Yves here. We’ve posted off and on for at least the past five years, via the dogged coverage at the Health Care Renewal website, over the way that electronic medical records are undermining the delivery of health care. Some readers instinctively reject that idea, but that is due to not understanding that these systems are entirely about billing, not about diagnosis or treatment, and regularly force doctors to navigate through numerous irrelevant screens before they get to the parts that are relevant to their patient. That wastes time and dilutes the doctor’s focus.
For instance, from a 2014 post, quoting a physician:
The fact of the matter is that the EMR [electronic medical record] remains in the United States a tool for maximization of reimbursement and as such is not a technological destination but rather a technological dead end. The driver for proliferation of this ‘dead end’ is the government being willing to fund its expansion with their fervent hope that it will be their magic bullet for finding the cheats and cheaters of Medicare….
The reality is the train has left, those of us addicted to patient care watch in dismayed horror as our productivity plunges and we struggle to restructure not our workflows but our clinical thought processes to badly designed, logically flawed, and obscenely overpriced documentation tools that distract the expert clinician from a high quality clinical encounter.
Quite honestly gentleman and gentlewomen of the jury, I don’t give a ‘rats a**’ about superior documentation, I am obsessed with superior outcomes, and as somebody who actually has to work with this junk, it all sucks………. and will continue to suck until such time as real world clinicians have veto power over the efforts of systems design teams with respect to their information design efforts…. What information design efforts? My point precisely…….
The ECRI Institute report put health care information technology as the top risk in its 2014 Patient Safety Concerns for Large Health Care Organizations report. That ranking was based on the collection and analysis of over 300,000 events since 2009.
Fast forwarding to today, see another example, this post at Health Care Renewal, Physicians Harassed by Overwhelming Levels of Messaging From Electronic Medical Records. Key section (emphasis original):
MedicalResearch.com: What are the main findings?
>Response: We found that, on average, clinicians receive 3.24 messages per patient visit, for an average of about 50 messages per full day of clinic. The number of messages also correlated with poor reported work life balance for dermatologist…
MedicalResearch.com: What should readers take away from your report?
Response: /b>As previous studies have shown, physicians are spending much more time in non-direct patient care and less time with patients. This is bad for everyone involved. Targeting methods to decrease this burden would be important in improving patient care and physician wellbeing … We are planning on examining the messages sent directly from patients more closely, hoping to target higher risk patients to decrease post and inter-visit messaging.
As the post points out, doctors in other specialities, such as ICU and internal medicine, are likely to receive even more messages per patient visit.
And to now to our main event below.
By Scot M. Silverstein, MD, Medical doctor, and Medical Informatics professional via NIH-sponsored postdoctoral fellowship at Yale School of Medicine 1992-1994, Faculty, Drexel University, College of Information Science and Technology, Philadelphia, PA, and architect of Drexel’s Graduate Certificate Program in Healthcare Informatics. Originally published at Health Care Renewal.
Medical Economics: Highly experienced physicians lost to medicine over bad health IT
The title of the article is actually “Physicians leaving profession over EHRs“, but that title omits the real impact of the phenomenon: seasoned physicians, along with their medical expertise, judgment and experience, are lost to the pool of people entrusted to provide care thanks to poorly designed and badly implemented IT:
Bad Health IT is IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, lacking in evidentiary soundness, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.
This is yet another article observing that the trajectory of health IT is not what the pioneers who taught me Medical Informatics intended:
Physicians leaving profession over EHRs
January 24, 2018
Until recently, most doctors created their own workflows and utilized only the technology they were comfortable using. But with the implementation of the Health Information Technology for Economic and Clinical Health Act (HITECH Act) in 2009 to stimulate the adoption of electronic health records (EHR), many physicians are finding things a bit too stressful.
In fact, a new study in Mayo Clinic Proceedings showed that physicians who are uncomfortable using EHRs are more likely to reduce hours or leave the profession.
I think it very fair to say that a majority of physicians are “uncomfortable” or at least “highly displeased” using today’s EHRs. Evidence for this assertion includes, among others, the Jan. 2015 letter from approximately 40 medical societies including AMA, American College of Physicians, American College of Surgeons, and many sub-specialty societies expressing their displeasure directly to HHS.
See my January 28, 2015 essay “Meaningful Use not so meaningful: Multiple medical specialty societies now go on record about hazards of EHR misdirection, mismanagement and sloppy hospital computing” at http://hcrenewal.blogspot.com/2015/01/meaningful-use-not-so-meaningul.html, and the Medical Societies letter itself at http://mb.cision.com/Public/373/9710840/9053557230dbb768.pdf.
The research showed that while EHRs hold great promise for enhancing coordination of care and improving quality of care, in its current form and implementation, it has created a number of unintended negative consequences including reducing efficiency, increasing clerical burden and increasing the risk of burnout for physicians.
Typical of the anodyne stories in the media on bad health IT, the issue of causing increased risk and actual patient harm is omitted.
Tom Davis, MD, FAAFP, who practiced family medicine for almost 25 years in the greater St. Louis area, says the primary reason he walked away from a successful practice was the EHR, citing its use, the ethics and the burden.
“I had 3,000 patients, many I’ve known for a quarter century, a few hundred of which I delivered, all immensely valuable relationships—and all burned to the ground mostly because of the burdens of the HITECH Act,” he says. “The demands of data entry, the use of that data to direct care and my overall uncertainty about how medical data was used in aggregate all helped poison the well from which my passion for serving my patients was drawn.
In other words, his expertise, knowledge and experience, and valuable personal relationships (enhancing trust and the obtaining of the best medical histories) with his patients was sacrificed to, in essence, utopians’ notions of cybernetic medicine and the wants of the financialization-of-medicine sector.
He believes that the information collected through the EHR is being used (at least in aggregate) for purposes other than the direct benefit of the individual patient so it would be unethical for him to represent otherwise to the patient.
I had previously written on this site about the EHR companies trafficking in medical data, as in my October 7, 2009 essay “Health IT Vendors Trafficking in Patient Data?” at http://hcrenewal.blogspot.com/2009/10/health-it-vendors-trafficking-in.html.
In the research realm, formerly working with one of the key figures in the now-defunct Human Genome Diversity Project at Yale, I myself am personally aware of indigenous peoples refusing to take part in data collection by western scientists because they feared misuse of the data.
I was right; the researcher proposed, and may have experimented with, using the genetic data to perfect a “forensic” identification capability essentially based on ethnic (“population”) origins.
I wrote on these issues at my September 8, 2005 essay “Academic abuses in biomedicine vs. Indigenous Peoples: The Genographic Project” at http://hcrenewal.blogspot.com/2005/09/academic-abuses-in-biomedicine-vs.html and my July 26, 2007 essay “Informed consent, exploitation and ‘Developing a SNP panel for forensic identification of individuals’” at http://hcrenewal.blogspot.com/2007/07/informed-consent-and-developing-snp.html.
I thus opine Dr. Davis’ concerns are quite legitimate.
As far as the burden, he notes he spent about four minutes of keyboard time for every minute of face-to-face time with a patient.
That is a huge waste of clinician time, with few proven benefits (at least outside the financial world) and known risk, e.g., ECRI Institute’s yearly “Top ten technology risks in healthcare” where health IT is usually highly ranking on that list, such as at my April 2014 essay at http://hcrenewal.blogspot.com/2014/04/in-ecri-institutes-new-2014-top-10.html.
Ramin Javahery, MD, chief of adult and pediatric neurosurgery at Long Beach Memorial, Long Beach, California, says there are obvious financial pressures that drive people out of private practice into a larger corporate structure, but the changes in the workplace brought about by EHRs are also driving older doctors to retire rather than deal with the costs or increased work required.
“Younger physicians who are comfortable with typing, computers and the truncated patient interactions generated by EHRs do not resist its presence,” he says. “Older physicians, however, are more likely to lack those comforts. When faced with a less comfortable work environment, they choose to retire, especially since many have saved enough to be comfortable financially.”
Where do I even start? Older doctors have a wealth of experience and hard-earned wisdom that is being sacrificed to the whims of those who think the medical robots of “Silent Running” are just on the horizon, it seems…
Regarding younger (i.e., less experienced) physicians and the “truncated patient interactions generated by EHRs“, those are two deleterious results of the technology. Less experience combined with less patient interaction, plus the distractions imposed by EHR-related clerical work, create increased risk of error and patient adverse consequences. There is little to debate on that point.
Kevin Gebke, MD, a family and sports medicine practitioner at Indiana University Health in Indianapolis, says the issue is not fear, rather it’s a matter of dramatic workflow change.
“EHRs were not designed by practicing clinicians and are not intuitive regarding the different processes that take place during a patient encounter,” he says. “Physicians must often choose between communicating with the patient and navigating within the records to enter or view relevant data. That can fragment care during a patient visit.”
His experience with EHRs is it has slowed down his workflow, causing a significant decrease in productivity.
The issue is certainly not “fear” or physicians being “Luddites”, as I’ve pointed out in my March 11, 2012 essay “Doctors and EHRs: Reframing the ‘Modernists v. Luddites’ Canard to The Accurate ‘Ardent Technophiles vs. Pragmatists’ Reality” at http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html.
The tension is not between doctors who “fear” technology or are Luddites, vs. the modernists. Rather, the true tension is between clinician pragmatists and technology hyper-enthusiasts (“Ddulites”) who ignore technology’s clinical downsides.
“Spread this decreased capacity to see patients across the country and we then have a magnified shortage of primary care providers,” Gebke says.
That shortage is, in fact, at odds with national policy on re-populating the pool of generalists to reduce costs.
Because of this, he believes a way to keep physicians from leaving the profession over EHR issues is to get them involved in design and improvement processes.
EHR redesign can only accomplish so much. I have reached the point where I believe the only solution to this seeming conundrum is to stop focusing on computers, and decouple physicians and nurses from cybernetic oppression. See my August 9, 2016 essay “More on uncoupling clinicians from EHR clerical oppression” at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html.
… In 2016, one of the largest complaints of hundreds of thousands of U.S. physicians and nurses is that they spend more time interacting with the computer than with patients. Patients complain they cannot get eye contact from clinicians – who are tethered to a computer screen entering data – during “live” encounters.
It is my belief there is no solution to this problem other than, where appropriate and advantageous, decoupling clinicians from data input and returning to paper for data entry, that is, specialized forms as in the aforementioned post. Data input needs to be returned to clerical personnel as in the aforementioned invasive cardiology system.
Finally, the predictable “things are getting better and utopia is just around the corner” ending to articles on the impact of bad health IT ends this Medical Economics article:
Things are improving
Munzoor Shaikh, director of West Monroe’s healthcare and life sciences practice in Chicago, says that while some doctors are leaving medicine due to technology learning curves, the industry is past the EHR implementation phase and has entered an EHR optimization phase where the user experience on the physician side should be improving.
“Those who have more patience than others have stuck around; hopefully this optimization phase will save some more doctors from leaving,” he says. “That said, there are some physicians who are fundamentally not built for this tech-driven world.”
The final line is nothing short of outrageous.
The truth is, there are all to many clinical information systems that are fundamentally not built for the good-practice-of-medicine-driven world.