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:
http://cci.drexel.edu/faculty/ssilverstein/cases/
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
Medical Economics
Keith Loria
January 24, 2018
http://medicaleconomics.modernmedicine.com/medical-economics/news/physicians-leaving-profession-over-ehrs
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.
I observed:
… 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.
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Before I got out of IT I was interested in the OSCAR EMR Clinical Management System. It was initiated by an MD and developed at a university. As for its quality and clinical (rather than billing) orientation, I’m not qualified to say. It has active developers and active users. Any comments? Was I right in having been interested?
This is close to what I do for work – dealing with EMRs from the research end. Our university’s hospitals use a widely used system called Epic, built on a creaky database technology called MUMPS designed decades ago.
Epic is a goddamn mess; the software does not allow efficient coding of patient information. Thus, most of the useful patient information ends up in unstructured patient notes, where it is essentially impossible to search by machine. It also makes it difficult to produce censored information that preserves privacy. Doctors are reluctant to give up notes because they cannot otherwise describe the patient’s treatment and condition efficiently and thoroughly (the note works fine for humans to communicate).
Meanwhile, the structured data is scattered across, I kid you not, 18000 data tables. This means even understanding where the information you need requires considerable effort, usually abandoned by all parties.
Nevertheless, Epic is very stable in its hold; doctors depend on it, tons of medical information is crystalized inside it. Furthermore it is widely used, which allows ‘interoperability’ with other hospitals stuck with the same mess. This sort of Enterprise solution is exactly what appeals to administrators despite its flaws; no one will be fired for buying Epic.
The legal mandate makes things worse – as with HIPAA, the privacy law, the laws do not determine how to solve problems, merely create penalties for failure to comply. This is a recipe for universal disaster.
MUMPS? Smith Kline Labs used a MUMPS based system in the early eighties in its very first computerization of its manual system.
When I was studying IT at the University in the 1980s, MUMPS was already considered a legacy technology that only survived in very few specialized fields.
Current health IT systems largely relying upon it is reminiscent of the banking and financial IT infrastructure depending on 40-50 years old software which has been repeatedly discussed in NC.
Major economic areas based on creaking IT. I am reminded of that historical school that gives prominence to the inability of a civilization to maintain its accumulated infrastructure as the incontrovertible sign of its impending collapse.
Is anybody still using Pick?
Yes, you would be hard pressed to get MUMPS skilled developers or designers/architects. Like trying to find people who know how to service gaslighting.
Programming languages are irrelevant to the issues being discussed in my essay.
Unfitness for purpose of commercial health IT is the issue I raise.
As both an information technology professional and physician, this is as obvious as if possibly can be: a focus on technology, as opposed to the realities of clinical practice, is destroying the profession of medicine.
What is unclear to me is why physicians and nurses who are not Information Technology professionals understand this, but Information technology professionals who are not physicians or nurses appear to not understand this, or dance around the issue of bad health IT that cannot be fixed because the whole concept of clinicians as clericals is defective.
A pen does not require a 500-page instruction manual, and doesn’t force a user to spend enormous amounts of time on entering non valuable, trivial information.
Pick is the database used for the McDonnell-Douglas hospital system, used widely in Australia into the last decade. According to a 2014 report, Queensland will be the last to retire the system, in 2019.
Yeah, Pick is still used in some vertical markets.
Let me take the other side of this. I worked in IT in the medical profession in the past, so have seen all of this firsthand, but don’t currently work in it, so don’t have a private stake in any of this any more.
There really is no good reason that physicians should be scrawling medical notes on paper in illegible handwriting. It was a necessary thing before the computer age, but it’s long past time that vital medical information go into a system where it is widely available throughout the enterprise.
Would you feel safe giving your money to a financial institution keeping its books on old ledger paper? Would you feel safe with an insurance policy at an insurer keeping the papers in overstuffed folders in boxes in a back room? Would you feel comfortable making a high dollar purchase where the sales person writes down all the information by hand on loose scrap paper and sticks it onto a spike like an order at a diner?
There are good reasons every other major industry in the U.S. other than the healthcare industry has moved to electronic records. Those reasons include: ability to share records; higher reliability of information captured (versus bad handwriting); better preservation and auditing of records (electronic records can be backed up, written records can easily be lost or destroyed); and radically improved ability to run broad data analytics.
Much of the piece above is, tellingly, not about the technology, but about the process. And I agree that process can be a major issue, and needs careful review. Efficiency arguments are also over-sold; in the short-term, electronic medical records tend to cost much more than they save (particularly since you have so many physician assistants going through the doctor’s written notes and having to manually enter them into the system because “I don’t use computers and never have”, which isn’t particularly efficient).
But the real, substantial arguments against electronic medical records by doctors – which I know from personal experience – are because they don’t like learning how to do new things, they don’t like anyone telling them what to do, and they don’t like the thought that an electronic record makes it much, much easier for another doctor or (horrors!) medical administrator to second-guess their decision-making. With all due respect to people with extraordinary education and abilities, those simply aren’t good reasons. Every working professional in every other field has had to deal with the change brought by technology, and I don’t know why doctors get a pass.
What many health enterprises are doing at this point is assigning staff to assist older physicians with the process of using the technology – again, in practice this often means staff taking the paper notes and entering them into the system. Wildly inefficient, but what else are you doing to do with a 70-year-old doctor who has no intention of learning how to use a computer. In the meanwhile, they’re waiting on a younger generation of doctors that are not only willing to use technology, but who see the advantages it can bring.
I tend to agree with your take. EMR systems should be considered a work in progress which, frankly, is not going anywhere. If anything, they’re too fragmented. There are hundreds (if not thousands) of balkanized proprietary claims formats and data structures custom built for every insurer, provider, and systems vendor, a cesspit of integration consultant profit stripping. Would a ‘Medicare for All’ implementation without electronic records ever not become a feeding trough of fraud and corruption? Without electronic records, any national plan would be dead on arrival. So yes, workflow needs to be drastically improved, obviously from Yves’ observations, but office staff rummaging through racks of manila folders in filing cabinets is ancient history.
You’re suggesting that electronic health records are experimental, and are being used upon human subjects without informed consent. That includes both patients and clinicians.
In fact, this is the reality.
There are ethical treatises on human subjects experimentation going back at least to World War II that indicate such experimentation is highly unethical.
I hear what you are saying – I am ‘semi-retired’ from a tech job in the health insurance industry and saw the complexity and work-flow issues that can be solved by IT – but at the same time I saw the gee-whiz-bang computer geek/uber-developer solutions to ‘problems’ that (for lack of a better term) turned into rube-goldbergian monstrosities divorced from the reality of the person(s) who actually had to USE the damn thing.
I am reminded of an old friend from college who was in the Peace Corp in West Africa. When we used to talk about his experiences, he often spoke of ‘appropriate technology’ as very important to success. That is to say, if a village was suffering from deforestation caused by excessive use of local soil-fixing trees/shrubs in cooking fires & for boiling water…the solution was NOT to give them shiny new propane ovens when the infrastructure and tech required to supply them was nonexistent, or to give them hi-tech membrane filters that would clog & need expensive replacements from elsewhere in the world.
Instead, the solution was to use a technology that fit with the local skills and was thus ‘appropriate’. For example – finding ways to make a mud-brick oven orders of magnitude more insulated and thus efficient with the local wood that was burned, thus using orders of magnitude _less_ of it. Or, identifying a water filtration system that used (say) a very small amount of activated charcoal and sand filtration that could be sourced locally and lasted for as long as the locals needed.
This electronic medical records issue is sort of an ‘appropriate technology’ argument in reverse: just because some fancy hi-tech IT-heavy cloud-tied AI/machine-learning solution helps in *one* scenario, does not mean that a similar rube-goldbergian technologists mess needs to be applied 100% in every other scenario.
Honestly, in 90% of the interactions i have ever had with physicians and other health professionals the only thing that mattered to me was that they were able to look me in the eye, ask me questions, identify the symptoms, and then physically set the broken bone…stitch up the gaping wound…and be caring and quick about it.
Appropriate technology – if the Physician is able to do the above – and then record the visit with a pen and paper, or just notepad.exe, fine. And I *really* do not want him/her futzing around on a screen while the above is happening trying to find the right dialog box to click ‘OK’ in.
As someone currently working in healthcare IT (primarily interoperability and data aggregation), I agree with The Insider. But I also appreciate that little attention was given to the impact to the workflow of older, experienced physicians and their support staff as the meaningful use juggernaut made its way through the US. My own doctors have told me how much they hate their EMRs and I have one who still uses paper and pencil and still delivers very high quality care (he gives his notes to a younger, computer savvy assistant for entry into their EMR).
The hospital EMR space is now dominated by two major players – Epic and Cerner. And consolidation is now underway for outpatient facilities (again with Epic and Cerner being the biggest fish in the ocean gobbling up small fry EMRs). Another trend in US healthcare driving EMR consolidation is the monopolization of health systems – where once a given region may have been serviced by a dozen or so different hospitals and outpatient clinics, the bigger players in an area are buying the smaller hospitals and affiliated clinics: as health systems acquire other hospitals, they force them to adopt their EMR platform. The primary focus of my work is moving clinical data between those systems while that transition to a single platform is ongoing (and it takes years for that to happen).
Epic is viewed by just about everyone not working for Epic as a bad actor (think of them as the Google or Amazon in healthcare). Their software is very high-priced and they do not willingly interoperate with other vendors. Ironically, the Epic system is based on the EMR developed decades ago for the VA system. Epic is the software behind one of the “better” integrated health systems in the country, Kaiser Permanente.
So let’s not discount the benefits of having clinical data available to physicians electronically. In Kaiser’s case, if I were to go from my home in So. Cal to San Francisco and have to see a doctor at a Kaiser due to an emergency, they would have my complete medical history available to them. The promise of this should be obvious – it eliminates unnecessary redundancy in testing, prevents mistakes, and, presumably, saves everyone time and money.
Also, while many doctors don’t like technology, virtually all health systems have practicing physicians involved in IT decision-making.
Finally, the US is not unique in experiencing the pain of adopting EMR technology. Canada, Australia and The Netherlands come to mind as leaders in making the adoption of technology in healthcare a success. I rather think the problem is the singularly problematic meaningful use guidelines that make adoption of technology in the US so very painful for experienced physicians.
MDs & hospitals do have instant access to medical records so long as those records are held by the same company, otherwise like in the old days wait till business hours to fax for the records. Then again in an acute issue tests must be repeated anyway with the old being used as a baseline.
You don’t have any basis for asserting that, and it is often not true. I have a buddy who was recently hospitalized. He happens to be a sys admin. He quickly figured out the records that had been generated during his stay were on two different systems that didn’t connect at all. Hospitals are often in hospital systems where there have been mergers. It is far from uncommon for there to be major IT integration issues in a merger, particularly regarding records. We’ve written about this ad nauseum in banking where IT is more mission critical than in health care.
In my experience traveling in rural hospitals for patients being transferred to other facilities operating on another system, say one uses Cerner & the other EPIC. We need to print & fax the records, also hard copy discs of tests are made for the next facility to read. If hospitals are in same system they usually have same EHR. If a person lives in NY & summers in FL and both hospitals use EPIC, out of state records can be obtained from EPIC.
Could you unpack the phrase “singularly problematic meaningful use guidelines that make adoption of technology in the US so very painful for experienced physicians?”
Martin, here’s some background on MU: https://www.cdc.gov/ehrmeaningfuluse/introduction.html
Basically, it’s a government-sponsored program in the US that gives doctors financial incentives (and penalties) to adopt EHRs. It has driven an enormous amount of healthcare IT spending in recent years. “Technology fatigue” in healthcare is a direct consequence of this program and at the root of the backlash described by Dr. Silverstein.
Medicine is an art, and one that requires, if done correctly, attentive listening to the patient’s responses to well-framed questions. This means that EHR input by the physician while consulting with the patient is a poor process. I suspect that typing is, in general terms, more distracting than handwriting, and regardless of that first point, time spent looking at a computer screen definitely creates the impression that the physician is not listening to the patient. This creates two confounding issues if the goal is to provide the best care possible: (1) the distracted physician may overlook an important issue; and (2) the frustrated patient may be less than fully forthcoming with the physician that is not giving appropriate attention.
EHRs by themselves, as a storage and archive technology, are fine, provided they are well-designed. The implementation issue is that physicians should not be doing the data entry into these records contemporaneously with seeing patients. Either physician workload needs to be adjusted to enable the records to be updated after each visit or at the end of the day, or appropriate clerical staff and procedures should be developed for the rapid and accurate transcription of handwritten notes (definitely on structured forms) to the EHR.
Any EHR is no better than the information used to generate the records. If EHRs worsen the quality of the underlying data, then the advantages aren’t that great–to me, the ability to find bad quality data in an EHR is not obviously a superior outcome to the inability to readily locate data written on paper.
This is the most profound insight in this thread.
Exactly.
As a salesperson, I HATE the computer. It does nothing for in-face visits. It doubles my workload as I cannot IMAGINE going into a sales visit with my laptop open. I take notes, like I’ve always done by HAND on a sheet of paper in my folder than accompanies me into the sales call. Then, because boss and corp want their DATA, I have to spend valuable time re-entering these notes into a laptop on my lunch breaks or after hours.
I HATE THE COMPUTER for that reason. Any salesperson bringing his laptop into a meeting and spending the time entering info rather than talking and listening. NO WAY. I feel for these docs. They are doing the same thing. Spending time on their laptop when they should spend the time talking, listening and actually connecting to the patient.
I directly confronted my primary care doc about looking at the laptop instead of me when I was recounting what turned out to be a very serious health incident in an attempt to get a diagnosis. She got all pissed off and fired me. But I gather she was forced to use the computer as the practice was transitioning to EMR, and wasn’t happy about it either.
The trouble is that they’re *billing* tools, not medical tools. Docs aren’t really *that* opposed to new tech, they learn new medical devices and techniques and tools all the time. But that’s not what this software is. It’s a financial tool, and as such it’s not designed for the convenience of the doctor or the safety of the patient.
The people in IT need to speak to the people in Big Pharma about how to get doctors to learn new things.
Big Pharma was able to teach doctors in fairly short order that opiates are not actually addictive despite millennia of evidence that they are. Doctors then quickly adopted the new time-release technologies of delivering opiates and introduced them en masse in short order.
Most telling comment in the thread. Unfortunately, it is difficult to imagine the focus on billing changing for EHR in the US since we’ve conceded to the financialization of healthcare.
This is not about not “learning new things”. This is about not wanting to use terrible tools that get in the way of doing one’s job. Administrativa has become more important that patient care.
We’ve featured many posts on the problems with EHRs. One is that they contain pages and pages and pages of boilerplate warnings in ER settings, most of which are not relevant to any particular operation. The result is that it degrades pre-op checks because the in-theater doctors flip through them and wind up skipping over reminders that are germane to that particular procedure.
People in medicine need to teach IT that when people are seriously ill & need care I do not have time to search through dozens of drop boxes to find what I need. EPIC and Cerner are garbage, interfere with actual care, as too much time is wasted searching for that relevant data specific to that patient that needs to be charted. All I need is to be able to read the note, only problem solved and the rest is junk for the end user. Can’t wait till these useless programs are thrown to the trash heap, but as they cost so much to purchase doubt that will happen any time soon.
Just to put in my two bit (bytes). Perhaps rd is being sarcastic. At least that is my initial reading.
Both my wife and I are mid-career physicians (not close to 70) who have had to work in the Epic system for the past 7 years and I can attest to many of the problems outlined in the article. It seems that many commenting here are in IT who simply can’t believe that healthcare providers aren’t loving the wonderful advances that EMR’s are bringing to patient care. I am not a Luddite nor do I want to go back to scribbled paper records but the present design of at least Epic (I don’t have direct experience with other present EMR’s) is not focused on patient care. Prior to getting Epic, our institution had an in-house developed EMR focused on patient care that was generally well-liked by the medical staff and easy to use. However, it did not meet many criteria that our administrators wanted, such as billing use. It also was inadequate for CMS requirements. So it was scrapped for Epic at huge monetary costs.
Epic is incredibly difficult to efficiently find pertinent information on patient’s health histories. And the longer we have it, the more junk is added to individual patient records. There are many times I go through multiple screens searching for the information I want. As an anesthesiologist, I find my ability to find pertinent info on patients somewhat aggravating. However, it has had a much bigger impact on my wife as someone providing direct outpatient care. Since she finds trying to fill out the required computer documentation while speaking to patients incredibly distracting, she waits until the evening to do much of her documentation. In addition, now anyone in the institution can add tasks to her personal electronic task list which always seems to have 50 plus items on it despite her constantly working on it. Finally, both patients and community providers can now directly interact with her electronically for almost any reason which often requires some response. This entails anywhere from 2-3 plus hours of evening computer work and multiple more on the weekend or when we are on vacation. This has a serious impact on work/life balance as well as her job satisfaction We have children as well and have contemplated one of us simply quitting or drastically cutting back to have some reasonable semblance of family life.
So I really don’t think the problem is one of most physicians simply refusing to learn new things or being open to the potential benefits of the EMR. This is not my experience at all in the large academic center in which I work. There are serious inefficiencies and impediments to patient care embedded in Epic because it was not designed primarily for patient care. A properly designed system could offer many benefits but this is not true of Epic, at least. Zapster put it more succinctly.
The core insight of the article and of your comment to it:
All those new fancy EMR are primarily geared towards implementing billing — not supporting physicians. As a result, they impose a workflow and data structures that hinder the activities of health professionals.
That is why the remarks by The Insider, JohnnySacks or Otis B Driftwood, while perfectly correct as such, miss the mark.
Maybe it’s a lesser-known fact about the way our convoluted heatlhcare system works, but the coding systems used to describe procedures, conditions and lab results are different for clinical use and for billing. In fact, there are people who specialize in coding billing statements in order to make sure the get the most $$ from the payer.
The healthcare IT vendors sell software that supports all activities within a healthcare setting, the clinical and the financial being two of the most important.
When EPIC came to the hospital where I worked it became my most demanding patient.
In addition to billing, EPIC is all about risk management. Say yes to a question and there is suddenly another drop down checklist, maybe almost entirely irrelevant, that you have to complete before you can continue trying to document what YOU thought was important.
When it first went “live” nurses were told that narrative notes (on a psych unit) were no longer necessary, only to find soon thereafter, that the “doctors’ view” did not allow them to access our charting enough to know what was going on. Oops, needed narrative notes to come back.
Also of interest was that, during the “build”
of the system, each agency had to start from a tabula rosa. In other words, each agency had to reinvent the wheel in terms of structuring their data base and functionality.
How other hospitals had done it was “proprietary”.
I think this is the key point:
There are serious inefficiencies and impediments to patient care embedded in Epic because it was not designed primarily for patient care.
I would go further and assert that the entire US healthcare system is not designed primarily for patient care, and the poor state of EMR in general is a symptom of that. Companies don’t get to be leaders in their field by delivering software that fails to provide what their customers want (or actively obstructs it) over a long period of time. The unavoidable conclusion is that you (the clinician, or the patient) are not their customer.
I worked briefly in healthcare IT a long time ago and found it to be a depressing series of projects that had little or no relevance to clinical practice and patient care. Once in a while we got to sit down with physicians and talk to them directly. Those were the best moments, because we could usually collectively come up with some ideas that would be relatively cheap and quick to implement and would make a meaningful positive difference to patient care and help physicians to do a better job. Invariably those were the ideas that would end up on the cutting room floor when it came to budget prioritization. Eventually we were restricted from talking too much to physicians because IT managers were worried that they would want things that weren’t in scope and would end up taking the project off track (I kid you not).
Success was measured, among other things, by the number of bug reports and complaints received. Since quality control processes like formal testing were almost nonexistent, it was nearly impossible to build a system of any complexity at all without creating a lot of bugs and UI/process problems. The best way to ensure a ‘successful’ project was to deliver something that was so poorly suited to the day to day reality of clinical practice that nobody would ever use it (thus few or no bug reports or complaints). Delivering something that was actually relevant enough to be widely used could often be a career-limiting move.
I would like to think that it’s improved since those days, and I have seen some examples where it’s appeared to work quite well (those were outside the US, possibly not coincidentally). But given my personal experience, I can’t say I’m overly surprised at the state of things today.
Yes, I’ve worked in healthcare for over a decade and while there are many people who do this for the right reasons, it can be extremely frustrating and demoralizing. I work in interoperability and I’m proud of some of the work I’ve done to get Cerner and athenaHealth and Medetech systems talking to each other. I reflect back on my own experience with my mother, who in the final month of her life was transferred from a hospital to a hospice facility and there was no continuity of care, her records from the hospital were not transferred to the hospice and my poor mother (and my sister, who was there as her advocate) spent many agonizing hours while the staff at the hospice were unable to give her the right medication. It was awful and traumatic for her and it could have been prevented if her records had been transmitted from the hospital.
Yes, integration is an important area (I do a lot of it myself).
I wonder if part of the problem is that finance employees and administrators have both a higher expectation of integrated and complete data being available (certainly my experience was that the most detailed and easily accessible data about patients was always financial and billing system data) and a greater willingness to spend time on ensuring that their needs are met from an IT perspective. IT projects can be enormously time consuming – there are many difficult questions and disagreements to be resolved about what they should do, meetings to be attended, political battles to be fought, and so on. All of that is not too far removed from what administrators do in their day to day work. Clinicians, in contrast, tend to (quite reasonably) see their job as caring for patients and begrudge anything that takes them away from that.
The end result of that is that stakeholders for IT projects often have a disproportionate representation from admin, finance or management and a lack of actual front line clinical staff – unless you make a conscious effort to correct for it, which will often be over the objections of the staff in question. At that point Conway’s Law implies that the resulting system will do a much better job of meeting the needs of the admin and finance community than the clinical community. This can happen even when all concerned have the best of intentions. Adding a layer of management dysfunction like I described only makes it worse.
I work in a medical field that often requires knowledge of a patient’s prior diagnoses and treatments, none of which are ever provided by the patient’s treating physicians. The EMR has proven to be highly valuable in my field. I can look up the information I need.
On the other hand, having had all too many experiences of my own as a patient whose doctor is tied up looking at/typing into a computer, I can say that the EMR decreases the quality of the doctor-patient relationship.
Many responders here mention the problem for some doctors with typing.
There is good software and hardware for reading cursive script. Why can cursive not be optional data entry? Why is this a problem?
My answer to all of your questions is yes I would feel safe depending on the company and who’s doing the record keeping. Just because it’s low tech doesn’t mean it’s inferior, and perhaps quite the opposite.
We have entire industries devoted to producing software that doesn’t work properly under the assumption that moar tech = better. I deal quite a bit with new payment processing software. So far my experience has been that it’s an attempt to reinvent the wheel for no apparently good reason. I recently watched one of these companies take about 20 emails back and forth over the course of about 10 days just to process one invoice through their new software platform that’s supposed to make things easier. Had they simply sent us an ACH after receiving the invoice we would have been paid quite some time ago.
Recently some marketing people in our company decided that Excel wasn’t the best tool for tracking certain data and were looking for something better because in the past things had gotten lost in the shuffle. What they’re looking for is a magic bullet that doesn’t exist because no matter what platform you use to track your data, some human being still needs to do the initial data entry properly (at least until Elon Musk invents mind reading software – I hear that’s next after the flamethrowers). Excel is just as good as anything for that. It all boils down to the Belichick mantra – do your job. Do it properly and it doesn’t matter if you do it with a pencil and paper or quantum computer.
The problems in the healthcare industry are better solved using something other than the factory model for hospitals, with some computer system keeping track of all the “inventory” a la WalMart.. If people were actually given care, rather than passed back and forth between doctors and nurses and kicked out the door as quickly as possible, I suspect the system would get much better results without needing a huge electronic record overhaul. My wife recently had surgery and was passed around between probably close to a dozen people during the course of the day. It was readily apparent that all of them were in too much of a hurry to devote much attention to her and follow through on her needs. About the only one who had some time to be helpful was one nurse we saw near the end of the day. She pushed back against the resident who was trying to get my wife out of the hospital fast in order to meet some metric she was given as a goal, presumably by some MBA with an eye on the bottom line and not patients’ health.
“Much of the piece above is, tellingly, not about the technology, but about the process.” It seems to me the real issue here is neither the technology nor the process but the motivation. If the reason behind any EHR system is financial, it will never serve patients and doctors. It will never be about health at all.
Computers and their idiot savant yuppie-nurds are very jealous gods, totally intolerant of any other center of attention; it’s time to stop worshiping the tools (a lot like adoration of a wrench or tire iron) and pay attention to patients and their problems!
well put, sir or madam!
as a patient, I loathe the computer. feels disrespectful, both of my time and the delicate nature
of health issues. On a recent visit, I could see the many screens of boilerplate my primary had to skim, rather than giving me decent eye contact. I felt for her, who seemed well-intentioned, but the whole
thing felt degrading of both of us, and an insult, given how inconvenient and costly healthcare has become.
it also exacerbates the implicit power balance between the gatekeepers and the hapless people who need healthcare.
we have allowed fetishized techy tools to destroy every discipline from the humanities to medicine, to everything…when will the idiot savant yuppie-nurds and their life-degrading junk be properly shunned?
or at the v. least, given robust side-eye when appropriate?
ends rant
as a cherry on top, my electronic records had been lost, so I had to waste
time recapping basic info during the appointment.
nb: I do realize data needs to be recorded by the physician, but this should be done
after the appointment, so the screen does not intrude upon the consultation.
“we have allowed fetishized techy tools to destroy every discipline from the humanities to medicine, to everything…”
You are right, of course, but don’t forget that behind the “yuppie nerd” is the higher saint: the administrator. These demi gods intermediate between us & the world of production with the one true god: the oligarch & the corporate form he takes here on earth….
Google seems to understand me pretty well when I do internet searches by talking to my smartphone…why can’t doctors dictate their notes as they examine their patients, and let assistants do the coding?
I don’t understand how paper records would solve anything. If the real problem is an excessively complex billing-code system, how will paper help?
Yep, it comes down to financial accounting, billing and insurance. All very unique to the US. That’s where the real problems lie.
I am not in medicine, but I interface with a lot of IT systems. You very quickly figure out if you are the customer or the product when you do that. By that, I mean that many systems are designed to simply collect data to be used by someone else and the focus is on the ease of use by the recipient of the data, not the generator. In other cases (far fewer), you are doing real interfacing with a system designed to help you.
In cases like Google Maps, you are both the customer and the product. They put their focus on making the experience user friendly so that you will use it, thereby generating the data they use to actually make money.
However, in most corporate settings, the data generator is in a command-and-control structure where they can’t say “No” without quitting, so the interface with them is low priority in design. The customers are the executives buying the system, so the selling points are the data they will receive from it, not the fact it will bring their floor operations to their knees.
I recently visited a new dentist. We did 4 Xrays, as normal, and he wanted to do a particularly deep cleaning. So talked with his associate about how much documentation he should provide to insurance so they would cover it. Then proceeded to take 20 more xrays.
to cover scraping my teeth with a pick.
And both the dentist and the insurance company are just fine with you having received 5 times the typical amount of x-ray exposure, a practice that in an earlier time (not so long ago, actually) might have been considered malpractice, or at the least unnecessary procedures that padded your bill.
Or do all dentists now have those digitally enhanced x-ray machines that use much less exposure? Those have to be paid for too!
The dentist collects more professional fees and the insurance company now has justification for the next round of premium and co-pay hikes. It’s a symbiotic relationship.
Grifters gotta grift … borg will be borg. I cannot think of a single skilled field (teaching, medicine, law, driving) where more IT made things better. It certainly has been a boon for IT but not humanity. (see what I did there)
I’m a public school teacher who for years has been experiencing the destructiveness of so-called education reform married to greed masquerading as techno-utopianism. And I mistakenly thought that we were the only ones having our profession destroyed.
However, while chatting with my accountant as he prepared my taxes last year, I was told that his daughter had finished school and was considering becoming a teacher. I raised my hands in a “stop-everything” way and in my most mock-melodramatic voice said, “Don’t let her do it!”
He then told that his daughter was looking at teaching because his wife, an MD, had already warned the young woman away from medicine.
Wherever you look, it’s bad out there…
That’s a telling commentary on the current state of both education and medicine in the good old US of A.
… and you would be wrong.
The digitalization of modern radiology practice through the implementation of PACS completely revolutionized the specialty and made radiologists profoundly more productive (and relevant) than ever before.
Don’t throw the baby out with the bath water.
There’s always resistance to change, even if is change for the better. I started my career implementing interdepartmental software for hospitals back in the early personal computer days. Younger, open-minded staff saw the potential of electronic record-keeping and messaging; older established professionals resisted any change to their paper-based workflows. It’s just the way most of us are: new technologies bring us back to square one, where our experience doesn’t count for much.
That said, IT professionals are often separated from and are therefore ignorant about the day-to-day work of the people they write software for. This, to me, is the biggest mistake we make when designing software: software developers are often poor in social skills, yet by merely observing first-hand how operations are done, they can spot inefficiencies that are missed by an analysis team that only talks to users about their work (that approach misses a lot, for many reasons).
If physicians don’t like the way software is implemented, they need to get involved in the process directly, and (most importantly) get used to being told “No” by IT professionals who know THEIR business and its limitations and strengths. Slavishly computerizing archaic workflows leads to unhappy endings.
IT professionals aren’t liable for bad patient outcomes, Physicians are. Maybe IT personnel would take on that responsibility too?
I didn’t think so.
Moreover, in some cases, the limits of information technology justify that it not be used at all, but that’s something that I feel gets overlooked. Not merely that the process needs to be changed to be more compatible with an IT solution–but that the IT solution just isn’t appropriate for the relevant needs.
For example, you want maximally secure data? Don’t put it on any electronic device at all.
Similarly here, IT processes may not be adaptable to immediate entry of patient notes or other medical needs. To the extent this is the case, then IT needs to get out of the way. Technology is just a tool.
In more general terms, I’ve noticed that technology seems to be very good at generating and archiving data–i.e., it provides tools to acquire and store discrete facts. It’s bad at turning data into information (operative conclusions based on data).
That’s pretty self serving isn’t? “We’re saving LIVES here! You can’t possibly have anything important to contribute.”
Let’s quit idolizing doctors, shall we? They are just as human and flawed as the rest of us.
The difference between doctors and everyone else is doctors have gone to medical school, done an internship, done a residency, perhaps done a fellowship, and know how to take care of patients. Similarly for nurses.
Guess who gets sued when things go wrong?
Those at the top of EPIC and Cerner donate a lot of money to politicians. They are also part of the group that comes up with rules for “meaningful use.” These are requirements that must be met as part of a medicaid/medicare care provider. Most patients are medicare.
I’ve been an internist for 40 years. We took on the eClinicalWorks EMR 7 years ago, and I couldn’t be happier. In fact without the EMR and new Medicare bonuses based on EMR reporting, I would have quit several years ago. That being said, there are some traits that let me succeed with the EMR. I have been into computing since the early ’70’s with PLATO. I cannot write or type worth a darn, and have been using Dragon dictation since it came out in 1997. The construction and flow of this EMR is very similar to my own, adapted many years ago from the now defunct American Society of Internal Medicine. I could see twice as many patients a day if I so desired. I don’t desire, so I spend time reading these blogs between patients.
I am a member of SERMO the largest medical blog I think on the internet. And I appear to the odd duck out as compared to most other docs posting there about EMR’s. I have no idea how many happy docs don’t post there.
If you don’t mind me asking, I presume, from your use of Dragon, that you are inputting your EHR data between patients? I ask because I think a big part of the issue is the process itself where physicians are expected by their employing institutions to input the data while the patient is present (i.e., to use the EHR for consultation notes, etc.).
I have the EMR open during the office visit with the patient, but dictate between patients in my private office.
Eclinicalworks just got sued by the federal government for a hundred fifty million dollars for fraud and dangerous flaws, and now they face a 1 billion dollar class action suit.
Just hope you don’t get caught up in it due to a bug.
Of course nothing is perfect. Before the EMR no one could read my notes, not even me! We have found glitches here and there. As I recall the suit was based on reporting of quality of care metrics, not patient care.
The suit was also based on dangerous defects. Read the complaint.
Further, the $1 billion class action suit is based on the fact that the system can’t maintain clinical data correctly and corrupts it, affecting millions of people.
“Stjepan Tot died from cancer, and the suit alleges that prior to his death, Tot learned about ECW’s failure to maintain his medical records in a manner that maintained their integrity. “In particular, he was unable to determine reliably when his first symptoms of cancer appeared in that his medical records failed to accurately display his medical history on progress notes,” the lawsuit claims.”
Of course I don’t know the case. But in 7 years nothing like this has happened to me, my group partners, nor anyone reporting something like this on SERMO. The above sounds like poor documentation.
This is an excerpt from an article at Science Based Medicine by Dr. Steve Novella, which is worth a look. He does not address billing but others do in the comments. As a research and diagnostic aid, he sees great as yet not fully realized promise, and deplores the inadequacies of the system he uses in his practice. He also provides some suggestions for improvement.
https://sciencebasedmedicine.org/medical-profession-is-underutilizing-computer-technology/
The shift of the clerical work to support staff is inevitable. The healthcare Information Technology experiment as of today is failing.
There are a million doctors in this country. If they pony up a thousand apiece that is a billion dollars. Use it to develop a computer based system that fits their needs. Then just tell the world: “This is what we are going to use” — and what is the world going to do about it.
Doctors’ union would be good informal cooperation base. Start out in most likely successful locations and then do the ink blot.
Rebuilding national labor union density would be a big help to back them up on this — and back up everybody else who is trying to straighten the county out in any way.
Just read a Wash Post piece doubting that Amazon, Berkshire and J P Morgan might be very successful making medicine more efficient/less costly because they have little experience in field (and little commonality in their own insurance needs). There is a philanthropic billionaire who is deeply invested in medical research and has a decent background in computer science: Bill Gates. Maybe he might even be interested.
Warren hangs out with Bill, a lot.
He only knows how to copy not create.
A well designed and well implemented EMR would be welcomed by most. Sadly it seems that the EMR is not well designed and/or well implemented.
Developers and IT project managers have (in my opinion based on my experience) gotten worse at designing systems that support established well functioning processes. For some reason they appear to believe that their own IT expertise is all that matters. They (without being subject matter experts) take it upon themselves to define and design a new process. Feedback is never asked for, unasked for feedback is at best ignored and from what I’ve seen the User Acceptance Testing (UAT) is now only a test if the application/system will run without crashing, it is not at all about to test if the users find the system to be useful.
I’ve seen systems designed by highly intelligent people who’d never seen the actual process. Their intelligence did not compensate for their lack of knowledge of the process and the poor end result was blamed on the end-users not using the systems properly. To me the behaviour of such developers and project-managers are arrogant beyond belief. Pointy Haired Boss from Dilbert comes to mind.
There is actually an engineering practice known as Design for User Experience (DUX) that was big in the 90s for a while, though it seems to have faded somewhat (but not completely disappeared). This was facially and obviously the right way to go about things: Have members of the development team become knowledgeable in the domain their system will be a part of, endlessly observing and interviewing experienced workers about how they work and what their pain points are. Systems are then prototyped (often on paper) and trials are run with more workers to refine the design and discard or adapt the parts that aren’t helping. I have worked side by side with people who are skilled at this and became a huge believer in the whole approach.
One well-known design produced by DUX was the Windows release where the Start button and task bar were introduced (I forget the version now). As I recall, even the word “Start” on the button was endlessly debated: Should it be “menu”, or “top” or “begin” or what? Evidently, through usability testing, they discovered naive users found “Start” to be the most suggestive about where to begin. This anecdote suggests the level of careful thought and experimentation needed to design a natural and easy to use system.
Also obviously, this approach takes more time and costs more money, at least initially. It honestly also goes against the grain for most software developers, who are drawn to the field because they like sitting by themselves inventing things in the privacy of their own heads. So there are powerful forces arrayed against DUX and only determined and far-sighted leaders with strong backing from above can make it happen.
Another factor, especially in an emerging technological area, is time to market. It’s quite common for the first product to enter a new market to become dominant, regardless or quality or value. EPIC seems to be in this category judging by the comments above. As much as we don’t like to believe it (I don’t!), spending an extra year making a “good” product generally means you are out of the race. The world is full of examples like this.
Medicine has been a guild practice. It is currently being ‘modernized’, i.e., industrialized by replacing individual skill and knowledge with intellectual capital and corporatized through what amounts to a modern enclosure act that legislates the means of production out of the reach of individual physicians. I find it particularly galling that I am paying (through forced inefficiency) to train the AI that is going to destroy my profession.
The economic implications annoy me, particularly when I think about how long I trained and what I gave up to get here, not to mention the time and heartache I put into my patients. But I didn’t do this for money and if push comes to shove I can just move to a cheaper state.
What really upsets me is what these changes are doing to the profession. The core values of medicine are based on the physician-patient relationship. When I take someone to the operating room I am assuming moral responsibility for them. I’m not some guy putting screw x into hole y (or not) and sending it down the kine. Or perhaps more appropriately, I’m not some engineer finessing the ECU programming so we can get better emissions ratings. When I entered medical school I stood up in front of my friends and family and swore an oath to put patients first. As hokey as that sounds I take it seriously. As medicine corporatizes corporate priorities will inevitably take over and it will become shareholders first.
I would not worry to much about “AI replacing your profession.”
The holographic doctor from Star Trek – Voyager is still far in the future.
But the technology hyperenthusiasts always tend to underestimate timelines. Cf: “2001: A Space Odyssey” where HAL 9000 was a cybernetic life form.
IBM has been touting Watson as a diagnostician for the last year ..? .. two?
A profession that has been at the forefront of creating an opiate addiction crisis needs to step back and take a hard look at their “guild” practices. The data is pretty conclusive that most new opiate addictions have been increasingly started on prescription drugs. Not all of those people were specifically prescribed to, but many were. The excess quantities in the prescriptions often became the starting point for a non-prescribed person taking them. https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use
So I don’t think enough of the guild members looked at what Big Pharma was peddling and said “WTF?” A properly designed EMR system should be able to dramatically reduce this type of over-prescription both in the number of people and the number of pills.
Pills mills in depressed areas and an abundance of cheap, easily accessible heroin started this problem. Now the average patient that actually needs pain medication has a hard time getting them and are so terrified from news reports to take needed opiates after surgery. Gov Scott owns some pill mills if I remember correctly.
Although the Joint Commission now denies it and restates its position the pain racket started in the 1990’s and Doctors were pushed by the hospitals and standard setting organizations to consider pain to be the fifth vital sign. Doctors were pushed to prescribe to treat it and were penalized if they ignored it. Even worse behavioral health programs were pushed even harder and to quote the JCAH, “The original pain standards stated “Pain is assessed in all patients.” This was applicable to all accreditation programs (i.e., Hospital, Nursing Care Center, Behavioral Health Care, etc). This requirement was eliminated in 2009 from all programs except Behavioral Health Care Accreditation. Patients in behavioral health care settings were thought to be less able to bring up the fact that they were in pain and, therefore, required a more aggressive approach.” How stupid is that? Behavioral health patients should get more narcotics?
And how did the JCAH come up with this outrageous intrusion into the practice of medicine? After this intrusion we were constantly assaulted with demands by nurses and administrators to treat patients pain. If we suggested an aspirin or or Motrin or “suck it up” we would get written up. From the Wall Street Journal:
“I gave innumerable lectures in the late 1980s and ’90s about addiction that weren’t true,” Dr. Portenoy said in a 2010 videotaped interview with a fellow doctor. . . . In it, Dr. Portenoy said it was “quite scary” to think how the growth in opioid prescribing driven by people like him had contributed to soaring rates of addiction and overdose deaths.
In a frequently cited 1986 paper — based on just 38 cases — Portenoy and Foley concluded that “opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse”. According to the Journal, that paper “opened the door to much broader prescribing of the drugs for more common complaints such as nerve or back pain”.
And there was pressure from organized groups to expand treatment of pain:
In the late 1990s, groups such as the American Pain Foundation, of which Dr. Portenoy was a director, urged tracking of what they called an epidemic of untreated pain. The American Pain Society, of which he was president, campaigned to make pain what it called the “fifth vital sign” that doctors should monitor, alongside blood pressure, temperature, heartbeat and breathing.
Of course, at that time, pain was being under treated, certainly in emergency departments. But by minimizing — really negating — the potential risks involved in chronic opioid therapy, proponents set the stage for the current epidemic of overdose deaths.
Before long, recommendations by Dr. Portenoy and other became incorporated in guidelines issued by professional society. And — I’m shocked, shocked to learn — drug company influence and money were involved:
In 1998, the Federation of State Medical Boards released a recommended policy reassuring doctors that they wouldn’t face regulatory action for prescribing even large amounts of narcotics, as long as it was in the course of medical treatment. In 2004 the group called on state medical boards to make under treatment of pain punishable for the first time.
That policy was drawn up with the help of several people with links to opioid makers, including David Haddox, a senior Purdue Pharma [manufacturer of OxyContin] executive then and now. The federation said it received nearly $2 million from opioid makers since 1997. . . .
A federation-published book outlining the opioid policy was funded by opioid makers including Purdue Pharma, Endo Health Solutions Inc. and others, with proceeds totaling $280,000 going to the federation.
Eventually, the Joint Commission became involved:
The Joint Commission published a guide sponsored by Purdue Pharma. “Some clinicians have inaccurate and exaggerated concerns” about addiction, tolerance and risk of death”, the guid said. “This attitude prevails despite the fact there is no evidence that addiction is a significant issue when persons are given opioids for pain
@rd
The last big VA study I read suggests that the majority of addiction develops out of chronic pain, particularly chronic back pain rather than post surgical pain.
The profession has been complaining about the loss of autonomy for going on 15 years now. It’s been a slow but steady process. One of the big things people complain about is the use of patient satisfaction scores in determining compensation. Guess who is really dissatisfied? The chronic pain patient who doesnt get their narcotics. Much in the way pushy parents get antibiotics for their kids colds, drug seekers often get narcs. It’s built into the system.
I know many fellow physicians who thought the “pain is the 5th vital sign” stuff was BS. But they felt too disempowered to fight it.
You could look at it as the unintended consequences of the shift from paternalistic medicine to shared decision making.
It’s similar to the way I still give people tylenol for fevers. The data supporting it is questionable, but the expectation is there and the system is set up to deliver it. Defeating the system is a heavy lift that has to be done on a case by case basis. Has to be worth it for the patient. I try to stick to the battles I can (efficiently) win.
And you’re mistaken if you think an emr is going to stop opiate overprescribing. Sorry I dont have time to get into the reasons.
Not to get way off topic, but I don’t think we should get too self-righteous about people who need long term pain meds. I was in a vehicle accident 8 months ago that resulted in the amputation of my left foot (an 87 year old lady ran a red light and t-boned me). The result was severe phantom pain. I ended up taking opioids for about 7 months, and only stopped taking them a few weeks ago.
Luckily my doctor was cool and supportive about it, but in spite of that I felt like I was right in the sweet spot of much of the ignorant condemnation in the media regarding long term opioid “abuse”. “He started taking opioids after surgery, then kept on taking them! Obviously a lying addict!” Each time I refilled the prescription I had to jump through many hoops and endure suspicious looks from pharmacists. I generally felt guilty and somehow morally weak in the prevailing climate of know-it-all pundits and moral enforcers.
I am fortunate in having a condition where the pain is (slowly) resolving. Many others are not so lucky, an have chronic or lifelong conditions where their quality of life depends on pain meds. We should be respectful and helpful to such people, and be thankful we are not walking in their shoes.
Everything is done with profit motive. Which means that if we have diverse standards or EMR systems, vendors win, IT developers win, Doctors win – but the patient looses due to lack of proper info, increased costs etc. Doctors win due to multitude of systems since they control the data and people cannot question their decisions since data is not available. Now what if we had one EMR for US – then info about patients will be available to all. But patients, hospitals, IT developers all loose. What is important? Greater good (all the people) or just the vested interests (providers, IT vendors etc)? France has 1 system. Why can’t we?
“France has 1 system. Why can’t we?”
Because we’re god-damned dumb enough to accept this crap.
A good set of hand written notes by a doctor are the only form of medical record that you can be sure was actually created by the doctor him/herself. Unfortunately those days are long gone. Check out this comment by a medical transcriptionist, left on a Zerohedge thread yesterday.
bunnyswanson Jan 30, 2018 10:44 PM Permalink
Take note of the fact all medical records are transcribed or edited by large corporations which outsources to India and pays their workers a pittance, after mergers and acquisitions have left only 3 nationals, one owned by JP Morgan Chase (Nuance, MModal, Keystrokes). A new “no blanks” policy is now in effect which means the scribe must “make it up” if a dictation is inaudible. No Quality Assurance is in effect, essentially.
DANGER WILL ROBINSON DANGER.
Bring Medical Record transcription back to the local hospital and give middle class mothers, wives, grandmothers an ability to earn a living wage.
=================================================================================
Watch the movie “Brazil” to see where this leads.
I “lost” my primo medical insurance 10 years ago at age 51 when my husband ran off with a much younger woman (premiums for her not as expensive, lol) and i couldn’t be happier about it. I now use an old school naturopath, my age, who sits with my medical chart, writing everything down long hand on college ruled notebook paper. Not any insurance company’s business! We are both happy about that.
And I have plenty in the bank to pay the naturopath, having not been forking it out to an insurance company for the last 10 years.
Good luck out there everybody, you’ll need it. When all the doctors quit, they’ll just put white coats on the janitors and continue on like nothing happened, the same way your nurse might actually be a bedpan changer given a set of scrubs.
I think my doc has figured out one good solution. He has a nurse-stenographer sit in on the office visit. She takes patient dictation on her computer and he concentrates on typing his diagnoses and prescriptions in on his computer and fast checking immunizations, etc. He’s very efficient these days and a good doctor.
Civilized! good on your doc.
21 years ago I was a beta tester for federal government Ehr project. I was asked to give a 30 minute talk about the experience at a national conference after my second year.
I talked about many of the things this article mentions. People hated my talk.the audience of doctors at that time so wanted to be believers. Needless to say I was never going to be invited to talk about ehrs again
My own personal physician started a direct primary care practice. He was sick of both the red tape and the costs. You can read about it here: http://sandpointreader.com/moving-past-medical-insurance-medical-care/
One thing I did not see brought up in the article or comments section is how a well functioning EMR system should look like. The Veteran’s Administration Health System has such a thing in VISTA, a DOS based EMR that is easy to use, has universality across all VA hospitals/clinics and has had widespread positive acceptance and accolades from physicians, young and old. The difference for most if not all new EMR’s is the need for billing. As the VA system does not have to bill based on Centers for Medicare and Medicaid Services diagnostic codes, or ACA reimbursements, you can cut out most of the needless data entry that is happening now. This can best be seen by what passes for medical records on a recent post by Kevin MD cross-linked here that described one emergency department encounter’s documentation as 10-20 pages of useless information with, if you’re lucky, one golden paragraph of clinically pertinent data in the stack of paper. Most physicians I know grumble about these useless charts that travel along with patients, but as the above article mentions, no one seems to know where to start to try to fix the system. This is a function of the medical societies having lost all control of their work spaces to administrative and political pressures.
It’s worth noting that VA’s VISTA system is available as open source software.
VISTA is terrible unless you are completely acclimated to it. There is no overarching design, its completely arbitrary. For example items on drop down menus are ordered, not alphabetically or grouped by type, but by the order they were added to the menu.
And the Va is buying cerner.
Not the sense I had as a medical student, resident and fellow rotating through VA hospitals. This politico article gives a good history for those not familiar with VISTA. It seems in may have been an inside job as to the deterioration of the EMR over the years.
https://www.politico.com/agenda/story/2017/03/vista-computer-history-va-conspiracy-000367
Quote: The truth is, there are all to many clinical information systems that are fundamentally not built for the good-practice-of-medicine-driven world.
And there is the patient side to this outrage which is that it is an illegal unwanted tax on my time and wallet!
In 2011 I was looking for an internist and the UCSF hospital system was crowing about their wonderful new facility and brand new medical record systems.
I got into my first appointment with the new internist and it turns out to be a non-ending interview at a desk with a nice young H1B visa doc.
Finally I protest that I am there for one thing and one thing only, I need to re-up my high blood pressure meds Rx.
She assures me that she will do that but first we have to answer all the questions the computer is asking her (me)
Kill me now, please, UGH!
It gets worse.
At the end she takes a brief minute or three to address the reason I’m there, issues an Rx and tells me to sign up to the wonderful online portal to see the results.
So..I do..and all that comes back in the very kludgy and obviously beta software site is that an event occurred and I was issued a “prescription’ WOW :-(
I looked for any references to previous visits as I had extensive history with the UCSF organization,
Nothing, crickets.
I went back down there and demanded to speak with with the doc and she told me “well the system is new and still being developed so we have to be patient, but no it doesn’t have any history and we don’t plan to add it in at this point.
Again, who is this system FOR?
And finally the kicker. I get the bill and it is for $1500.
My medical insurance will only pay a small fee for a doctor visit towards that.
I refused to pay that bill.
Software is no longer a tool, it is a whip and a collections device.
And software changes every day because the coding is so poorly executed.
I do not feel a responsibility to learn the new software rules every single day.
My current question in life is considering how to utterly disconnect from this stupidity.
I ‘ve worked in tech for the last 30 yrs and back then I loved it but tech has totally changed from being a tool that serves into to a tool that serves me up to someone else.
And I’m over it.
Reminds of 2 things:
The Chinese execution squad that makes you pay for the bullets.
And
That Twilight Zone episode “How to Serve Mankind” where humanity greets the Aliens bearing a message on serving mankind by taking us to their planet, where it’s gonna be GREAT!
At the end a guy runs up screaming Beware- it’s a MENU!!!!
Want more software fun & games for profit?
Google this phrase: Marin County Oracle Deloitte Payroll Debacle
Spoiler alert: Marin County bailed after expending $ 30 Million for a system that never went live, filed suit and lost because they signed airtight contracts with these vendors.
Triumph of the Will, the Neoliberal update
As a very young attorney, I got to start my career when advice was all given via letter and billing done on paper. I spent maybe 1% of my time on things other than the practice of law. In the intervening years, every firm I’ve been at has been persuaded to buy increasingly expensive and increasingly complicated software packages larded with features nobody had ever asked for and which serve no purpose.
Now I spend 40-60% or more of my time managing software, clicking on things, waiting on tech support, etc. (I.e., not the practice of law and not billing.) Every single innovation since the fax machine has been a huge net negative for productivity. Not coincidentally, I have to work 12 hours a day to get done what used to take 8, all thanks to productivity-enhancing software.
Last year my current firm was sold a new “practice management” software suite which we were promised would have seamless integration with existing data. This seamless integration required the senior partner to essentially suspend working on the law for four months while managing the transition.
Across industries, these days, many workflow issues are made into “tech issues” before a thorough investigation and all personnel issues are addressed. The door has barely closed on meetings before everyone assumes some software or hardware could fix the problem.
Then in comes software/hardware that is adapted to already problematic workflow, so the tech issues mount with more tech to attempt to fix the workflow issue. Somehow the answer then becomes “we need more tech or coders.”
Example: A contractor for a certain department does not want to change their work hours, which would help with meeting deadlines. For some reason (personal relations?), no one is trained to do this non-rocket science duty to adjust workflow or even replace that person with another contractor.
So the company spends a big hunk of cash on a new computer system to adjust to a contractors workflow (yes, the insanity exists).
TA -DA – a personnel workflow issue becomes a 2 year tech development nightmare that adds work to other departments.
The VA is giving up on what they developed and switching to the Pentagon’s medical records system. Computer systems are not intuitive. They have to be learned. I’ll be the guinea pig for a new batch of computer doctors till I die. These systems are implemented because they make money for somebody. In my case it was to get rid of typing pools and have professionals do clerical work. It made Bill Gates the richest man in the world for a while until surpassed by Amazon. I am so old I cannot read twitter rants. They make no sense. I want to highlight the comment above that Medicare for All can only work if there is IT to implement it effectively. In today’s for profit crapified world is that even possible. After 32 years X86/Windows 10 is falling apart in slow motion.
What we are dealing with here are physicians who need an excuse to retire.
None of these people are quitting their practice to take jobs as greeters at Walmart. They are simply retiring because like a lot of their age peers, they waited too long to learn about the digital tools of the profession and now the annoyance factor has triggered a change of life. Research shows that retirement triggers often involve automation, organizational reshuffles, or jerk bosses.
What stories like these do not address is that they assume these luddite physicians are still on top of their field – a loss to society when they retire. Bunk! If they cannot navigate a table PC, they are likely not downloading (and reading) the latest issues of Lancet, NEJM, JAMA, etc. either. My previous – now retired – personal physician and I would get into arguments about my care because he had limited knowledge about appropriate tests to run or treatment options – he was annoyed that kept bringing up stuff he should have known (if he was keeping up with the literature).
With all due respect, if that isn’t idiocy, I don’t know what is.
One counterexample: I have orthopedic issues I won’t bore you with, but as a result, I have been seeing orthopedists since I was a kid. I had a problem in the 1990s which meant I was having trouble walking. I must have seen 10 orthopedists before I found one via referral who told me what I needed to do to get better, which was remarkably simple. He was also the only one who looked at my gait.
He was over 50. He also kept the person who referred me to him from having back surgery, when every other MD insisted she had to have it. She recovered fully by following his orders. He specialized in pediatric orthopedic surgery for kids with cancer, so he’s got pretty rarified skills by orthopedic standards (the dirty secret is they are carpenters and most love to operate and are too willing to go there). I saw him again with a chronic problem and he was way better than the sports MDs I had stupidly seen first (don’t ask why I didn’t go to him right away….referrals from people who swore by MDs who had treated supposedly similar problems with turned out not to be so similar).
He’s still practicing and I’d see him any day over everyone else. And amusingly his office is low tech, he won’t take insurance but he charges much less than other orthopedists for an office visit.
You are illustrating two critical issues:
1. As long as doctors are fee for service and there are too many of them you are going to see unnecessary treatment. Years ago when there was a relative shortage of surgeons only those who had a good chance of improvement got surgery. Why would a fully employed surgeon operate on something that would complain? That started to change with the massive increase in doctors in the 1970s. Now the only solution would be to put all doctors on salary with no bonus for surgery or excess treatment even if the patient or the patient’s lawyers want it. And, of course, no consideration of patient satisfaction…..since studies show that patient satisfaction means simply that they get what they want…..not what they need. Try talking someone out of back surgery who has a active personal injury case!
2. The government or society should not be required to pay for treatments that are ineffective or elective. If there is no good evidence that a treatment works it should not be paid for by the citizenry. So if you want a stent in your heart and the evidence suggests that a pill will work as well you can buy your stent with your own money. If you have an arthritic knee and you can walk you should pay for your own total knee. If you want back surgery and you don’t have a significant neurological deficit……have at it on your dime. Studies have shown that when patients pay for care where outcome is subjective they seem to get better results…….the payment of hard cash may contribute to a halo effect.
3. The EMR is for billing. In the old days you got a computer called the brain which is much faster and has more memory than a PC. With a glance the doctor recognized you and recalled your history using his memory. That was a lot faster and more efficient. Unfortunately, your medical history was tied to that brain so if the Dr. died you would lose the records. With time I suspect the EMR will improve. It just will take time. If all doctors were on fixed salary they could start to think about patient centric EMR. Until they take fee for service out of medicine the EMR is going to suck.
Please tell me what evidence there is that there are too many doctors in the US. The evidence is that we have a physician shortage. Wikipedia notes: “Thousands of foreign doctors come to practice in the United States each year[53] while only a few hundred doctors from the United States leave to practice in foreign countries even short-term.[54]”
I had an orthopedist push an unnecessary surgery on me in the early 1990s. This was the second-best knee guy in NYC, which meant he spent only half his time treating football players. The “best” guy did that close to 100% of this time.
And if there were too many doctors, you’d expect to see them competing for patients, which would mean better, not worse, levels of service.
The US has a systematic bias towards overtreatment and has conditioned patients to expect too much from doctors, which leads them to demand too much treatment, like asking for operations with low success rates rather than accepting they might have to live with an impairment.
Even though I support evidence-based medicine, the simple generalizations you offer rarely work. First, there are very few areas where there are enough studies with big enough sample populations to reach any conclusions. Second, as MDs will tell you, patients are different. Even with high efficacy drugs, there are very few that work for all patients. They will also regularly report that treatments that commonly work for most patients won’t succeed for some and they need to try other intervention.
And your “if you can walk with your knee” standard is absurd. Some people are in very severe pain. Others can only limp and are impairing other joints in doing so. You act as if people want surgeries, when most people avoid them like the plague. Doctors were the ones who pushed stents, not patients. The only exception is back surgeries, where patients are often in pain. Being on steriods long term is bad for your health and can also weaken your ligaments, setting you up for other injuries. But most patients and not prepared to hear that many back operations have a low success rate.
This is far more complicated that the simple handwaves you offer. The rest of the world has healthcare that it government provided and doesn’t have patients overconsuming surgeries or drugs. Your assertions here are completely counterfactual.
But remember other countries have much better overall outcomes with many less physicians (especially surgeons) per capita. What you are paying a surgeon for is his experience with what works and what does not. Since each patient is different there cannot be a cookbook solution in any but the most obvious cases. In order to be sure the patient’s welfare comes first the fee for service link has to be broken given our ratio of doctors to patients. Doctors from around the world come to the US because of the usual attractions of a first world country, but also because the income is much higher than in their native countries and the demand for them is really from the rest of the medical industrial complex. When they get here they bill just like the doctors already here. Doctors did push stents because it is an expensive procedure and there was patient demand but as you know the recent studies have brought a lot of that into question. Doctors will fill the available time with treatment. Patients are often better off when the doctors are playing golf. Even with total knees it is not a bulletproof operation and the infection risk is often underplayed. And that is not really curable. A large number of the total knees done in the US are, for example, revisions for prior failed procedures.
Public health experts attribute the differences to inequality. Highly unequal countries have much worse health outcomes due to the stress of inequality. We’ve written about this before. This quote come from 2007, in the Financial Times, the financial crisis, before Greece was put on the austerity rack. And even with that, life expectancy in Greece has still continued to rise, while it has fallen in the US in each of the last two years:
https://www.nakedcapitalism.com/2015/12/us-life-expectancy-flat-for-third-year.html
The US also has the worst obesity in the world…
And I don’t agree with you on stents. There are sold, not bought. I don’t know of a single person who asked for a stent (unlike back operations). Cardiologists recommended them. Worse, it was considered a sound recommendation until recently.
I agree with Tomonthebeach. Interestingly, there is some data to support his claim that older physicians are often not functioning at the top of their fields:
Physician age and outcomes in elderly patients in hospital in the US: observational study
BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1797 (Published 16 May 2017)
Cite this as: BMJ 2017;357:j1797
This does not surprise me. As a young physician, I see my more experienced colleagues struggle to manage the volume and complexity that have come to be the norm in hospitalized patients (this trend also exists in outpatient care). This aversion to EMRs is likely part of the underlying difficulty they have coping with what medicine has become. There is much weeping and gnashing of teeth over the amount of time we spend on the computer. As care becomes more complicated and multidisciplinary, the old ideal of a doctor sitting atop a mountain making clever diagnoses (in illegible handwriting) is becoming dangerously antiquated. EMRs are necessary to provide good, complex care.
Atul Gawande said in an interview that the most important thing we need to change in medical education is eliminating the idea that medicine is a craft profession (paraphrasing from Ep. 26: Atul Gawande on Priorities, Big and Small – Conversations with Tyler podcast). It seems to be the case that, while having a good relationship with your patients is important, they actually get better care when the physician functions effectively as part of a larger unit. But it is tiresome spending all those hours in front of the computer…
Again I restate that the tension is not between luddite physicians and modernist technologists. The tension is between pragmatist physicians and nurses with a serious job to do and serious obligations and liabilities, vs. technology hyper enthusiasts with no liability who ignore the dangerous downsides of health it. Ddulites, as it were.
The Veterans Administration uses electronic records. From my perspective as a patient* for over 40 years, they seem to work well. Perhaps because they are for medical treatment, not for billing.
My point, I guess, is that there are tested, workable systems available. As long as their purpose is primarily medical and not billing—they work fine.
Medicare for all.
*I am a disabled vet.
Here in Mexico, I have national health insurance. Because of my age (72) there is no premium. When I call for a doctor’s appointment, I speak with a person who keeps the schedule for several physicians. The appointment could be as soon as the next day. When I get there, I am directed to the door of the individual doctor’s office. I knock, the doctor opens the door, we go in, sit down and talk. The doctor makes hand written notes. If need be, I take notes because I am responsible for my own care. There are no long forms with check boxes. There is no note taking on the computer. And there is zero sense of being rushed. The whole process is personal and not technology driven and the training of many doctors here is on a par with those in the US without constant straightjacketing of compliance with raw “numbers” that are out of context with lifestyle and other issues. In other words, doctors get to practice medicine, not just administer within the constraints of policies and guidelines.
A friend recently had a knee replacement. Before her procedure, the entire team from the surgeon to her assigned post-op nurses came in and introduced themselves. The surgeon was top notch, the hospital was modern and immaculate, and she said not for a moment did she feel like a number nor was she rushed out of the hospital before she was given a complete set of xrays and felt confident about her next steps for recovery. Her out of pocket: 3800 pesos. That’s about 200 usd.
Health care here puts the emphasis on *care* and this is the difference. It’s not a business model. It’s a respectful human model.
Mexico has national health insurance. Now we really know why some want to build “The Wall.”
Ah, tell the docs to suck it up and get on with life. Many other professions have gone through the sea-change of a move toward electronic management and production (mine was architecture).
It’s not like the docs were running an efficient system before. US health care was muddled long before this.
So doctors nationally and internationally are complaining about this technology preventing them from practicing good medicine, and you’re telling them to suck it up?
Unbelievable. Perhaps you should reread my essay at Healthcare renewal.
It is the old code problem.
In was expensed, not capitalized, so there is no depreciation. It cannot be replaced because it is “integrated” (as is a tangled ball of string), and management only get bonuses for minimizing modifying the code to the minimum necessary.
I agree and disagree with Clive over this statement:
Yes, you would be hard pressed to get MUMPS skilled developers or designers/architects. Like trying to find people who know how to service gaslighting.
People can learn. The learning curve is expensive, and produces no return on investment.
The problem is a financial one. Maintenance for software was never budgeted, only minor improvements. Many years of “minor improvements” only increases the tangle in the ball of wool.
As an aside, I’m willing to bet the Pentagon’s software is worse, and a 30 year old F35 with all it’s software is frightening to contemplate — except from a rent extraction point of view.
The only solution is Climate Change. (/snark).
Little to add but that this seems to be another extension of rule by MBA. I refer to the overuse of a qualification where it ceases to add value. One example is found among the plethora of staff at colleges and universities, who know little and care less about teaching. Another is here, where administrators superimpose business priorities on the human value of medical services, valuing them only at the price at which they can be billed.
Instead of managing an organization and its principal systems, business priorities now drill down to the delivery methodology and billing for a single aspirin. The model for this seems to be 20th century time-motion studies. Every motion is billable to somebody, so code it. If it can’t be billed, staff shouldn’t be doing it. Every worker is now a profit center, or else.
I understand that there is great resistance to this. It is being enforced through a variety of mechanisms. One is the daily e-mail to staff, expecting them to respond to the question, “How are you feeling?” No one with the slightest experience of corporate HR priorities considers this a genuine question. It is designed to generate a statistical pattern for admin staff to “evaluate”. It is designed to weed out; which weeds are culled, complainers, for example, depends on the organization. It is also designed to shift liability to staff in the event of mishaps, which are inevitable, given ubiquitous short staffing, and the complexity and nature of the work.
This software itself was designed around billing. Other purposes are ancillary. One aspect of that seems to be that service providers are encouraged to use the treatment code that corresponds to the billing code providing for the highest reimbursement from insurers. That there are now bachelor degrees granted in the field of medical billing supports most of the comments to Dr. Silverstein’s article.
It would be easier to design meaningful electronic records if the emphasis was placed on narratives rather than bullet points. If importance was given to intelligent discussions on the case at hand rather than the innumerable data inputs. So let us say I saw a case of a complex kidney disease in an elderly patient who needs immunosuppressive therapy with myriad side effects but who also has coexisting blood and cardiac disorders, I could limit my history and physical exam to pertinent positives and then dictate or type a 2 paragraph note on the controversies that surround the complex decision making and the upside and downsides that led to the formulation of a treatment plan. Regrettably by the time you come down to doing this, you have run out the clock so instead of a conversation and or thesis the next physician can build upon,d you have 20 pages of garbage. And everybody loses. As a consultant I would end up teaching with this narrative and as an internist I would end up learning, and questioning, to further the conversation. Too utopian I guess as then the bean counters would be out of a job. One of the major reasons why physicians are disillusioned is this loss of meaningful and sometimes didactical interactions. Restore it I say.
What EMR? In or outpatient? This never happens to me in the office with eCW and Dragon. I have no ’20 pages of garbage’ to ever deal with. And no ‘running out of the clock’.
Machine learning.
Who needs doctors when you have Big Blue?
Machine learning needs data. Lots and lots of data. In order to get that data into a learning system you must force the clinicians to document. Then, after you’ve got all of that valuable historical data (symptoms, diagnosis, treatment and outcome) you have what you need to utilize the computational power that is readily available.
Why would you pay $450K a year to a 35 hour/week gastroenterologist to tell you to take Maalox for your stomach pain when you can have a $10/hr tech enter your symptoms into a system and pay 50 cents for a time slice on the diagnostic system.
The world is changing. Data is the key. Soon you’ll be using Amazon for medical diagnostics and treatment planning. /sarc (or maybe not)
And just wait till a person needs surgery for that gastric cancer. Let Watson try that.
As far as data abuses, if you read my essay, I rest my case.
I am not implying that the gastroenterologist disappears. Just that the scope of their engagement with the patient is reduced drastically. There are significant efficiencies that can be realized by AI diagnostics. I am not pre-judging outcomes either. Just stating this is a partial and significantly overlooked justification for the EMR.
With respect to surgical intervention the AI combined with robotics is already impacting practices https://www.sages.org/meetings/annual-meeting/abstracts-archive/robotic-gastric-bypass-the-future-of-bariatric-surgery/. This will accelerate given Lin/Chen/Yan Network in Network impact on computing architectures applied to learning systems.
Wrt data abuses I have no argument. Why should we trust that system providers are acting in the best interest of the patient.
Seems that whenever you have anything to do with health and software it has the potential to be a right dog’s breakfast (https://www.theaustralian.com.au/business/business-spectator/learning-from-the-qld-health-payroll-fiasco-/news-story/174743f09e91d9550521b04d45d43ac3). Designing software that actually works in the real world is not something that would require a Manhattan Project and you would think would appeal to those who want to ‘disrupt’ things – though I would never trust them. Designing software that works should not be that hard, especially when there is so much profit to be made from a proper working system. I suppose it is forced requirements like this that has led US health care costs to go from 5% of the GDP in 1960 to the present day 17%.
Hey, maybe AI can save the day here! /sarc
Highly Experienced Physicians Leaving Medicine Due to Electronic Medical Records
Yes, I recently lost my best physician in years, Dr Mark Bohlander at Kaiser, because he wouldn’t trade patient contact for working the EMR. Why wouldn’t health systems like Kaiser invest in transcriptionists instead of losing great doctors?
Because they’re not health systems. They’re money-generating systems. It’s impossible to be both.
The real value of an expert’s notes is not what they say directly, but their ability to trigger the appropriate memory cascades upon subsequent review by the author. A transcriptionist would mangle the doctor’s input, and thus fail to serve the real purpose of aiding the doctor’s memory.
P.S. Kaiser is a nonprofit, and appears to be a legitimate one. It’s not a money-generating enterprise. It actually has a half-decent IT system, at least at the patient-facing side.
My family physician group consists of two physicians and their son and daughter in law physicians. ALL of them love the electronic medical records system. They say it allows them to track their patients through specialist visits and coordinate care much more easily and accurately. I have seen the results of this in my own medical care there. They do employ two full time people who assist them in the data entry routines and tell me they consider that just smart office management. They spend as much time in a visit as needed with each patient and yes it does mean a long wait sometimes but we know we will all get whatever time we need so most of us know to bring a book or pad and don’t get too bothered.
I understand that much of the EMR system is about billing but much of it is not as well . It depends on how each physician utilizes ALL the features of the system. The older doctors in our practice are just as computer savvy as their younger children and that makes a lot of difference as well.
My sister in law worked in billing for a practice consisting of several older physicans and a younger. The older ones were completely clueless with computers and did not even use personal email. They ended up retiring early because they flatly refused to learn the system at all or hire more staff. When the younger doctor who purchased the practice brought in new docs and staff who were proffient in all features available through the system patient care quality and satisfaction increased dramatically according to my sister in law. She was quite surprised as she was not a fan initially.
Merf, I agree. A good electronic system is better than a good paper system. The difficulty is the proliferation of bad systems.
Doctors using decent paper systems shouldn’t be forced to retire by IT upgrades. They should be allowed to practice with a usable system until they retire.
The IT adoption should take place gradually by trial and error, not fiat. Doctors should have the freedom to pick systems that work for them and for their patients.
My personal experience seems to be counter to this. I get most of my health care from an HMO. When I am treated by doctors in the HMO, they have rapid access to all my medical information. There have been numerous times when their diagnoses were aided by information in my records from other doctors in the HMO.
In two cases where I was referred to doctors outside the HMO, I noticed the difference that occurred because these doctors did not have access to as much information as the doctors inside the HMO.
I agree with this. From what I’ve heard locally, Kaiser Permanente is actually fairly efficient for standard medical care, particularly pediatrics and basic adult medicine. I can’t speak to how well it works for chronic illnesses or hospitalizations, where it sounds like one might have to fight a bit for full treatment, but then again one doesn’t need to separately wrestle with an opaque and fraud-ridden hospital/insurance billing system.
And their electronic medical records system doesn’t seem to be a total waste of time either.
However, “EMR” is not a magical incarnation. It’s just as vulnerable to crapification through lousy incentives that any other human system is.
I think Yves’ point in the article isn’t so much that EMR is inherently evil, as it is that “EMR systems so crappy that doctors retire early” demonstrates yet again how bad the system is.
Surprisingly for NC, I am disappointed that so many of the comments in this post really missed the point. The choice of the phrase “Electronic Medical Records” was probably deliberately intended to mislead, and on this point only it seems to have been successful — in that even discerning readers still view the system as one designed to improve care. Although that was the big selling point (I remember Bill Clinton extolling its virtues in his 1992 campaign), this system was never intended to be about using a patient’s medical record to improve care.
More properly this system should be called what it truly is: Electronic Medical *Billing*. Therein lies the disillusionment of doctors — trained to be artists and healers of people, the system discounts their skills and judgement, and has instead deputized them to be gatekeepers and beancounters for the FIRE sector. Rather than improving outcomes, Electronic Medical *Billing* inhibits patient care and the best practice of medicine. It’s no wonder doctors are feeling like teachers and college professors. Perhaps this is the first (hopeful?) sign of a schism in what Thomas Frank calls the “professional class”, in which the predators turn against their fellow professionals?
Why is it that so many IT people believe that they know better than the people actually in the trenches how they should do their jobs? If Docs are saying this software is interfering with patient care why are IT people saying that its the Docs who just don’t want to learn new techniques? Who the hell do IT think they are? And as has been said, this is the same attitude from IT that many other end user communities experience. IT people insist on telling their customers that they don’t know what’s best for them, but IT does.
The answer to that question is obvious. IT personnel are usually technology hyperenthusiasts who don’t consider the downsides to technology. This is in part because they have no training in areas such as Social Informatics that studies the social impact of technology. Google that term.
1. EMR is awful and the entire medical/insurance industrial complex woefully parcelized. There are forces here that are committed to making government provided services more rather than less efficient, The reference to Mexico suggests that things may be better elsewhere. How about Canada/France/UK/Germany…?
2. One wonders what Berkshire Hathaway/Alphabet/Amazon will do with their health care initiative.
I don’t see any good reason why EMR systems should not be treated as medical devices by the FDA. (Of course not focused on individuals’ health, but on public health.) As such, EMR systems would not be allowed to deploy until it has been proven be safe and efficacious, i.e. nobody should become worse off because of a system, and it must be proven to significantly improve health.
Ironically, those commenting that the doctors should just “suck it up ” and spend 3 waking hours daily as a data entry clerk (rather than examining and treating patients) are the true Luddites. Instead, they should demand that their Congressional representatives mandate uniform affordable efficient EMRs that resemble Google rather than MS-DOS.
Having reviewed this article and comment thread I’m interested if any commenters have new insights given what we are learning about the extent of privacy violations and Facebook and related entities.
To believe the data being entered into these electronic health records is not being sold for financial gain is the height of naivete’. As for the clinicians who allow their reputations to be leveraged in an effort to extract the most intimate information possible from the patients who trust them, well at worst they’re voluntarily complicit and at best, useful idiots.
The EHR is like an email or your internet use history—never allow anything to be put on your record that you’re not willing to have shouted from the highest housetop.
PS—as for the EHR “not going anywhere”—possibly, but they have essentially become the plumbing of our healthcare world— very expensive to run and maintain, quickly becoming unusable without constant maintenance. As we reach the limits of what we, as a society can spend on healthcare, the EHR may go the way of the Roman Aquaduct.
I’m sure the Romans thought they would always be around too.