EHRs in the real world

I agree. For a practice the size of the one where I am working, the costs of purchase and introduction are formidable. I would have to train all the staff, or pay contractors to do the same. There are substantial follow-on expenses each year for maintenance. The systems are proprietary with limited, usually solitary suppliers (and there has been an unfortunate record of company failures with practices being left with orphaned systems.) There is the extra hardware to buy and install.

I work relatively efficiently. My inefficiencies are not those an EHR will help much. Missing charts aren’t really a problem. I chart quickly and document effectively to the level of service I am providing.
I don’t need to work from remote locations where I need access to all my records. I don’t spend all that much time writing prescriptions. In all, I don’t believe an EHR will allow me to see more patients in a workday or bill at a higher coding level or save me time while I wait for records to be fetched. The cost savings of persons fetching records isn’t likely to be all that great unless a system is so efficient that it will allow me to eliminate my front desk check-in and checkout staff which it will not, since they are needed for other tasks the EHR will not eliminate, like scheduling and collecting copayments.

It will cost me a lot of money now and in the future. It is dubious that it will benefit me. (Do I really believe that I will have access to a web of interconnected databases of all my patients’ equally wired doctors and pharmacies so that I will be able to acquire a full list of current medications without asking the patient? No. Will communications with all my patients’ other doctors become all that much easier? No.)

The government iniitiatives to promote EHRs with a stick and no carrot are benefiting computer companies and software writers. They are the primary beneficiaries. Unless there is to be some secure yet easily accessible master library of patient data outside of a doctor’s office that everyone can access when needing information on a patient, I am not convinced that there will be any significant portability of patient records, only a lot of competing disconnected office systems each with its own discrete collections of patient data. Where will the benefit to safety in screening for medication errors come from? I don’t see any.

“Huge amounts of over-documentation have also occurred.”

This is a huge problem. Reams of text can be inserted simply with a ‘insert normal exam here’ keystroke. The documentation then appears far more robust than the actual physical exam, review of systems or history of present illness. It leaves the reader with two challanges, 1) find the important bits, those that the experienced focused examiner would have sought and documented in the paper system, among the chaff on the voluminous documentation and 2) determine the veracity of all of the reams of allegedly negative information, simply and mechanically inserted into the text but which might not have been equally rigorously established as negative in the real exam process.
The burden of handwritten (or manually typewritten) notes is that the writer must be parsimonious of word. Excessive ease of documentation leads to recording negative facts more strongly than warranted.

Josh, you write as one who seems to spend a lot of time with a computer and has become facile enough to belive that everyone interfacing will have the same efficiency and acceptance of it. I just wish that were true.

As to cost, much depends on what has to be networked, and whether the software in all the networked devices is as well written to afford easy interoperability and in/out flow of data to a database storage device. In my specialty, there is a lot of device-generated data that needs to be attached to patient records: charts, angiography capture, photography, and multiple other device inputs that have to be assembled into a complete chart. All the machines have to work seamlessly with a very high order of reliability, or the EMR will be a failure. Text from chart entries are the simplest components. There are a few privately developed commercial systems in the market, but they are expensive, and the follow-on costs are high too. I have been looking at them for a couple of years now, and there are still concerns. There is also a regrettable history of costly failures of earlier systems whose developing companies went under and for which there was no effective follow-on support. That has made a lot of people cautious.

Most doctors aren’t unwilling to change, and aren’t technophobes either. EMRs are as much a business decision as a technical one, and there are no examples of screaming business successes or clear advantages of these systems in places where they have been introduced. Best case is possibly a break-even, and I haven’t seen too many of those (most were beta sites who got below-market pricing for early adoption) and almost every case took at least a year to introduce the system and create a working database just for intramural use. In no cases have I seen any worthwhile extramural applications. None.

With the margins of third-party payors already trimmed, I just don’t believe there is much of a carrot to offer to those taking the risks and bearing the up-front expense of these systems. Threatening to cut reimbursement for those who don’t buy these systems has a high risk of blowing up in the faces of those making those threats–I would just as soon tell those payors to get lost, if in the end that were the cheaper alternative. I sure don’t owe Aetna or Medicare anything.

So much of the EHR I get formwarded to my office is rubbish. It is more legible than handwritten notes but less likely to be relevant. I will get entire sections about the prostate exams done on female patients. Sometimes I even learn the both the prostate and the cervix appear normal. Crap is crap even if it is legible crap. I dictate my charts. I do have “normal exam” templates that my real live transcriptionist uses, but I check them and the transcriptionist will call me to tell me if I say something stupid. That is 3 cross checks. It isnt cheap but it does protect my patients and provide a legible record for me, my referrals and posterity. Screw the emr

Josh,
As a former IT professional, now in medical school, let me offer a suggestion: when people say that there is a problem with implementation, the problem has to be addressed. I recognize that the first instinct is to blame the users, but bear in mind that if an elegant, efficient design does not meet user expectations, or cannot be used effectively by its intended market, it’s simply garbage.

The mark of good software is one that pleases its users. Period. It is not the job of the user to adjust to fit the software, it is the job of the software to suit the user, and the task he wishes to accomplish.

I do know the frustrations of designers, and the frustration of implementors, and I do sympathize. But begin at the beginning, and listen to the problems. Those problems are real for those users, and have to be addressed before they will use the software.

my $.02

what are EHR’s? I skimmed the article but couldnt seem to find out.