are a serious hazard to patient health. Yet we’ve regularly had readers refuse to believe that, despite warnings like the ECRI Institute putting health care information technology as its top risk in its 2014 Patient Safety Concerns for Large Health Care Organizations report, or the president of the Citizen’s Council for Health Freedom warning that “EHRs are endangering your life” or press reports like this:

Arthur Allen at POLITICO Pro eHealth (http://www.politico.com/story/2014/06/health-care-electronic-records-107881.html) says government-imposed EHRs are:

  • Driving doctors to distraction
  • Igniting nurse protests
  • Crushing hospitals under debt

“In short,” he writes, “the current generation of electronic health records has about as many fans in medicine as Barack Obama at a tea party convention.

Some readers assume that anything must be better than hand-written and potentially difficult-to-read doctor notes. And the 50,000 foot explanation, that the systems are a huge and costly fail from a care perspective because they are designed primarily, if not entirely, for billing, seems insufficient.

This post will hopefully satisfy the skeptics by giving granular detail with real-world examples of how these electronic record systems distract doctors, regularly employ dangerous “check the box” approaches, produce voluminous and repetitive patient files that routinely go unread, give nurses contradictory instructions, and too often result in patients being given “care” that harms them.

One of my friends, the daughter of an MD who worked for the NIH and later a Big Pharma co, said she’d never go to a hospital without her own private duty nurse. That was before EHRs. Once you read this article, you’ll think twice about going to a hospital in the US without that sort of extra protection.

By Dorothy J. McNoble, MD, JD, who can be reached at Badmedicine005-at-gmail.com

In a now iconic experiment, subjects are asked to sit in bleachers watching a basketball practice and count the passes among players on one of the teams. A few minutes into the experiment a man in a gorilla costume walks across the court. Fewer than 50% of the subjects notice him.

In a variant of the experiment, a man stops a stranger on a somewhat busy street to ask directions. While they are talking, two men carrying a large piece of plywood walk between the two men and when the plywood has passed, the original questioner has been switched to a different man. Again fewer than 50% of people notice the change.

Recently, I witnessed an “invisible gorilla” episode in the hospital. I took my neighbor to the hospital after she had fainted. She had low blood pressure and a slow pulse. The nurse examined and interviewed her, but spent most of the interview facing the computer and inputting data. A few minutes later, my friend was moved two beds down and exchanged places with another patient due to some equipment problems. When the nurse returned to check on my friend, she addressed her by the incorrect name and questioned her about the symptoms of the patient who had been there earlier. I corrected her and she checked the armband to confirm.

There can be no denying that emergency rooms are busy and the staff are often overwhelmed, but I think this demonstrates that the new “three way” which dominates patient interactions – the patient, the computer and the nurse or doctor, risks turning patients from the central focus of all interactions into the invisible gorilla.

Anyone who has tried to wade through their own hospital records or watched as a primary care physician tried to decipher the “data dump” which is supposed to summarize the events of a recent hospitalization, will recognize that the promise of the efficient, orderly modern electronic record is far from being realized. In theory, the computer based electronic record should be perfectly suited to its task. In recent decades health care, especially inpatient hospitalization, has become increasingly complex. There are many more participants, doctors, nurses, dieticians, consultants, occupational therapists, respiratory therapists, social workers and the interventions and therapies and medications administered during a hospitalization have also increased dramatically.

The electronic record, with its ability to prompt clinicians with reminders, organize large amounts of data and allow access from any point in the hospital and even remote locations, seems the perfect tool to create an organized, complete, flexible document free of errors and redundancy. The EHR as a working document during the hospitalization should be able to immediately reflect changes in the patient’s condition, accommodate instantaneous changes in medication and therapy, allow input from a host of clinicians and remain clear and comprehensible. After the patient discharge, the EHR should be an easy to understand narrative of the event of the patient’s hospitalization with the patient as the obvious central figure.

However, instead, the EHR has become an unreadable, unholy mess in which the patient is increasingly eclipsed. How did this happen? Was it due to limitations of software capacity? Insufficient funds devoted to the development of the EHR?

All of these problems undoubtedly contribute to the difficulty of developing the optimal EHR system. However, I believe that the main impediment to the creation a good EHR is not technical limitations or financial constraint. Rather it is due to the decision to utilize the EHR as a billing document. Many of the decisions about how to organize the medical record, how to format the document, and what data to include or exclude arise from the need to use the record as the support for and documentation of “billable events” during the hospital stay.

The Checklist

As noted above, there are many more parties participating in a patient’s care than there were two decades ago, and each of them has more documentation required and more interventions to conduct. The checklist format is appropriately suited to this task as it helps the clinician to do a complete exam, appropriate for his or her special area.

However, reliance on checklists often diverts attention away from the patient as the clinician taps away on the computer, entering various “required fields” and ignores the patient. Moreover, while clinicians each have their tailored checklists, there is a mind-numbing amount of repetition and overlap. This wastes time and results in a bloated, redundant record.

For example, while assisting my friend in the emergency room, I noticed that no fewer than five doctors, nurses and consultants confirmed that she had obtained her flu vaccine and that had had a screening colonoscopy within the last year. In fact, during her ER stay and her hospitalization, there were dozens of these repetitive, checklist inquiries, always obtained while the clinician was facing a computer and not the patient. Added up, all of this box-checking seriously detracts from the time which could be spent actually examining or talking to the patient.

The checklist, originally intended as a way to assist clinicians to combat fatigue or forgetfulness, has now become a housekeeping chore and a billing tool.

Moreover, the checklist has been used as a mechanism for outright billing fraud, specifically Medicare fraud. Medicare has historically designated five levels of increasing patient complexity and severity of illness and allowed physicians to select the appropriate level, and bill for care delivered to that patient. Obviously, the highest code was to represent the sickest patients and the reimbursement would be accordingly increased. Quite clearly, Medicare auditors could examine only a limited number of charts (especially in the days prior to electronic records), to determine if the selected billing code conformed to the patient’s clinical status. Auditors developed a shorthand system to decide if the code matched the patient’s clinical status and this was a checklist system. In its simplest form, the more elements of the patient’s history and physical exam the clinician documented, the higher the billing code would be allowed.

Clinicians very quickly figured out a way to create expanded checklists for most of their patients and bill accordingly, irrespective of the patient’s actual severity of illness. Eventually, Medicare recognized the widespread fraud and began auditing, hired “bounty hunters” and engaged in “clawbacks” of fraudulent billing. Many physicians and hospitals have been convicted of Medicare fraud on this basis.

Checklists should be tailored to the patient’s need, should not be redundant or repetitive and should not be used in lieu of appropriate examination and evaluation, and most certainly should not be used to “upcode” and charge more than is warranted by the clinical situation. Judged by these criteria, the modern EHR is a failure and helps neither the clinician nor the patient.

The most dangerous of the checklists are the order sets. These are a list of self-contained orders for all aspects of patient’s care from diet and activity to medications and invasive procedures. These expanded order sets can be initiated by the physician with a single click of the mouse.

Initially designed, as were all of these checklists, as an aid to preventing errors and omission due to fatigue or forgetfulness, they now serve less salutary goals.

First, the order set absolves the physician of any responsibility for reviewing the extensive medications and therapies to which he is subjecting the patient. These order sets routinely contain 20-40 separate orders and the physicians rarely edit them for an individual patient.

Second, the order set often contains directives to the nurse for managing a myriad of events or problems which might arise, events such as a drop in blood pressure, low urine output, fever, fast heart rate, even change in blood count. The nurse is given a therapeutic intervention to initiate with no directive to call the physician. The physician relinquishes his or her responsibility to carefully follow the patient’s clinical course and intervene as needed.

Third, they are a means of insuring that various billable events end up in the chart.

Finally, a hospital inpatient typically has multiple physicians caring for him, all of whom rely on their own order sets. The result is another data dump of overlapping, redundant and often dangerously inconsistent and conflicting orders. For example, a patient who is admitted from the emergency room and goes to surgery, then to the recovery room and the ward may have as many as 150 orders entered in the first few hours in the hospital. The surgeon, the internist, various consultants and the pain management physician are all likely to be using a “single click” order set. There are few safeguards to identify overlapping or inconsistent and incompatible orders and this poses a real danger for the patient. These are not benign or purely theoretical charting inconsistencies.

One example which occurred frequently in my own practice was the problem of bowel and dietary management of patients who had had often complex bowel resections. These patients had delicate areas of bowel suturing which required decompression and protection from any stretching or tension which would result if bowel contents were allowed to flow through them. The therapy was a nasogastric tube which pulled all the bowel contents out of the stomach to protect the area of bowel suturing. I always ordered that the tube be kept on suction and no liquid or contents be placed in it.

Unfortunately, the order sets of the other physicians almost always contained a “laxative cascade” which provided for laxatives for patients with no bowel function. In addition, internists frequently ordered that oral medicines be placed down the tube. The nurse thus had conflicting orders about how to handle the nasogastric tube and when to begin trying to use the patient’s GI tract. Many times, the nurses simply followed the order of the two or three internists and, contrary to my order, “challenged” the patient’s bowel function in a dangerous way.

This type of conflict arose in many areas such as patient activity, when I knew that the patient’s complex abdominal closure demanded bedrest, but the internist, adhering to a non-indicated safety protocol, would order early ambulation.

There was the constant battle over anti-coagulation. Another reflex safety protocol demanded blood thinners be given to post-op patients to prevent blood clots to the lung. However, in many instances blood thinners posed a danger to a patient with a hemorrhagic dissection at surgery. At times, I did not catch the internists order for blood thinners and the patient would be endangered. This order chaos is a seemingly immutable feature of the modern EHR and the patients are not served by this system.

The Auto–Fill and the Carry Forward

Physicians, nurses and all clinicians caring for patients in the hospital are under increasing pressure to deliver more care in less time, and to document that care more extensively so that it can be billed for. As a result of this pressure, two features of the modern EHR have been implemented: the auto-fill and the carry forward.

The auto-fill utilizes a widely used feature of modern software. When the physician sits at the computer to write a daily note about the patient’s condition and the plan for continued care, he can click one button and, as determined by an internal program in the software, the computer searches various data bases and enters a myriad of data in the note. Specifically, the daily physician note has historically documented the objective findings of the previous 24 hours: vital signs, medications, dietary intake, urine output, labs, x-ray results. This is the data on which the clinician must rely to proceed to the next part of the note, the assessment of condition and the plan for care. Again, historically, the clinician had to find the data either in the electronic record or, in the written chart, and decide which data to include and then transcribe the information.

However, it is trivially easy for the computer to search the various data bases and enter all of this information WITHOUT THE PHYSICIAN EVEN BEING REQUIRED TO LOOK AT IT. This unquestionably saves time and is more efficient than having the clinician manually type in the information. However, physicians routinely fail to examine all or part of the data and simply include it in the record without scrutiny. Hospital administrators, physicians and quality assurance personnel will deny vociferously that this happens, but I encountered this very problem constantly during my own clinical practice.

One particularly memorable case occurred during my last few years in practice. I had performed a complex bowel resection on a patient with two separate tumors. She seemed to be doing well post-operatively, but one day when I went to examine her, I noticed that the internist had entered a five page note in the computer. This was my first experience with auto-fill, and I assumed that a note so extensive indicated that the patient had had a problem the night before and I had not been notified. Without reading the data carefully, I rushed into the patient’s room to check on her. She seemed fine and to be recovering on schedule. I went back to the computer to examine the note and realized that all of the patient’s previous CT scans had been included as well as a four page pathology report. When I asked the internist about the note, he said that he had not read the CT scans or pathology report himself, but had just included them in the data portion of his note “automatically.” More data equals more billing, pure and simple. As a corollary, less physician time spent with patients or completing records equals more work the physician can do and more billing for the hospital and the physician.

So ubiquitous and meaningless has this auto-fill portion of the note become that in one hospital, this key data, on which all decisions should be made, has been relegated to the end of the daily patient note, like a tangential footnote instead of critical information.

The carry forward is a trivially technologically easy version of “cut and paste,” and it is used by clinicians for the same reason as auto-fill – easy documentation, less time spent, more billing available. The carry forward is used in the assessment and plan portion of the physician record. Quite simply, the physician incorporates his previous listing of patient problems and his plan for solving them. I have admitted patients with a perforated bowel, performed surgery and been a week into an uneventful recovery and noticed that the internist note continued to list “perforated bowel” under the patient problem list and included a repeating reference to the findings on the admission CT scan. These constant carry forward notes are redundant, confusing and useless for patient care. They simply provide padding to justify billing and serve as a “time saver” for the physician.

These documentation shortcuts are not new in medicine. In the era of the paper chart, physicians used the shorthand “WNL” to describe various aspects of the physical exam. WNL was shorthand for “within normal limits,” but everyone knew that it meant “we never looked.”

We are now in an era of “WNL on steroids. That is, with the convergence of checklist medicine, the auto-fill and carry-forward features, and the piling on of tangential safety and bureaucratic entries in the chart, the physicians and nurses seem to have relinquished their obligation to carefully monitor the patient’s clinical condition and assume responsibility for each of the therapeutic interventions taken.

Feeding at the Trough

Healthcare is the largest single industry in the country and the source of the greatest job growth. However, the growth in clinical care positions are not responsible for most of this increase. Medical and nursing schools have at most a negligible increase in graduates, and ancillary clinical training, such as occupational therapists is also growing slowly.

A large part of the increase in participants in the healthcare industry is due to the dramatic increase in federal, state, and local health care bureaucrats as well as the increases in hospital administrators, auditors, plan administrators and other non-clinical participants. These government and administrative bureaucracies are theoretically in place to insure efficiency in the delivery of care and to monitor and insure patient safety. The security of their roles as integral to patient care is assured if they can require that their particular area of concern is a mandated part of the medical record. For example, there must now be documentation in the EHR about smoking cessation, potential for elder abuse, vaccination status, use of seat belts use of child safety seats and a variety of other issues. Although the inclusion of these global safety and care concerns is laudable, the medical record has become bloated with repetitive, inappropriately placed mandatory documentation of these often peripheral and distracting subjects.

For example, when I reviewed the emergency room record of the patient I had brought in for fainting and low blood pressure, I saw that the first two pages had no reference to the reason for her admission, but had entries about vaccination status, the name and phone number of her outpatient pharmacy, the use of seat belts, the query about abuse in the home, a smoking cessation notation, the placement of the IV, including a standard description of the sterile technique used, a description of her living arrangements and the names and phone numbers of her emergency contact and her physicians. Only at the bottom of the second page was there a brief discussion of her main symptom, and there was not elaboration on the event itself – had she just taken a new medication? Had she been dehydrated, not able to eat or drink for some reason? Had this happened before? The chief complaint and history of present illness, which should be documented immediately, was never even placed in the emergency room record. Instead, somehow the monitors of the bloated crushing, non-clinical superstructure are able to justify their existence by having their marginally relevant concerns dominate the record.

Surely, the powerful EHR software could allow these myriad, disparate notations to be made, but categorized in an appropriate area of the EHR, not on the first two pages of the ER record. In particular, the detailed description of placement of a standard IV with standard IV fluid does not need to occupy three lines on the first page of the record. This is done only because of the necessity to “capture” this billing event. In fact, the emergency room record is more a narrative of billable events than medically proper narrative of the patient’s emergency room course.

Focus Fatigue and Limited Bandwidth

As discussed above, the structure of the EHR is designed to serve its purpose as a billing document, but makes it very challenging as a dynamic health care management tool during hospitalization or a concise, complete, well organized, non- redundant narrative after discharge. These structural features are a real impediment to clinicians trying to care for patients or understand what happened to patients after the fact.

There is an ample body of literature discussing the inefficiency and inaccuracy which results from multi-tasking. When doctors and nurses attempt to examine and obtain histories from patients while scrolling between various lists on the computer screen to be certain that all the billable bases are covered, it is clear that their ability to attend to the patient is compromised.

In addition, when the record itself is lengthy, repetitive and contains large amounts of prominently placed, but extraneous information, the clinician is likely to lack the mental stamina to wade through the document, switching between screens to find the relevant information. Moreover, the much touted “safety” features of the EHR are themselves often so ubiquitous and distracting that they lose their efficacy.

For example, recently a hospitalized patient was prescribed an antibiotic by a physician and a pharmacy generated warning appeared on the screen about a possible allergy. The physician believed that this might be an “auto-allergy” alert, that is, the patient denied the allergy, but the computer continued to generate the warning because it was pre-programmed to do so. The patient was given the antibiotic, and eventually manifested an allergic reaction. When the record was reviewed, no fewer than 17 physicians and nurses had hit “override” when seeing the warning. The records are now replete with these safety warnings, as well as with many checklist programs which demand that the data be entered in a particular order.

What may have begun as an attempt to amplify the safety of the “checklist manifesto” has become so arcane and distracting, that clinicians cannot attend to its voracious appetite and still provide efficient, expeditious patient care. Our cognitive limitations mean that we have only so much bandwidth with which to work, and if the record itself, with its demand to navigate computer screens and satisfy often marginal or useless documentation requirement consumes this precious cognitive resource, the patients themselves risk becoming the “invisible gorilla.”

The Electronic Tower of Babel

Finally, the reliance upon a market based competition model to determine how an EHR system is selected has resulted in an electronic Tower of Babel. Hospitals and physician practices select among and contract with competing EHR companies, and the patient finds himself in the center of system of non-communicating silos.

Patients often have multiple providers and, in an urban area, may have care at different hospitals as well. The EHRs are seldom compatible and there are always delays as the various offices and hospitals try to obtain printed records from another facility. While the theory is that the best EHR systems would emerge, the patient’s interest may be better served by a single system which can be understood and utilized by all health care entities.

Certainly, Medicare standardizes their billing submission requirements and many physicians think that Medicare should have insisted upon a single medical record system to facilitate communication about patients, especially when that communication is time-sensitive, as in the case of an emergency.

Thus, the usurpation of the patient electronic health record by its need to serve as a billing document, and the utilization of documentation shortcuts, such as auto fill and carry forward, coupled with the very human limitation to focus on t a limited number of matters simultaneously has turned the electronic record into a monstrous, unwieldy document which serves neither the patient nor the physicians well.

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99 comments

  1. Terry Flynn

    Electronic health records are a time-bomb. My best friend’s father worked in IT in the NHS for years and when he retired predicted the over-budget problematic system the NHS was trying to implement would blow up or fail in critical instances. A system is only as strong as its weakest link…in the NHS email is frowned upon/disallowed for certain disciplines (mental health). Thus faxes from my psychiatrist had to be scanned in to the system at my General Practice in order that changes in meds be made…..I had to complain when it was obvious they just sat in a tray for weeks on end. GPs often then have to read a (badly) scanned letter from a consultant, switching between screens and systems. ‘Coding systems for diagnoses’ were regarded as a joke and ignored.

    In Australia, with more private sector input it’s even worse – a system that allows you to register at multiple general practices and obtain drugs from multiple GPs because it didn’t quickly enough centralise your meds. It, too, failed spectacularly at secondary care, with letters not properly appearing on systems, incompatibility of systems meant to code diseases etc. The only online system that worked well was the entirely STATE-run MEDICARE system of ‘bulk billing’ – where your GP appt attendance charge was automatically paid by the govt. If you attended a ‘posh’ GP who charged more than the state rate, they could easily use the govt system to charge you the excess. A wheeze I exploited was paying my two psychiatrist sessions a week ($330 each) on my credit card (getting me airmiles) and getting the Medicare rebate of $300 per session credited to my debit card each time! But the clinical data still didn’t properly go through to my GP’s ‘complete record’ and needed a separate request for info when I left Aus and wanted evidence of my clinical history etc. What a dog’s breakfast.

  2. Alex

    I live in a country with single-payer and electronic health records, and they seem to work OK, but of course I’m seeing this only from the patient perspective. Any readers out there not in the US that can share their experiences as professional users in single payer or similar health care systems? Does the reduction in the billable services motive seem to make for better EHR systems?

    1. Yves Smith Post author

      This is very much a US story. I saw doctors in Oz back in 2002-2004 using screens to input data and it didn’t seem too distracting. Plus I had the impression the software was standardized, if not universal. addressing the problem of compatibility and transfers. Can Down Under readers confirm or correct?

      1. Terry Flynn

        Though I agree it wasn’t distracting to have the Dr entering data on the screen, the system wasn’t standardised when I was in Sydney (2009-2014). My “total medical record”, when requested by me when leaving, looked like a bunch of Word documents with tables of results pasted in, and the output from the two main General Practices I used definitely didn’t use the same system. Plus all the secondary care data from non-GPs looked like an NHS file – just a load of letters scanned and inserted in with no tie-ins in terms of actual diagnostic coding etc. The most ‘professional’ looking bit was the Medicare billing/reimbursement (the govt scheme).

      2. Terry Flynn

        PS Of course looking at it from another perspective, maybe the “internal system” in Aus is standardised and “what a doctor sees on the screen” is standardised and readable. It might just be that aspects of the “front end” (such as how the details are outputted when a patient wants their records”) are not well coded.

        In the UK there are two “patient records” I can access online for my NHS record – the summary one is not bad in terms of diagnostics (for primary care) but you need a certain amount of medical knowledge to understand it (so I’m generally OK with it) – the “main one” is a mess.

        1. Willem

          It is the billing process, combined with electronics in general that is taking an awful lot of (precious) time for doctors in the Netherlands.

          The billing process
          In the past, only the final diagnosis and side diagnoses were registered in a national electronic system by a nurse or a secretary of the health department. For this the nurse or secretary went through the discharge letters of the doctors and distilled the diagnosis from the letters themselves. Although this was not a perfect system (although studies revealed that it worked pretty accurate when diagnoses of nurses/secretaires were checked by a third party, for instance a health researcher 1), this had the advantage that billing was independent of the diagnosis that was registered by the nurse/secretary (no reason for fraud). Since 2007, doctors have to fill this diagnosis in themselves. The idea is that doctors are more able to fill in the right diagnosis than a nurse or secretary. And the hospital now urges doctors to fill in a diagnosis, because that is the only way how they will receive money from the insurance company that pays per diagnosis.

          However, there are two types of doctors:
          a) those who do not care about electronic diagnoses, and they are likely to fill in the wrong diagnosis. So for example, when someone was hospitalised for suspicion of myocardial infarction, but the disease was ruled out after anamnesis/physical examination, a doctor may fill in myocardial infarction (meaning hospialisation, treatment, sometimes surgery, etc) as diagnosis because this is the first diagnosis to pick from a long list of diagnoses. Leaving a diagnosis ‘blank’ will not be tolerated by the hospital that has a whole industry of people who are payed to harass the doctor to fill in the diagnosis as otherwise the hospital will not get payed by the insurance company of the patient. Since an average doctor sees dozens of patients per week, the filing in of diagnoses of patients can take quite a while, certainly when he or she did not fill in the diagnosis of patients for some weeks in a row. That can also increase the amount of wrong diagnoses since type a) doctor fails to see the relevance of doing this task. Generally speaking doctors of this category work for the government (who see this electronic diagnosing as a nuisance/ waste of their time)
          b) those who do care about electronic diagnosis since some diagnoses will retrieve more money than other diagnoses. So they opt to diagnose the patient with the most expensive diagnosis plus some alternative diagnoses as well for which they spend time that also could have been spent on the well being of a patient. Generally speaking these doctors work as ‘private’ doctors (those who receive money from the insurance company directly).

          Electronics
          Since doctors see many patients each day, they do not have much time for the paperwork. In the past, this meant: lot’s of handwriting: how the patient is doing, if there are any changes in medication, etc, which one could often do at the same time as when he or she saw a patient (with an electronic screen in between I find this impossible). Once in a while a doctor would summarise all relevant info to, for instance, a GP by dictating a letter to a secretary of the department who typed the letter for the doctor. Nowadays most doctors have to type these letters themselves and this takes much more time. And since time is precious in medicine, this leads to incentives to write ‘one size fits all’ letters by for instance an automated system that the author refers to above.

          All of this is bad for medicine in general, although I certainly believe that it was imposed (since 2007) with the best intentions of the world.

          What would work best for me is the pre 2007 era in which only

          – Relevant medical history
          – Relevant allergies
          – Laborotary findings
          – Actual Medication
          – Radiology findings with a short report of the radiologist saying whether the differential diagnosis is confirmed or not

          are registered electronically per individual patient (this is a nearly automatic procedure, does not take much time and is useful info)

          All the rest could be handwritten in a file that is maintained by one doctor/specialty that is fully responsible for the well being of a patient during admission or outpatient visit.

          All the handwriting should be summarized once in a while (the definition of once in a while depends from patient to patient) by a doctor who dictates a report that is next typed into a letter by someone who has experience with typing letters (e.g. Secretary of a department)

          Diagnoses are not electronically filed by doctors, but by a secretary/ nurse of a department into a national system (very good for research purposes and quality control)

          The total health cost will not be driven by a procedure or diagnosis, but by the amount of people who work in a hospital, number of lab tests, Radiology tests, medicine prescriptions, use of operation rooms, etc that can easily be checked by an accountant of a hospital and/or insurance company. Of course that means that you cannot bill per patient, but money is of no issue to a doctor (who only wants to help/treat patients). And for the government or insurance company it should not matter which patient received a certain procedure. What matters or should matter to them is how much the total amount of money spent per year by people who payed for their health insurance contrasts with the total amount of money that health insurance/ government has to pay on a yearly basis to medicine. As long as they don’t make a loss, national healthcare is as healthy as it can be, and it saves the doctor a lot of time.

          My apologies for the long comment. I hope it was helpful.

          1. The Dutch situation explained (in Dutch): https://www.ntvg.nl/artikelen/pleidooi-voor-het-behoud-van-de-landelijke-medische-registratie-voor-betrouwbare/volledig

  3. juneau

    Medicare mandates EHR and if you don’t follow some of their checklist requirements you actually lose money on your fees. I have seen 2-3 percent fee reductions for refusing to do electronic prescribing (instead using paper) beyond the deadline and for not having the manpower to do other monitors they insist on for no obvious clinical benefit.

    The VA system had a good EHR 20 years ago that could have been adopted unviersally with some tweak IMHO. What a shame. Cannot wait to see electronic notes go. Good for prescribing not so good for talking to the patient while in their hospital room or in front of them in the office.

    1. johnf

      The VA system had a good EHR 20 years ago that could have been adopted universally….

      I believe the system was written in MUMPS, my all time favorite name for a computer language.

    2. Kris Cerone

      The VA has had an excellent EHR since at least 1992, when I worked there. I just read they are dumping it and buying the Cerner system, tragic. It has been adapted to run on Windows. The reason it was not adopted universally — $$$$$$!!!! I was at a conference when EHRs were first being developed. In a question and answer session with David J. Brailer, MD, the the National Health Information Technology Coordinator, I asked, “Why not the VA electronic health record for all?” His response was that it was a good system. He went to the next question and individuals in the group converge on me to “explain” why I was so wrong. I was not wrong. They were defending all the vendors who were preparing to make a killing off their products. So they did at the expense of the patient and the doctor.

      1. Disturbed Voter

        Correct from my non-VA government perspective as well. The VA system was designed for doctors by doctors. Unfortunately that isn’t what IT people and Admin people like to see. Medical personnel are socially considered to be mere technicians, compared to management … at least in the US.

        There simply aren’t votes for Congress unless largess is handed out. And the modern EHR system is mandated by the need of Congress to get re-elected. Same as the MIC. VA doctors don’t rank as donors to Congress-criters … Cerner does.

        1. heartlanddoc

          I remember using the VA EMR as a medical student in the 1990’s. When my hospital implemented an EMR (Cerner, go figure) about ten years ago I couldn’t help but wax nostalgic for the VA system.

  4. Jack

    This whole article appears to not so much be an argument against EHR per se, but rather the incorrect usage of the EHR. A previous commenter mentioned the VA. I obtain treatment at the VA and I can tell you they have a great EHR. Why probably? Because its emphasis is not on billing or government mandated screening/questions about the latest health priority, e.g. car seat usage. I can access my records online from anywhere, the exact same records that the physicians use to treat me. There is a delay in tests, reports etc. to allow the physician to review them before the patient sees them, but these preemptions have an automatic expiration, for instance in 3 days the block is lifted on lab tests. As far as going to a hospital without a nurse, or at least an advocate I wholly agree. Doctors and nurses make mistakes, and everyone should have someone along who can bitch, moan, complain, and question every test and procedure. I long ago lost my innocence in regards to the capabilities of health care professionals. They are human and make mistakes and errors just like the rest of us. Every individual needs to be responsible for their health care and they need to always question what a Doctor says and recommends.

    1. Yves Smith Post author

      With all due respect, you are you missing the point. Your good VA EHR does not operate anywhere in the US except in the VA. There is no impetus whatsoever to improve the disastrously bad EHR that is in place elsewhere.

      1. Tooearly

        Moreover your open source VA EHR is about to be scrapped for a very expensive dysfunctional one.

    2. ger

      Obeying doctors orders is more like a religion among most people, even if it kills them. Questioning a doctor would be heresy, for both the doctor and patient!

      A recent experience with EMR system would have lead to a serious health condition except for my nosy attitude. As a new patient at an ENT clinic, I filled out the usual six-eight pages and pushed them into the slot at the receptionist window. On the bottom of the ‘allergy’ form, I hand wrote a concise note regarding the extreme auto-immune response I would have with steroids in any form or combination.

      The doctor comes into the examining room, turns to his computer display to review my now EMR and asks a couple of questions. Pecks on the keyboard
      and says, I have sent a prescription to your pharmacy with no discussion about the drugs. Remember the hand written note above mentioned. At the pharmacy, as custom, I ask to see the drug before paying. To my dismay, there were three different drugs, two were steroid based. I called the clinic immediately and inquired if anyone actually reads the forms…and if the did, why do I have steroids on the pharmacy counter. The response was, “there was not enough space on the EMR form for all that information”. In 2008, I found myself in a hospital heart lab with a scope run up my femur artery to see how much damage had been done by steroidal nose spray!! Be nosy!

  5. Dr Mike

    Family doc in Toronto. I’ve used EHRs extensively in primary care and find them invaluable. But we’re not subject to the over the top billing requirements of the US so don’t have to wade through checklists as the author describes.

    The more I read about US healthcare the more baffling I find it. In Canada we’re often accused of rationing care but I think the article highlights where less care is better for the patient, as well as cheaper for the system. Why do surgical patients all have internists as well as their surgeons? The issues of conflicting orders seem like an organizational problem and failure to delineate who’s in charge. In every hospital I’ve worked in various Canadian cities, one doctor is in charge. If a patient had a particular issue that is beyond the scope of that physician they’ll get advice from another service about that specific issue. The idea that an internist and surgeon could give contradictory orders about bowel routines post-op is an issue of too much care. This is clearly the surgeon’s domain so why is the internist even involved?

    1. Anon

      It’s important that the “doctor in charge” not be immune to discussion with other doctors (and nurses). I had to leave one hospital early just to get away from the invincible “doctor in charge”.

      As the lead-in to the article indicated, having your own medical advocate while in the hospital is imperative.

  6. Jim Haygood

    Like a lot a bad ideas, EHR was imposed top-down by federal politicians trying to play doctor. EHR was one of the “magic bullet” components of Hillary Clinton’s failed health plan in 1993.

    Her ideological twin GW Bush kicked off a ten-year program to promote EHR in 2004, making it federal policy that all Americans have EHR by 2014. The American Recovery and Reinvestment Act of 2009 (ARRA) stipulated that all public and private healthcare providers and other eligible professionals (EP) were required to adopt and demonstrate “meaningful use” of electronic medical records (EMR) by January 1, 2014 in order to maintain their existing Medicaid and Medicare reimbursement levels.

    What do lawyer Hillary, MBA Bush, and lawyer Obama know about practicing medicine? Bloody nothing. Getting idiot politicians out of the picture (presumably still possible for concierge medical practices that shun Medicare & Medicaid) is Step 1 to fix the mess they made.

    Meanwhile, arranging accompaniment by a private-duty nurse for hospital visits makes eminent sense, and might even pay for itself by confronting out-of-network billing scams at the point of origin. One can’t be too careful when dealing with racketeers in biz suits and white coats. Nurse … Efamol!

    1. QuarterBack

      Don’t fool yourself by thinking that, after Citizens United, the politicians have any significant control of the healthcare agenda. Virtually all of the strategies, talking points, and legislative verbiage are prepared by industry. Politicians, as a class, are far from the top of the food chain. Their role has been reduced to serve a sales professionals to the agendas of the investors in the industry. What is often intentionally confusing is that many of these agendas cross multiple industries. What may seem a counterproductive investment within a single industry may actually have enormous impact on profits in another industry. The politicians also serve to support the illusion of control, illusion of debate, and the fallacy of cause and effect. This is a macro problem, where the interest of the largest investors control the course. Don’t confuse symptoms for the disease.

    2. Vatch

      A few large corporations are making large profits from the sales of their electronic health record software systems. This is a prime example of the investment theory of politics in action.

      1. Jim Haygood

        Because they peddle their tushies so cheap, the ROI from buying politicians can be in the thousands of percent.

        Who says prostitution isn’t legal in the US?

  7. Carolinian

    Today’s post and yesterday’s seem to be making a compelling case that the “reforms” of the ACA were all about managing cash flow to the medical industry. The prioritization of the EHR as a billing instrument could be a metaphor for the entire system. In a sane world socialized medicine would be the answer which is why most advanced countries have adopted it. We’ll see what we get in our world.

  8. Sam Adams

    Perfect: nurses print out electronic chart before all med changes have been recorded and made on patients’ charts. Dr does rounds and makes recommendations without considering the changes already made. Double or triple doses. Not great, especially with chemo. People don’t work like little programmed robots .

  9. Moocao

    I agree with some points to Dr. McNoble’s critique to EHR.

    1. Over-documentation: This is indeed a serious concern. Unfortunately, the lack of documentation would lead to litigation in certain cases. Documentation is no longer just about the care of the patient, but also a practice in “litigation prevention”.

    2. Auto-Fill and Carry Over: Huge problem. Academic institutions now require all physicians to redact their note daily, but I can assure you that due to over-documentation requirements, it is a much easier to “carry over”. This unfortunate problems do compound and create patient errors when a specific medical event occurs, and one literally cannot use the MD’s progress note and have to find a previous RN note about the event.

    3. Focus Fatigue – alarm fatigue: EXTREMELY serious problem. In the inpatient setting, one sees an alert every day. Some are outright ridiculous. Some EHR utilizes a shotgun alarm approach, then asks the Hospital Staff to “thin down” the alarm logic at a later time. Unfortunately the resources devoted to “thinning the alarm” is non-existent, leading to some hilariously stupid warnings. Imagine watching an alarm pop up for Doxycycline with a category D alert on a 79 YO patient with COPD every single time. It gets numbing

    Disagreement to Dr. McNoble’s essay: Checklists

    Checklist is a cornerstone in medical safety. Using a checklist has shown to improve surgical care and reduce the risk of operating on the wrong leg/organ/etc. The utilization of a sepsis bundle has been shown to improve patient safety survival. Checklists are NECESSARY. Checklists, however, needs THOUGHTFUL UTILIZATION. Unfortunately, this will depend on physician’s ability to navigate, and it is indeed much easier to just “click and forget”. Checklists prevents the following: sepsis patient in July receives 30mL/kg IVF, and first antibiotic hung within 1 hour of admission. RN forgets the blood culture prior to antibiotics administration as the resident MD forgot to put in the order for it, and the RN is a new grad. No initial blood cultures drawn, subsequent blood cultures negative. Due to patient stabilizing on initial broad spectrum antibiotics and no cultures are drawn prior to antibiotic administration, the broad spectrum antibiotics are continued, leading to the patient arriving 1 month later with watery diarrhea.

    1. Yves Smith Post author

      Um, she provided multiple examples of checklists where they regularly led other doctors to implement instructions, like laxatives and oral meds, that were dangerous to her patients who had had bowel surgeries and not stressing the bowels was imperative. So it does not appear that you’ve thought through how checklists undermine care by doctors not looking or even thinking about whether the defaults make sense in that case, and the nurses wind up implementing contradictory and potentially dangerous measures.

      1. EoH

        Thanks, again. Your monitoring of comments is invaluable in keeping them on track and the discussion moving forward.

      2. Moocao

        This is the reason why all checklists should have very minimal defaults. The utilization of defaults should only be needed in absolute care, such as my example. Your example would be more along the lines of opioid order sets, where an MD should utilize clinical judgement for selection

        Checklists are there to help making clinicians think about the patient. The fact that a physician did not utilize his/her clinical judgement should be factored. Defaults are dangerous and should not be implemented widely unless discussed by various healthcare individuals, but we should recognize that checklists are indeed necessary so that important time sensitive orders are enacted.

        Our argument should be how to make checklists better and more readable.

      3. Scot Silverstein MD

        In theory checklists are great. In practice, in the messy real world of medicine, they can and do have unintended adverse consequences.

        Medicine is not aviation. Medicine is a poorly bounded, conflicted, highly variable, uncertain and high-tempo domain filled with frequent essential improvisations.

        See “Hiding in Plain Sight – What Koppel et al. Tell Us About Healthcare IT”, Nemeth & Cook at https://www.researchgate.net/publication/7738740_Hiding_in_plain_sight_What_Koppel_et_al_tell_us_about_healthcare_IT

        It is a two-page article brimming with insight as to why Health IT is not working as advertised.

  10. cocomaan

    Seems to me, after reading this article, that the best medical records probably look like a long-form essay.

    Fantastic article. Thank you.

  11. marieann

    Very sad article, made me cry. I saw this first hand when my husband’s brother died unnecessarily in February.
    This was in the US, we are Canadian and I am a retired RN, being retired for 13 years perhaps this is how it is done now over here, I surely hope not.
    All the nurses had their eyes on their computer and never seemed to actually assess their patient. They were never able to answer questions about him without looking at a computer.
    They kept asking my husband if he (his brother ) was eating…they didn’t even know the basics about their patient.

    You know the healthcare in the US is so great, he had a MRI done within 2 days………fat lot of good that does when the nursing care is deplorable

  12. Sutter Cane

    Not a doctor, but I work in records management. Huge push to make everything electronic. It is an improvement for SOME records, but for others, especially records that have to be kept for decades, paper is a better option. As long as it doesn’t get soaked or burned, paper can last for a long time. Electronic file formats, not so much.

    People have watched too many episodes of CSI or something, they think everyrhing has been digitized, and are amazed when they find out we have to request a box of paper records from storage. And you really don’t want to let them know that you have stuff on microfilm, they think that’s from the dark ages! Of course, the historical archives has 100 year old newspapers that you can still read thanks to microfilm, meanwhile there are electronic files from just a few years ago that we can’t even open anymore.

  13. BoycottAmazon

    How (most) USA Electronic Health Records Degrade Care and Endanger Patients.

    Cat’s miao most places I’ve lived, and essential for anyone living a mobile life. Anyone unconcious on a ER table is in no position to tell a doctor about drug allergies and other critical information.

    Kind of shocked to read earlier this week that Yves was not even sure if she was or was not given a steroid to treat her eye scratch. The urgent care we visited in the USA gave us a 8 page print out of the test results, diagnosis, drugs applied in the clinic, as well prescribed, warnings about possible interactions, including foods, how to follow up, etc; similar to what I’d expect at my home country. Maybe we were lucky.

    1. Yves Smith Post author

      No, you misread my comment. I most certainly DID know I was given two antibiotics. I always know what meds I am taking. I was surprised to learn that there were topical steroids used on the eye.

  14. programmer3

    I work at a medical coding software company that automatically suggests procedure and diagnostic codes based on the documentation, and I can tell you that features such as “auto-fill” and “carry forward” don’t help the billing process much at all, and in many cases impede it. The additional verbiage just reduces machine coding accuracy.

  15. YYB

    Yves,

    I retired in 2010 at age 69, after 44 years of practice. The final 3 years involved EHRs at both a large multi-specialty clinic and at a teaching hospital, though the clinic and hospital systems were mutually incompatible. The clinic system was particularly clunky, despite frequent upgrades that required relearning the system. The deal-breaker, as far as I was concerned, was that the complexity of the system and tsunami of drop-down boxes (see Dr. McNoble’s superb discussion above) which required me to face the computer and interact with it, while having an over-the-shoulder discussion with the patient. This was anathema to me. My decades-long practice style had been face-to-face positioning with maximum eye contact and body language that said, “You have my full attention.” How could any patient possibly trust me otherwise?

    My response to this situation probably fell under the rubric of ‘civil disobedience’. I abandoned any attempt at real-time data entry and continued my career-long face-to-face style, scribbling brief paper notes as the encounter progressed. Between patients (or more likely at the end of the day) I would rush back to my office and do the computer data entry. Obviously everything took twice as long as before. (That’s an exaggeration. A factor of 1.4 to 1.5 is probably more realistic.) Obviously, my productivity plummeted. To their credit, the MBAs who had assumed the power positions in the organization let me be, though they could not have been happy with what I was doing. Probably I got by with slow-walking the transition only because I was the senior member of the group and everyone knew the checkered flag could be seen from my windshield. Younger physicians and mid-level practitioners who tried that would probably have been tossed out on their respective ears.

    This is not intended to be a diatribe against electronic health records in general. Nor is the word ‘data’ the plural of the word ‘anecdote’. I don’t claim that EHRs cannot work, only that I was unable to make them work. In spite of being reasonably tech-savvy for an old goat. Would that I could offer a quick and easy solution for this nettlesome situation, which has been so well documented by Yves, Dr. Noble, and multiple eloquent commenters. Or any solution. Sorry, I can’t. Perhaps someone much smarter than me can.

    “In theory, there is no difference between theory and practice. In practice, there is.” Yogi Berra

    Kudos to you, Yves, to Dr. McNoble and to NC’s unsurpassed commentariat.

    Regards,

    YYB

    1. PhilM

      “Health Care” is a dream business for the MBA bastards who have learned to structure every advertisement in the imperative. It’s the only industry where they can sell anything they want–any product, any service, at any price–once the “customer” is helpless and desperate in the hospital.

      As we both know, much of the literature in medicine and surgery exists to justify doing something, anything, to the patient. Health care in America is now just agribusiness-style animal husbandry.

  16. Off The Street

    Out of curiosity, how are American medical and nursing students being instructed on EHR usage and changes thereto? Does that represent a material component of their course and practicum work?

    Will medical and nursing schools next be candidates for sponsored courses, brought to you by Big Pharma, Big EHR, Big anything? That would seem to be on track for the next extension neoliberal business model and mindset, although the second law of Go Die could be problematic.

    1. polecat

      ‘Big Pharma, Big EHR, Big anything?

      “Wellcome to Carls Jr ! • You are in physical distress ! • A medical intermediary will assist you momentarily • You are also out of credit, and cannot receive your order of fries • At Carls Jr we aim to please • Fuck You !”

      We’re getting there, one imbecilic step at a time.
      ‘Sigh’

  17. flora

    Now Amazon and Microsoft are going head-to-head in cloud based EHR health ‘care’.

    According to a recent CNBC report, Amazon has a secret health-tech team working on medical records, virtual doctor visits, and health applications for devices like the Amazon Echo.

    “For those who may have forgotten (or never knew), Microsoft has been targeting some of these same spaces for years with its HealthVault patient-records service. Earlier this year, Microsoft extended HealthVault with a new Insights research project designed to provide users with analytics around patient-health.

    http://www.zdnet.com/article/amazon-may-be-going-head-to-head-with-microsoft-in-healthcare/?loc=newsletter_large_thumb_featured&ftag=TRE-03-10aaa6b&bhid=22293505075082242411452950795158

    What could go wrong?

    Thanks for this post.

    1. flora

      adding: suddenly I imagine all the doctors and nurses are being used as free data entry clerks by Amazon and Microsoft to pump up their stock prices.

  18. Denis Drew

    NO MATTER WHAT MED SYSTEM YOU ADOPT FROM WHATEVER COUNTRY YOU LIKE, the financialization and crapification (your post) of American medicine will not cease without a countervailing force. I am talking about re-building US labor union density across the board. Hopefully it may begin thus:

    I believe that so many registered voters in California would sign a ballot initiative to make union busting a felony — that they might have to line up around the block. Basic requirement: need as many registered voters to sign up as 5% of last governor’s race voters (365,000). Basic source: 45% nationally earn $15/hr or less –- and –- bottom 45% incomes nationally down to 10% of overall income share from 15% two generations earlier (California wages higher, but prices too).
    http://ontodayspage.blogspot.com/2017/07/california-shills-around-block.html

    6% union density in private US economy equates to 20/10 blood pressure — it starves every other healthy process.

  19. Tim

    In short,” he writes, “the current generation of electronic health records has about as many fans in medicine as Barack Obama at a tea party convention.“

    That analogy is way out of date. It should now read: “the current generation of electronic health records has about as many fans in medicine as Donald Trump at a Democratic Party convention”

    1. redleg

      FIFY
      That analogy is way out of date. It should now read: “the current generation of electronic health records has about as many fans in medicine as Donald Trump progressives at a Democratic Party convention”

  20. Tim

    My son has serious allergies. They tested him and the doc told us he was most allergic to pistachios and walnuts while he typed in the test results on the computer.

    Went back since months later and while he is furiously typing on the keyboard for our latest visit he says he was/is not allergic pistachios he is allergic to almonds. We said what? that’s not what you told us, and he says “No, it says right here….

    Well which is it MF? It kind of matters.

    Just my own random personal Anecdote.

    Some people are great Multitaskers, usually the female variety, but many are not, maybe we need to scrutinize our doctors more carefully going forward.

  21. Tooearly

    No mention about the desire for BIG DATA to accesss and sell your health information which ultimately relies on EHRs, eprescribe, and the like?

  22. Angie Neer

    Just my little anecdote: went to the eye doctor for a check-up. Same doc I’ve been going to for years. The front office gave me a voluminous medical history and personal information form to fill out. I asked, “don’t you already have all this information?” The answer, with a straight face: “Well, they just installed a new electronic records system, and accidentally erased all the old records.” Fortunately I don’t have eye problems (yet) and there wasn’t anything medically important to lose in my records. But all the other patients? How is this not a disaster for the practice? And when I did get in to see the doc, she spent most of the appointment grumbling at the computer screen while wrestling with their wonderful new system. Just another illustration of who’s really in charge in the health care biz.

  23. Tooearly

    As a practicing family doc my biggest fear is how effective the EHR aid at destroying the doctor patient relationship. Time spent staring at the screen in the exam room and out of it is time not spent hearing the patients story, listening with our whole body, being present to their suffering.

  24. David Barrera

    This fashionable word- multitasking-is very quickly used, as is the action the same word seems to refer to. For example, a common daily trivial multitasking activity par excellence would be sitting on the couch scrolling down and browsing Facebook memes online while listening to Fox news & eating peanuts. Are all these people doing these multiple activities all at once, geniuses who can do so many things at once? Evidently not. This is only possible when the simultaneous tasks at hand are smooth to the multitasking subject and “processed” without the slightest of resistance and scrutiny by her, since they all conform to her agreeable arranged mental structures.

    1. Yves Smith Post author

      With all due respect, you have this wrong. There are TONS of studies that have shown that people cannot process reading a screen and having TV on at the same time, that their “performance” for each task is impaired. If you think you are doing both well you are kidding yourself big time.

      1. David Barrera

        We could argue my wording was incorrect or you misread or misinterpreted. Either way, we at least loosely agree. Note from my own quote: “..and “processed” WITHOUT the slightest of RESISTANCE and SCRUTINY BY HER (the multitasking subject)…” I read my paragraph once again & stand by it. Process was under quotation marks and is opposed to reflective thought, questioning and so on.

      2. David Barrera

        Yves,
        I would respectfully disagree with “their performance for each task is impaired”. This is not necessarily the case. To continue with my example above, the multitasker listening to Fox News while going through his pal’s Facebook memes performs at his best as quantitative and accelerated consumer.

        1. skippy

          Multitasking is a marketing productivity myth based meme, it was not derived from any sort of cognitive studies. –

          May I gore you with an inconvenient truth? (See what I did there?)

          We sacrifice our power of full presence when we’re multitasking, and we do so for a perceived benefit of improved productivity that simply doesn’t exist.

          Research indicates that multitaskers are actually less likely to be productive, yet they feel more emotionally satisfied with their work, thus creating an illusion of productivity.

          This bears repeating. Forget for a moment that multitasking can be incredibly rude, we’re not actually accomplishing what we think we are–we’ve been fooling ourselves.

          In fact, research also shows that multitasking, i.e. trying to do two cognitive things at the same time, simply can’t be done–the mind doesn’t work that way. Even trying to parallel path a cognitive activity and a more automatic activity doesn’t really work. That’s why the National Transportation Safety Board reports that texting while driving is the equivalent of driving with a blood-alcohol level three times the legal limit.

          https://www.inc.com/scott-mautz/psychology-and-neuroscience-blow-up-the-myth-of-effective-multitasking.html

          disheveled… chalk another one up for the market based rational agent model meme generator e.g. more productive people get the cheez thingy…. chortle….

          1. David Barrera

            That multitasking is not what popular culture thinks it is, does not mean multitasking does not exist. Multitasking can be very productive from a narrow economic point of view and for bad constructed data. A doctor who is listening to his patient’s problems while checking boxes and surfing computer screens is able to see more patients than otherwise in a given time period. That is productivity for you; this type of productivity may well be incompatible with what medical practice should be all about.

            1. Yves Smith Post author

              First, you are shifting the grounds of the argument. That is bad faith argumentation.

              Second, I can tell you as someone who has a computer in front of me all day and also gets phone calls is that the minute I start reading on the computer or trying to type, I stop hearing what the person is saying. Cognitively, it’s as if their voice cut out.

              Third, a recent study confirmed how easily distracted people are, that merely having their smartphone phone in the same room reduces their performance on tests.

              Fourth, even having to switch from reading to listening impairs retention. Studies of PowerPoint use have found that the typical presentation, where you have slides with words outlining the topics being discussed, results in worse comprehension that presentations where the only visual elements are ones that really need to be visual, like charts.

              1. David Barrera

                That is fine. I did not say anywhere differently and I do not believe you have given a fair reading to any of my comments-which is what caused the back and forth to begin with-. If you reread my first comment and its geist properly, you would find out that we are are not disagreeing much.

                1. Yves Smith Post author

                  You said:

                  I would respectfully disagree with “their performance for each task is impaired”.

                  You are now trying to say you didn’t write that? You’ve got a record above of what you said, and it isn’t ambiguous.

              2. heartlanddoc

                Not to mention that glucose levels in the brain plummet when a person rapidly shifts tasks.

              1. David Barrera

                I don’t think so. And are they always independent from each other? And is always good teaching a quantitative analysis separate from a qualitative one?

        2. skippy

          Let me put it another way David.

          The term multitasking is in itself a concocted bit of Bernays speak, it has zero relevancy in discussing the human condition, tho it might highlight the cognitive or behavioral conditioning it evokes.

          disheveled…. sorta like Beetlejuice x3.

          1. David Barrera

            Thanks for the discussion, skippy. I had two replies to your comment, which are awaiting moderation??? I guess they will pop-up later

          2. MoiAussie

            Sorry skip, the term has a respectable history in Comp. Sci., where it refers to using a single processor to run multiple tasks (application/processes) simultaneously by rapid task switching whenever a task has to wait or a time quota expires.

            Like many computer terms, it’s adoption to describe human behaviour results in fake/misleading analogies. What’s wrong with “having several things on the go”?

            I find the closest I get to multitasking is when I manage to get 20 important things done in one day by thinking carefully about what order to begin, continue and complete them, and then interleave them optimally. And that’s really an example of good scheduling, not what most people mean by multitasking.

        1. David Barrera

          People listen to music while taking showers; there is nothing to object to it. A classical or jazz music lover who wants to appreciate all the polyphonic lines, the highs and lows subtleties, the internal influences from former composers or periods that the composition brings about, etc.,will center all his attention to the activity of listening to the music and not to other activity. Customer Service Reps answer the phone saying “Thank you for calling Wells Fargo. This is Lisa, how may I help you? “,and switch to the necessary computer screen while uttering these words. It is a courteous introduction, its numerous daily repetitiveness by Lisa does not exclude its politeness and perfectly allows for her simultaneous computer work. I read yesterday Yves’ article on equity funds. I, by no stretch of the imagination, have the experience and exposure to the subject that she has. I did not allow for any distraction while reading her work. I gave her the respect and time the knowledge and effort she put to the article deserved. I was not predisposed to agree or disagree with her, yet after meticulous reading, coupled with my own knowledge and a bit of additional research, I made a general comment which reinforced some of her main points.
          The fashionable multitasking corresponds to real practice. It is a popular word which would need to be replaced by a more suitable one though. Its danger, efficacy from a narrow economic perspective and the conditions of its possibility come about when it commodifies and belittles important human relations (like the doctor-patient relationship or the parent-child relation); when several echo chambers are heard and seen simultaneously (like the one line memes and the Fox News); when intellectual products are commodified to simplicity and reductionism to satisfy quick consumerism. This sort of multitasking does exist and is the enemy of pause, of reflective thought, of quality as opposed to crapification, of respect to others’ virtues and true being. As Anthony Stegman said above, my post is very strange…a lot of gibberish. Yes, communication is not communicative in the sense you think it is.

          1. David Barrera

            Self-correction Yves article was on private equity, more leverage through credit lines

        2. Sue

          I see kids text messaging & talking to their moms every day . Language interpreters listen to the source language & speak in the target language: one single clear global meaningful action of interpreting with several components or elements as a function of it. Understand what multitasking is and what is not. Here, some help next for ya’.

          The two toxic separate categories of multitasking are:

          1. Lack of negativity & passing unchallenged ontological status through the pipeline
          2. Regarding the multiple tasks unworthy of one focal concentration point. #2 is very close to: sharing your attention to many because no one is worth your full attention

          Important: #1 and #2 do not comprise a unit

          1. Yves Smith Post author

            Translation is not multitasking. It/s one task, Not relevant.

            Re texting, you are kidding yourself about the level of cognition going on. When I am talking on the phone and intermittently looking at the computer, I am cutting out during parts of the conversation. I am missing information on one channel to deal with the other. And any e-mails I write while on the phone are rudimentary. I’d NEVER attempt to do anything more complicated.

            People cannot parallel process. There is tons of cognitive research, including decades-old work by economist Herbert Simon that won him a Nobel Prize on this topic showing how little people can hold in memory buffers and how long it take to retrieve information from memory to access it. These are fundamental limitations of how the brain operates.

            Per above you are falling for the fallacy cited by Skippy: people flatter themselves that they are good at multi-tasking when they suck at it. Look at all the car accidents and cases of people stumbling off curbs or running into posts or pedestrians while texting and trying to do other stuff. There are similarly plenty of studies that show that driving is impaired while people are talking on the phone or a passenger, but talking requires less concentration than texting (you are composing AND using your fingers) so the accident rate isn’t quite as high, but the risk is real enough that many states ban using a cell while driving. Or did you manage to miss that?Cognitively, it’s no different than trying to talk to Mom while texting.

            1. Sue

              Yves,
              I love your website and love what you do, but sorry, you are not reading my comment well. You are changing my words and partially agreeing with me without your realizing about it. Yesterday I said “language interpreters” and “interpreting”. Interpretation is not the same as translation (which is the word you used and changed on me!). Interpretation is all verbal; translation is all in writing . Very different! The language interpreter listens to a speaker in one language while verbally renders in another language. The interpreter cannot stop listening to the source language while speaking in the target language. This can be cognitively very challenging and complicated, yet is very well done daily all over the world. However, I did not even deem language interpreting a multitask activity. Here, a meaningful work , as a unit with one aim, comprises under its umbrella several skills and components which, if we were to look at them independently or isolated from each other would amount to several tasks. But I repeat, to me this is not multitasking, and for sure is not multitasking in the common sense the term is nowadays used. I think we are on the same page on the rest with one or two caveats. I consider text messaging and driving, and text messaging and talking to mom, multitasking. I referred to how toxic multitasking can be. I will rephrase yesterday’s comment: one diffuses her attention among many tasks, losing a a focal point and/or a meaningful unity; one does not give her full attention to one, to give very little and perhaps insufficient attention to some or to many- So, what are we arguing about? I suspect you and I are ok with someone putting the dishes in the dishwasher while chitchatting with her mom on the phone. This is noncontroversial multitasking and the combined nature of the activities are suitable for multitasking . Let’s suppose that while you are reading my comments, you engage in phone conversation with Lambert. This is multitasking. Had you done that ,you could have misunderstood my comments. To do two things is not the same as to do two things well….but you are doing them. And well can mean very conflicting things. For instance , my doctor is looking at her computer screen and typing and clicking when I am explaining to her for 10 minutes all my health issues. It is possible-rudeness aside- that she misses important verbal and visual information from me. Other NC commenters-including MDs-have confirmed this. On the other hand, she is certainly fulfilling her organization’s computerized work requirement. She is pleasing management, is keeping her job and is helping the organization to meet volume goals. Leave unintended consequences aside: this is multitasking. The most interesting cases of multitasking are those where the lack of negativity plays a primary role. I am sure we will discuss them at another time.

          2. skippy

            You should have a peek at the role of dorsolateral prefrontal cortex for executive cognitive processes in task switching. Journal of Cognitive Neuroscience, 1998, Vol. 10.

            In today’s information-rich society, people frequently attempt to perform many tasks at once. This often requires them to juggle their limited resources in order to accomplish each of these tasks successfully. This juggling is not always easy, and in many cases can lead to greater inefficiency in performing each individual task. For example, using a cellular telephone while driving can lead to both poor communication and poor driving. In the brain, juggling multiple tasks (“Multitasking”) is performed by mental executive processes that manage the individual tasks and determine how, when, and with what priorities they get performed. These executive processes act like a choreographer who orchestrates many individual dancers so that they can perform as a single unit, or an air-traffic controller who schedules many airplanes that take off and land on the same runway. If the individual dancers or airplanes are not scheduled appropriately, the results can be catastrophic.

            Multitasking can be difficult when a person must perform two tasks simultaneously, but problems can also occur when a person switches from performing one task to performing another. Performing two or more tasks in rapid succession requires an individual to reorient to each new task, which itself takes time and other attentional resources. In our research, we have studied this aspect of multitasking using a task-switching paradigm. In our task-switching experiments, participants either perform a single task throughout a trial block, or alternate between two tasks during the trial block. By comparing completion times of single-task and dual-task blocks, we can measure the cost (in time) for the task-switching processes. By conducting these experiments, we have been able to understand how aspects of the individual tasks (such as task difficulty and task familiarity) can affect these task-switching costs.

            Look this is about Cognitive Neuroscience and not peoples perceptions about what their doing, how they feel about it or off the cuff observations of others, especial if there is even a hint of bias [environmental suggestion or otherwise] about.

            I will reiterate the term – Multitasking – origins are not based on any scientific meaning, purely a market based assumption that got traction as a bit of jargon with good PR/marketing. It was a buzz word used by administration to get people to do more, making things [people] more efficient, e.g. taking on more tasks for the same pay, but hay, its a nice short pump to the balance sheet. Anywho the market demanded it.

            Disheveled…. something about people doing stuff for a little bit of ribbon [Neapolitan], funny thing about mental ribbons, Dopamine.

  25. Peter Van Erp

    I was at the dentist yesterday. My paper records are still in the same file folder they’ve been in for at least 30 years, through three different practices. The hygienist was dreading the coming changeover to electronic records…

    1. a critical thinker

      the hygienist? they are now pretty much all PT and they have a very low rank in the game. in short, of what relevance is it what a hygienist thinks about records: answer, not much.

      1. MoiAussie

        So because they are of low rank, and endure crappy employment conditions, their opinions about something they deal with every day is worthless? Elitist.

  26. Sue

    Karl Marx. I learned from his writings that capitalism and turnover speed of transformed capital are best lovers.

  27. Dorothy J. McNoble, MD, JD

    I am honored to have had Ms. Smith and Mr. Stether post my essays the last two days. I also appreciate the thoughtful and important debate in the comments.
    I will respond to many of the comments on both essays on my humble blog. The blog is on Medium.com and is entitled “Bad Medicine:What You Don’t Know Can Hurt You.” The associated email is badmedicine005@gmail.com.
    I respect the limited space of Naked Capitalism but would like to have the opportunity to respond to many of these thoughtful comments, so, if anyone is interested, I will post some additional responses/comments next week.
    Also, I learned a great deal about insurance, scheduling, medical and surgical problems during my years in practice so I welcome any questions. Please feel free to email me with any questions, concerns, criticisms.
    Dorothy J. McNoble, MD, JD

    1. Malcolm MacLeod, MD

      I loved this article, and I loved practicing general pediatrics, until the computer started
      taking me away from patients and looking at a screen. That’s why I was happy to retire
      early, and it’s gotten far worse now (I retired in 1996 from Northern California Kaiser-
      Permanente Medical Group).

  28. DavidRN

    As a 36 year RN, I agree wholeheartedly with the article and will add a couple more points. Both of them have to do with the realities of human behavior and the perverse incentives created by the EHR:
    Item 1: Quite often, to get to the screen one wants to document a particular item is a lengthy process of going through multiple screens. We are constantly reminded to log out of the computer if stepping away from it for any reason. One can be disciplined for failing to do so. So, you have logged in, gotten through 5 or 6 screens to get to the one you want, and are halfway through documenting an assessment item. An aide comes to tell you that the patient in bed 9 is having pain and needs medication for it – so – Are you going to log out of the computer and immediately go to deal with the patient’s pain – or are you going to finish your documentation process first? In the old days of hand-written notes, it wouldn’t be a question – you deal with the pain first and finish the note later. With the EHR, not so simple.
    Item 2: You are documenting an assessment of the patient. You are offered a menu of possible choices for, let’s say, the condition of the patient’s skin, or maybe their mental status. You can pick one from that menu just by clicking on it. And you are offered a box where you can type in your own narrative description. None of the offered items to click on is quite right for your patient, but one of them is “pretty close”. You are in a hurry and have a heavy workload. Do you take the time to type in the precise description that fits the patient? – or do you click on the one that’s “pretty close”? You know damn well what a lot of busy doctors and nurses will choose.
    One of my ongoing rueful jokes is that, for all the acrimony in Washington, the one thing that politicians of both parties seem to agree on is that we need more computerization.

    1. flora

      re: 2
      This is the sort of thing that results in drift away from accuracy, where less accurate information becomes “authoritative” by virtue of pushed/forced “restricted-choice data” entry and the subsequent “computer analysis” of essentially inaccurate (by virtue of restricted choices) data. If not exactly GIGO, close enough to cause problems in aggregate. Not a virtuous cycle. Thanks.

  29. mrtmbrnmn

    Words to live by (or at least have a fighting chance to remain alive): Noone should cross the threshold of an American hospital for a surgical procedure WITHOUT A LAWYER ATTACHED TO YOUR HIP!!!

  30. H. Alexander Ivey

    From my own observations about digital (aka computer) systems, dating back to the early seventies, is that digital systems are only good for 4 things:
    1. find information
    2. sort information
    3. move information
    4. change information

    Anything else, they aren’t good at. So, much of what the good doctor talks about as being a faulty implementation of, or an abuse of, some ‘good’ idea for a digital system to do, is something that is really impossible to do on a computer. Okay, to concede to the literalists, is something that can not be done well, if done on a computer.

    1. MoiAussie

      You forgot possibly the most important and transformtive: 5. Visualize information.
      And just around the corner: 6. Understand information.

  31. xenophon61

    Thank you for this very solid article which, coming from a surgeon with combined MD and JD backgrounds, has obvious value. Still, I think that the EHR debate revolves around some core issues:

    – the practice of clinical medicine, in the ward or outpatient setting
    – need to access and interpret data (by both health care providers, as well as administrative staff)
    – need to document the course of illness
    – allow reliable and rapid collaboration
    – enhance safety

    There is a multitute of other aspects, deriving from its central role, also quite critical: maintaining patient privacy, shielding the providers against litigation, reliable transmission of information and rapid collective assessment.

    To my mind, this is a legitimate “there-is-no-alternative” state of affairs, and I find it very sad that physicians and patients alike fail to grasp its significance.

    Reminiscing about jotting entries in a paper chart, or retrieving a microfilm is OK, I guess, but really not compatible with current practice. Myself, I still prefer analog film photography, but just can’t imagine not maintaining a clinical database (albeit without the maddening billing superstructure, as exists in the US).

    Just for context, I am a 56-year-old cardiac electrophysiologist in Athens, Greece, trained in the U.S. during the ’90s. I remember, quite fondly, the VA hospitals in New Haven, CT, and Brooklyn, NY, and their (terminal-based) EHR.

    Veterans were so much sicker than average, and despite the archaic underpinnings of its centrally administered EHR, prompt availability of their medical records actually made a difference, even when providing dental care. It was also the height of the HIV epidemic, and drugs were so much easier to get when all data was at hand (T-cell counts, etc).

    Fast forwarding to today, I have no personal experience, but will refer you to the writings of a retired cardiac electrophysiologist from the University of Lexington: Dr. David Mann has quite a lot to say about EHRs in general, over at the EP Studios site linked below.

    https://www.epstudiossoftware.com/tag/ehr/

  32. jackiebass

    A lot of this is because in the US health care has become corporatized with doctors becoming employees of the corporation. To make money the time allowed to see a patient has been reduced. In my case my doctor is now allowed 20 minuets instead of as in the past 30 minuets. So they now see three patients per hour instead of two. One problem I see is many doctors don’t have the time or just don’t read the records. From what I’ve read in France everyone has a plastic credit card size card that contains all of their records. The doctor can simply insert the card in the computer to access your records and add to them during your visit. The card is returned to the patient after the visit. One question I thought about is how do they handle it when a patient loses or destroys the card? Also if the provider isn’t paid in a short period of time the insurance company is fined. The biggest problem I see with US health care is that the expert, your doctor, doesn’t have much control over how you are treated. The insurance company and an MBA call the shots.

    1. Enquiring Mind

      Some US docs will tell you that they have had to fire their insurers, meaning to stop accepting their coverage, reimbursements, conditions et al. A neighbor did that because he objected to the short and shrinking time allotted for patient visits. “You can not diagnose and treat a patient in 6 minutes”. He decided that there were other insurers with slightly more humane systems, although that list has been shrinking.

      Another doc left his private practice to join Kaiser Permanente, as the paperwork in the former was interfering with the practice of medicine. He and his partners miss their old practice, but not the constant and growing administrivia.

      1. mn

        Maybe everyone should use planned parenthood since they will never be able to afford this garbage.
        care providers spend more time charting & less time caring
        we must use check box options, no free text or add comment (only as last resort), why? RESEARCH
        are we being spied on? who has access to our most personal information. why do I need to start asking people if there is a gun in the home.
        useless, why? An elderly patient got a flu shot at their long term care facility, another at their MD and a third at the hospital in the same season. If you don’t bother to read the record you still repeat treatments.

    2. Sue

      I’ve changed my general medicine doctors 7 times in the last 10 years. I’ve had good PPOs. I used to make appointments, but due to overbooking the doctor didn’t ever see me until 45min or 1hour after the scheduled appointment time. Time with doctor in the same room never exceeded 15 or 20 minutes. Of the 15 minutes she spent at least 10 min with computer, typing. I was sick for 3 years and none of the doctors could pinpoint with accuracy what was wrong with me.They prescribed me pills which made me feel worse & I had to quit taking the pills three months down the road. They pretended or they falsely believed they knew what my illness was & acted as if the computer knew it too. My luck changed at the moment I took matters into my own hands. I read four or five books of medicine in German, Spanish and English & diagnosed & prescribed myself via an overseas acquaintance. I’ve been very healthy since & haven’t gone to the doctor in the last three years.

  33. Beans

    Great article Yves.

    I practice at a well respected medical center that implemented the EHR about 10 years ago. Originally it was a good tool that make communication between doctors easier – now it is a frustrating, distracting resource suck that I despise. Two years ago I made the decision to leave academics and enter private practice and the EHR is a big reason why. My private practice is paper chart based – and completely under my control – I don’t answer to corporate or academic mandates, quotas or manager reviews. While I took a big hit on income, the ability to talk to my patients face-to-face and control the type of care that they receive has been a welcome relief. I had enough years in the saddle to be able to now run a “hobby” practice – and by hobby I mean one that is not viewed as a financial source of funds for me but rather an enjoyable place to spend my time.

    I fear for the future of medicine. The electronic health record has changed the way doctors process patient information and decision making. It has change the way we teach residents and the way the residents learn.

    I fully agree – Every patient entering the hospital or having a condition that requires ongoing medical care needs to bring along a patient advocate.

  34. flora

    From a 2013 article in InformationWeek.
    Healthcare Experts Confront EHR-Related Medical Errors

    ” “The fundamental approach to health IT needs to change,” lead author Dr. Blackford Middleton, corporate director of clinical informatics research and development at Partners Healthcare System and 2013 AMIA chair-elect, told InformationWeek Healthcare. “We’ve been installing it and not measuring it like we would any other intervention.”

    “It is time, Middleton said, to take a step back and assess the direction of health IT, EHRs and the federal Meaningful Use incentive program. “We were motivated by the mounting evidence that there were unintended and untoward consequences with using health IT,” Middleton explained. ”

    http://www.informationweek.com/healthcare/electronic-health-records/healthcare-experts-confront-ehr-related-medical-errors/d/d-id/1108419

  35. Anonymous

    Recently went to an acute care clinic and told them we be paying cash at the end of the visit.

    The doctor didn’t use the EHR for much of anything and just gave us a paper receipt with a couple items scribbled down to take to the desk. I’m sure we wound have paid much more with insurance.

    They’re like kids in a candy store with the EHRs. No other profession gets to decide how much they can bill without some sort of tangible explanation of services.

  36. HH

    The gratuitously differentiated systems in use across American medical institutions are a reflection of the singularly uncooperative character of the medical profession. Predatory corporations exploit this weakness to further balkanize and undermine common sense efficiency in automation of patient records. It is intuitively obvious that every patient should carry a standard medical information card tied to a universal database built on common standards – yet we cannot achieve this. Americans blame this failure on “technology” but the real reason is the low trust and high combativeness that characterize our society. The government, which should have a leading role in rationalizing this mess, is crippled by the Reaganite auto-immune disease in which the people seek to destroy their own government. Meanwhile corporate profiteers enrich themselves by serially building and replacing deficient systems. This mess will be reformed only when the madness reaches levels of such absurdity that people begin leaving the USA in large numbers for medical treatment in sane nations.

    1. ambrit

      Below a certain threshold of financial resources, the patient population is constrained by not being physically able to travel to these other “sane” medical venues. It’s called a “captive population.” You’ve described a highly stratified health care system, when one includes the rest of the world in the mix. This is one definition of the basis for a “Jackpot” outcome.

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