Why EHRs aren’t meaningful to doctors and hospitals

Electronic health record (EHR) advocates in Washington don’t seem to get it. They don’t seem to understand that hospitals and doctors aren’t rushing to install EHRs because many EHRs, despite the constant talk that EHRs are a prerequisite for good care. Caregivers are not walking the talk, because in their view, EHRs,

  • aren’t ready for prime time
  • slow productivity
  • decrease revenues,
  • show scant returns on investment
  • don’t talk to one another
  • distract from time spent with patients
  • are limited as communication tools

If I may use bureaucratic parlance, EHRs aren’t “meaningful” to clinicians. This may change as EHR vendors, doctors, hospitals, and IT consultants gather at the $27 billion EHR government trough, but it will remain slow because economic and health reform uncertainties.

Washington hopes to overcome resistance to EHRs with a carrot and stick approach. CMS will reward doctors and hospital with bonuses and other rewards for adopting EHRs and penalize those who don’t with lower fees and withdrawal of the Government’s Good House Keeping Seal of Approval.

Unfortunately, the Washington elite overlook the hassle factor. To qualify for the up to $64,000 subsidies for physicians and millions of dollars of handouts for hospitals, providers will have to “qualify” for payouts by meeting 23 to 25 “criteria for “meaningful use.”

The problem is: what is “meaningful” for government may not be “meaningful” for small hospitals and small practices, who are struggling to make ends meet.

Katherine Hobson, who writes the Wall Street Journal’s health care blog, captures the essence of this problem for hospitals in “Only 2% of Hospitals Could Have Met ‘Meaningful Use’ in 2009.”

She says, among other things, that,

  • “Despite all the talk about digitizing the health-care world, only 11.9% of U.S. hospitals had adopted at least basic electronic medical records by last year, and only about 2% had done enough to qualify for future government financial incentives, a study finds. The study, published online in Health Affairs, covers responses from 3,101 hospitals surveyed by the American Hospital Association.”
  • “It’s actually not surprising that hospitals were slow to adopt new systems in 2009, given the horrible economic conditions, difficulty of raising money for capital investments and uncertainty over what the final government requirements would be.”
  • “The study found a widening gap between larger, nonprofit, urban hospitals and critical-access, small or medium-sized, public or rural hospitals in the adoption of digitized records. For example, 7.5% of large hospitals would have met the requirements, compared to 1.2% of small ones.”
  • “Of course that gap is only a concern if you believe that electronic medical records are a good thing. For their part, the authors write that electronic records have been associated with the potential to improve the quality of care for underserved patients, improve patient safety via electronic prescribing and improve adherence to evidence-based care.”
  • “If you adopt a new technology, and do it badly, you can end up making productivity worse or causing harm. This is not a plug and play.”

Those at the top of the health care tree in government say EHRs are a wonderful thing, but small hospitals and doctors in small practices with limited resources, who provide most care in America, are not ready to go out on the EHR limb.

Yet, despite obstacles and slowness in adopting, a combination of things – widespread “free” or inexpensive EHR systems, speech recognition programs enabling doctors to easily incorporate their thoughts and the patient narrative into EHRs, advances in wireless “touch” technologies, social pressures from patients, and financial assistance from payers – will help make the “inevitable” more “evitable.”

EHRs will eventually evolve from below, but they need not and are unlikely to be forced from above.

Richard Reece is the author of Obama, Doctors, and Health Reform and blogs at medinnovationblog.

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  • Cheapo

    a nice and real perspective, i am in support of ehr, but only when it is truly perfected, right now EHR reminds of the state of the art palm pilot from 2003, the 6000 dollar plasma screen TV, the apple Newton, the VCD, the commodore amiga, the motorola star tac, all these obsolete machines, wait 3-4 years, let the early adopters work out the kinks, and the rest of us will get on board when the tech is perfected.

  • http://applied-infosystems.com Robert Wieseneck

    I think that while the government might mean well, it bogs down things with so much “red tape” that it defeats itself. As was mentioned at the end of the article there are several inexpensive programs that would be very helpful to the health industry, and I hope this will be a start to improving the state of EMRs.

  • http://www.hl7standards.com/blog Jon

    Good, realistic view. However, implementing EHRs are good for patients. We cannot collect our data efficiently and manage our care without an EHR being in place. I know, getting the data from the EHR then is the challenge, but we cannot begin the process until the data is in an electronic format. After this is in place, over time, we will be able to use our data to manage our care more effectively, similar to the way we try to manage our financial well-being. Thanks for engaging the discussion.

    • rwatkins

      “We cannot collect our data efficiently and manage our care without an EHR being in place”

      I do that with well organized paper records. Please explain what you’re talking about. Thanks.

      • http://www.hl7standards.com/blog Jon

        What I meant is until our data is in an electronic form, we cannot get our data transferred in an electronic form. It has to start somewhere, and an EHR seems like the best way.

        I know there are too many references to the financial industry. However, once my data is in an electronic form at the bank or at a credit card company, I can now pull that into one portal, like Mint, and manage my financial well-being. It would be great to do that with health care information as well.

        • rwatkins

          “until our data is in an electronic form, we cannot get our data transferred in an electronic form”

          Tautological. Please give me evidence that this will improve your health.

          • Cheapo

            only thing to improve your health is patient compliance and good healthcare, ehr is great in theory, and is the wave of the future whether you like it or not, the fact is I don’t want to do it either and will wait a long time to implement it, but it is coming and you need to prepare, the powers that be will have it no other way and as a physician you unfortunately are not part of “the powers that be”…i think that is truly the inherent problem.

    • J.T. Wenting

      Utter BS.
      Only an incompetent person is incapable of archiving and correlating information on paper.

      Doctors (and indeed everyone) have been doing that for decades, often centuries and into the thousands of years.

      If you were correct, people would still be dead today from lacking healthcare at the same age they would die in the stone age, and those using EHRs would suddenly live to a ripe old age.

      And EHRs won’t magically produce efficient and flawless records, in fact they’re just as likely to lead to errors as any other means.
      But with an EHR the doctor can now blame someone else (the IT company maintaining the system) for his errors when he messes up (important, as he can now deflect malpractice lawsuits onto others, good for his income).

      At best it makes communicating between different professionals easier, allowing records from one hospital to be linked to that of another through computer networks rather than through fax or scan&email.
      And there are major problems with that, especially where it comes to protecting patien/doctor confidentiality and patient privacy.
      It’s a very small step to allow government agencies and insurance companies access to those records for example, much easier to arrange and much easier to cover up than with a paper trail.
      And then you have a situation where some bureaucrat can look over someone’s EHR and decide that he’s not worth treating because in combination with his tax records he clearly won’t generate enough tax revenue for the government to compensate for the cost of the procedure.
      If you think that’s theoretical, look no further than the UK where such a system is already in place (though they’re only partially computerised).

      • Adam Rothschild, M.D., M.A.

        I strongly believe that the largest value proposition of so-called EHR systems is not in the record-keeping component at all but rather in their (someday) ability to use clinical decision support to help doctors practice better (i.e., evidence-based) medicine. For the record, I am a practicing family physician and formally trained medical informatician who has thought about this issue daily for over 10 years.

      • r watkins

        “Only an incompetent person is incapable of archiving and correlating information on paper.”

        And what do you think happens when we empower these people to enter data into the EMR!

  • http://Jasondapore.com Jason Dapore DO

    Business drives technology. What other industry would adopt technology that decreases productivity and a less impressive end product (patient visit)? There is much work after the initial purchase to streamline the process and make the final note meaningful and representative of the encounter. I agree with the above analogy, but at least the purchase of a plasma TV brought some level of joy to the life of the early adopter.

  • http://www.pizaazz.com Glenn Laffel, MD, PhD

    I have many problems with this article, but the most fundamental one is the author’s tendency to lump all EHRs into one basket. There are indeed many “clunkers” out there that have the problems mentioned by the author, but there are also an increasing number of newer EHRs that have overcome, at least to an extent, many of these problems.

    Some EHR vendors have incredibly loyal followings; their users swear by the product. One of the best things about HITECH is that it “should” accelerate the consolidation of this industry…and although there’s no guarantee this will happen, hopefully the consolidation leaves the most usable ones, and the ones with the most value, still standing.

    I’d like to ask the author, how many docs do you know that have made the (admittedly difficult) transition to an EHR and then said, “ya know what? I like it better the old way” and actually went back to paper? Which EHRs has the author used? An instructive follow-up article he could write would compare his experiences with different EHRs and draw lessons from that. That’s something we could all learn from.

    • rwatkins

      ‘how many docs do you know that have made the (admittedly difficult) transition to an EHR and then said, “ya know what? I like it better the old way” and actually went back to paper?’

      In my experience, LOTS of docs say they would like to go back, but the transition process was so excruciating they are absolutely unwilling to go through it again (in reverse).

      But that’s just anecdotal. The question so many of us ask is that, after all these years/decades, shouldn’t there be some good studies out there that prove what EMR propagandists claim?

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    Just to add to Glenn’s perspective, there is also a marked evolution in the large “clunkers”. I’ve been seeing some really “old” and really large products recently making pretty amazing strides towards “non-clunckiness” by integrating new web technologies, cleaning up those old and tired user interfaces and coming up with very interesting work flows for physician documentation.
    Couple this with the emergence of Networks and the beginnings of data exchange, and you may feel compelled to reexamine those “legacy” opinions.
    It may take 3 or 4 years to attain perfection across the board, but there is already significant utility in HIT if you pick your products carefully.

    • Dr.Z

      Margalit … let us know when they get there.

      I’m not interested in going through an install and an update and a patch and another update and retrain our staff each time … before we are there.

      If this were really beneficial to docs and their practices wouldn’t you think there would be more of us already up and running like a ’34 Buick?

      If the major payer paid 100% of what I bill … who covers 40% of our pts wants us to implement an EHR … I’ll ask “what color would you like us to buy?”

      When the major payer who reimburses 60 – 80% of what we bill … and who threatens a 25% cut in fees every year … and then says that if we don’t adopt our EHR and demonstrate MU by 2015 then we’ll beat you with a stick. Well … I can tell you what I’m going to tell them to do with their stick.

      We’ll either have MU by then or we may not … but if they pull out the stick … then we’ll simply drop our Medicare pts from the practice. Simple as that.

  • imdoc

    So, if it is all so great why do we need a government force feed? Like others said, technology is adopted when it is deemed useful by the purchaser. For those who want to manage their own health data, a personalized health record is a better option. I think centralized systems functioning as a PMR would minimize expense for physician and patient, put patients in control of the information, and accelerate improvements.

  • http://joecascio.net JoeCascio

    As a software engineer and a veteran of 10 years in cardiology image and report management systems as a CTO, I am very glad to hear there is resistance to forced adoption of EHR. I can testify to at least the fact that cardiology image reviews could not be adequately captured in digital form without transcription. The natural language nuances of a diagnostic or interventional report are beyond the current state of simplistic radio-buttons and check boxes, and the reviewing doctors cannot and will not spend the time to type in the information.
    As a career software engineer (aka programmer) of 40 years, I have witnessed many attempts to force pre-planned software on apprehensive users. The results are usually not pretty. As many commenters have noted, what usually results is just the opposite of what’s intended, a loss in productivity, higher costs, frustrated clinicians and sub-standard patient care.
    Having said that, I also believe that true savings, better outcomes and better productivity can result from EHRs, but ONLY if they are allowed to develop organically, from the bottom up, in close cooperation with the people that need to use them. Good software is always developed in a tight loop of develop, try, fix, redevelop, retry, using agile techniques to quickly address mismatches between the perceived and real requirements on the ground.
    There is real potential to develop a grass-roots EHR, if you will, by letting many different developers attack different aspects of the problem in the small, rather than an overly ambitious, politically tainted and “coordinated” attempt in the large. Software develops in a close analogy to natural evolution. Let every flower grow and pick the ones that bear the most fruit. Trying to pre-plan such a vast system will never work.
    Thanks for listening, and again it’s good to know that clinicians’ gut instincts in resisting line up with at least one software professional’s experience.

    • Donald Green MD

      Your comments ring true with this blogger.

      There has to be as you have stated a resistance to top down development that has corrupted many clinical priorities for an electronic medical record. I would suggest posting at geekdoctor.blogspot.com since your viewpoint is missing from Dr. John Halamka’s(Boston Beth Israel’s chief IT person and a major player in setting information exchange criteria) site. He belongs to a school of thought that is all set to impose very complex rules and guidelines for the ONC to follow and to have everyone implement. There is a strong push for global reporting as a number one priority for various agencies versus strong confidential medical documentation and retrieval of information for benefit of the patient. This should be first in place before any further expansion of data sharing. Many small offices simply lack the kind of office flow capabilities that makes use of any EMR product burdensome. This has to change first but in an educative mode not through draconian measures. I think your clear writing style may help to influence a better direction for all practitioners by posting on the site mentioned. I also encourage others to do the same.

      • http://joecascio.net JoeCascio

        Thanks for the point to geekdoctor!! I’m going to make open-source EHR and EHR standards a session topic at HealthCampCT in April. I hope that we will get both developers like myself as well as practitioners to attend so I can learn more about what’s happening out in the real world of medical practice.

        • http://diagnosticinformationsystem.com Bob Coli, MD

          Mr. Cascio,

          A physician-centered, value-driven competitive market in which vendors must compete on transparent prices, product quality and usability is what will produce the benefits of “naturally evolving ambulatory and hospital EHR software that lets every flower grow and lets users pick the ones that bear the most fruit.” Hopefully, HITECH’s EHR and HIE subsidies, the increasing national focus on patient safety and growing physician demands for more usable and affordable products will help disrupt the status quo and lead the American HIT industry in this beneficial direction.

          Realistically however, physicians and private sector entrepreneurs can’t wait for the government to establish the competitive, value-driven market that would benefit physicians, patients and vendors with the most valuable HIT products or to create the clinical content and process standards necessary for data liquidity and full interoperability.

          If the leading EHR (1) and HIE platform vendors are seeking to add value and brand differentiation to their products, there is one clinical innovation that would be welcomed by all physician users. This is a simple, standardized solution for a software defect that has created significant problems in patient care processes since clinical computing was first introduced into hospitals in the 1960s. The specific systemic failure is that existing EHR and HIE platforms are still using infinitely variable formats to report cumulative test results as fragmented data that is incomplete and hard to read.

          This flawed test results reporting format is familiar to every physician EHR and HIE user who orders diagnostic tests and then views and shares test results. It is a hidden “unsafe condition” that increases the probability of producing the three types of adverse EHR “events” recently described by the iHealth Alliance and its EHR Safety Event Reporting Service (http://EHRevent.org). The faulty format endangers patient safety by disrupting physician thought flow, workflow and care flow, wastes time by making it difficult to find individual test results and follow trends and wastes money by contributing to duplicative, redundant and non-contributory testing.

          Right now, physicians have no alternative but to do the best they can because it’s the only method available for electronically displaying and exchanging vital test results data. The variable reporting format has never been redesigned, probably because it has been overlooked by vendors and quality improvement organizations, and practicing physicians have never had enough leverage with vendors or government agencies to have it fixed.

          The vendor and platform-neutral solution is to develop, introduce and sustain an open standard format for test results reporting and content exchange. Combining reporting format standardization and clinical data integration will enable easily read test results information to be displayed on up to 80 percent fewer screens and to be shared efficiently for the first time.

          This might be a potential topic of interest to participatory medicine clinicians and HIT experts at the HealthCampCT next April.

          (1) http://www.healthcareitnews.com/news/black-book-rankings-names-top-emr-vendors-2011 and http://emrdailynews.com/2010/11/24/the-onc%E2%80%99s-certified-health-it-product-list-total-swells-to-126

          • http://joecascio.net JoeCascio

            I agree completely that open standards for interchange formats are the solution. This approach has worked very well for imaging with the DICOM standard. I would very much like to discuss this with you further and hope you can make it to healthcampCT.

  • ErnieG

    I like JoeCascio’s perpective. I am a young physician who is comfortable with computers, and have made the plunge into EHR over a year ago, using reportedly one of the best systems available. I would rather go back to paper, at least for now, but the investment was so large it is unthinkable.
    Unfortunately this “meaningul use” criteria has forced the vendor to focus on meeting these useless criteria, instead of focussing on solving the problems we have with the software. Excellent systems will come from the bottom up , not vice versa. It is classic bureaucratic mistake to believe that complex solutions to common problems can be mandated, that (or even define) “clinically meaningful use” can be defined by bureaucrats, and expect physicians to pay for it (the “incentives” are small change).

  • Primary Care Internist

    If the government’s motive was really to improve the quality and consistency of care, they would simply GIVE a common electronic record and order-entry system to everyone who bills medicare. Then they would mandate that any business entity that bills medicare or medicaid (ie. probably 99% of hospitals, doctors, and nursing homes) uses the software to get paid. Vista (the system used by the VA) would be one example that is good and already proven. Another advantage of this is that so many doctors have trained in university programs linked to a VA hospital, so are already familiar with the software.

    This immediately solves the problem of inter-operability and communication between doctors and hospitals. It will also intuitively save money to medicare and medicaid by making previous test results easily accessible thus avoiding unnecessary repeat ECHO, stress test, specialty consultation, etc.

    But this will never happen. Why? Because too much money is changing hands between EHR vendors and the gov’t. Any industry that can afford such vast marketing campaigns is just getting too much gov’t money. This phenomenon is a cancer in many industries, but chief among them is healthcare. Notable other examples are DME companies (e.g. “scooter store”), diabetic supply companies (remember those Wilford Brimley commercials?), visiting nurses, and home hospice agencies.

    The answer is so clear, only bureaucrats cannot see it, since they’re blinded by the greenback.

    • Dr.Z

      Great idea! Let CMS buy, install, and train us all. Suggest they start in Maine and start working west.

  • Max

    Enough with the ‘it will improve patient safety and productivity’ blah blah blah garbage. I will accept it if they just forced me to do it and said ‘it’s the law’ and I’ll go to jail if I don’t use it. Just tell me that instead of trying to lie to me. Force me to use EMR and I’ll either use it or get out of medicine and take my Medicare(publically)-funded GME into another industry and give America the middle-finger for paying for my education and leave with the knowledge they paid for tucked inside my head forever.

  • Jack

    I truly believe EMR is driven by business/software companies and disguised as “better healthcare delivery/improve healthcare” and shoved down physicians’ throats.

    Now we are already on our 2nd generation of EMR in our practice. I DO see benefits of it within the practice itself. However, is it worth the investment??? MAYBE. The $$$ and man power that are spent is ridiculous, especially with government constantly changing it’s regulations.

    My personal BIGGEST complaint about EMR

    It doesn’t talk to other doctor’s office or hospitals unless WE implement interfaces (btw, we get to pay for that too).

    I know there’s no perfect solution but if the government want EMR to succeed and do what it’s suppose to do………BUILT ONE and give it away for FREE!!!!!!!!! Make every practitioner + medically related companies (including insurance carriers)use the FREE software.

  • http://emegency-room-blogspot.com girlvet

    Are you seriously still fighting electronic medical records? Give it up. They are here to stay. It is about CHANGE. If you can’t accept change in health care you might as well get out because change is the name of the game. New docs, who are used to technology, will leave you in the dust.

    • Vox Rusticus

      Give it a rest. Most doctors are not luddites. The problem is that EHR products are of a quality that would fail if introduced as a sink-or-swim mass-market product. The only reason these outdated crummy products have any toehold is the fear of being penalized among the doctors and practices that have to buy and use them. They really don’t make work easier at all as they are. All the promised future “benefits” are complete smoke, made to the great benefit of the software companies, who have yet to demonstrate a successful community-wide cross-platform integration of different products to construct a secure yet accessible silo of information that allows the immediate availability of all of the data pertinent to a patient’s health care.

      Where are the data silos? Where is the access? Until that problem is worked out in a very real and concrete way, the benefits of EHR are science fiction.

  • r watkins

    The false claims made for EMRs (improved patient safety, increased revenue) have definitely increased resistance to adoption. A little honesty at the outset (i.e., that EMRs are primarily useful for insurers and government agencies to collect data, and 99% of the benefits will accrue to them) would have been very helpful. And nowhere was that honesty more absent than in the performance of the primary care medical societies, who chose to represent the interests of the EMR companies rather than those of their member physicians.

  • http://joecascio.net JoeCascio

    Real adoption of EHR will happen when it can piggy-back on trends like this: http://goo.gl/4mc8e (“Tech-Savvy Doctors Are Putting Smartphones and iPads to Work in their Medical Practice”. ) We’ve got to put choice of solutions and pace of uptake in the hands of those who will actually have to use the technology.

    Many individuals making similar individual choices is the true test. Bottom up innovation is the way things work in the Internet age. Ideas can start small with virtually no investment, get a toe-hold with early adopters and spread by work of mouth. A top-down imposed solution has a high probability of being a train wreck, except for the prime contractors for the EHR systems. That is how we got $600 toilet seats on military aircraft.

    If an EHR module that was simple and useful and addressed even one part of the problem could be downloaded on iTunes or from the Android Market, for free or say $0.99, that would go a lot further toward EHR adoption than any government-mandated piece of bloatware from one of the industry heavyweights. Open data standards and an open app market would encourage innovation instead of stifling it under layers of bureaucracy.

    In the software world, really disruptive innovations come mostly from individuals or small groups who work on the front line with user or who are users themselves. Think of all the amazing iPhone and Android apps that people build because it’s what they themselves wanted to have.

    Government can do its part most effectively and less expensively by simply supporting standards activities through agencies that already exist, like NIST. Standards mean interoperability and true competitiveness.

    ps. I am looking forward to a vigorous discussion of this topic at HealthCampCT, in April in New Haven, CT.

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      I’m sorry Joe, but I am not aware of any enterprise software that is downloadable from iTunes for 99 cents.
      Your bank does not download software from iTunes and neither does Walmart or Toyota or Southwest or… you name it.
      EHRs, the software residing in hospitals and physician offices, is enterprise software and in most cases it is mission-critical.
      I can see the possibility of consumer software on iTunes that will allow a patient to view records in the EHR, just like you can pay bills on your iPhone, but that’s about it.

      • http://joecascio.net JoeCascio

        Actually, many, corporation, including banks are making free mobile apps available to their clients and employees. It’s all about access. Just because something is “enterprise” doesn’t mean it has to cost an arm and a leg. If the appropriate open standards were in place (to my previous comment), app developers anywhere could create simple, easy to use mobile apps to access the enterprise database. Even, as you so aptly put it in your previous comment, the old “clunkers”. :)

  • HJ

    There are a few medical systems in my area that use their use of an EMR as selling point in their advertisements. As patients flock to these corporate medical centers, those left behind will adopt an EMR.

  • Jack

    I am all for private innovation. However this is one area where I believe ONE is better than many.

    I compare this somewhat to our mobile industry. Currently we have two different predominant technology running our cellular towers (GSM and CDMA) but even within these two, companies runs different variations so there are FOUR major companies. Each company is pouring $BILLIONS trying to keep ahead of each other. Seriously..what a waste and we still don’t get good coverage. If there is a regulation to STANDARDIZE our mobile technology we wouldn’t waste so much $$.

    Same with EMR. We are spending $$$ in various EMRs around the country as physicians and hospitals but sadly they don’t even communicate with each other. If the government would standardize it so MD offices and hospitals can access same records that’s when productivity and patient care will see most improvement.

    Bottom up driven sounds great except you are wasting $billion trying to achieve that goal and it’ll just end up like our cellphone industry, fractionated at best.

  • http://mmodal2.wordpress.com/ Lynn Kosegi

    Wow. In my opinion, to lay the blame for lack of adoption of the EMR at the feet of the doctors because of their inability to accept change is unfounded, not useful – and frankly rude.

    But courtesy aside – I know of a facility whose young doctors (you know the ones – the ones who are going to leave the others in the dust?) did indeed take to the EMR. And their insistence on using the same type of abbreviations in the EMR that they use while texting and IM’ing, along with the insistence on copying/pasting information that they THOUGHT was still current, but was not, was causing the facility major quality problems.

    Now, don’t get me wrong. I think the idea of electronic records is great. I’ve got years of experience in hospital HIM depts and transcription companies and know about misplaced records, misfiled or missing reports, and edits made on one paper copy that never get communicated to recipients of the original. The idea of shareable, high quality, documentation that enables collaborative patient care is a beautiful thing.

    The idea of technology that FACILITATES what doctors have to do instead of getting in the way is wonderful.

    But saying the EHR will magically make all that happen AND that it will improve patient care? Exactly how does that happen?

    A few weeks ago I went to my doctor because my seasonal allergies were horrible and were causing my asthma to act up. My doctor’s office had just implemented an EMR and the doctor sat down in front of it. The medical assistant had asked me to jump up on the exam table and the doctor sat with her back to me as she asked me questions and typed.

    She was really proud of the fact that she’d ordered my prescriptions electronically – no paper – and told me I was going to receive a printed summary of my visit on my way out past the reception desk.

    Funny. Because she never examined me. I’ve had asthma since I was 8 years old. In all the years that I’ve gone to the doctor, I have never once NOT had my breathing listened to, or my nose, eyes, ears, and throat checked. I’ve never NOT been asked how many times I was using my rescue inhaler.

    Isn’t it amazing how that EMR made it possible for that doctor to treat me without ever examining me? Maybe next time I can just answer a few questions on a website. Who needs a doctor at all?

    Point being – adoption and use does NOT automatically equal better patient care. Functionality does NOT automatically equal usefulness.

    Now – the first company to create the tools to enable the creation of truly useful information in a way that doesn’t take too much of the doctor’s time and doesn’t interfere with the doctor-patient relationship – the one who will build the tools based on the needs of the users – will have something to talk about.

    I was at an event last week hosted by the Pittsburgh Technical Council’s Women’s Network (shameless plug – I’m proud to say my employer M*Modal won their best IT company aware for 2010). The panel was giving advice to entrepreneurs and developers about product development and marketing.

    One of the panelists had one of the best lines of the event. “Don’t make dog food that the dog won’t eat.”

    But I suppose if a really highly touted dog food wasn’t accepted by dogs, the dogs would get the blame for that too….

  • Anon-MD

    Jack,
    Do you even remember the days when we ~HAD~ one phone company? Most of the major innovations occurred when that industry was unregulated. What you call waste, the rest of us call progress.

    True, innovation involves failure. And risk. And not knowing which one will win out .. (Beta-max anyone?) But if you expected a government mandate to pick the winner, we’d probably be using rotary cell phones right now.

    I also have to disagree strongly w/ girlvet. I like the more rational explanation which is – if it were so beneficial to medical practice, we would have to be forced NOT to use it, not forced TO use it. The very fact that we are not adopting the in droves is because they are NOT ready for prime time. Doctors are not luddites. They have iPads, iPhones, blackberries. They use home PCs, play video games (some), and search the net w/ Google, Pubmed, medscape. They use Twitter, Facebook and blog.
    These are NOT technology averse folks. These are folks who practice real, not theoretical, medicine and know that they do not need an EHR to do it.

    Additionally, it is clear that the purpose of the EMR is not to help doctors, or patients, but as noted above, to help govt, pharma and the insurance industry monitor us.

    No thanks

    • joe

      I remember Ma Bell and innovation without standardization as is going on right now with EMR’s is making the present system a mess.
      How about another analogy anon. NATO before standardization, When soldiers from different countries in the alliance didn’t use the same bullets, didn’t use the same equipment, were not even able to talk with one another because of different equipment. That is what is going on presently in American medicine. This idea that we should have ground-up innovation ignores the simple fact is most importantly doctors, hospitals, and other entities need to be able to talk with one another and that is not happening with today’s EMR’s. Patient’s suffer and doctor’s suffer. You like going through 150 pages of paper notes for every admission from hospital X or every consult from doctor Y. How many times have you done a consult without the needed info because it “wasn’t available”. This is a national issue and some type of standardization is in order so we can communicate with one another..period. Statements such as “bottom up innovation” and “allowed to develop organically” (whatever that means, I take care of patients not tomatoes) ignore the reality of this mobile society in which patients regulaly travel across the country. Heck, I can’t get the records from the next hospital down the road. Somebody needs to standardize this system, but it will never happen as pointed out due to the vendors paying off congress. In my years since training I have yet to come across a system as good as VA’s Vista, and I have trained on multiple which were adequate to awful. Standardization will never happen as congress has been paid. Patients and doctors will continue to suffer because of this issue.

      • http://joecascio.net JoeCascio

        This is the whole problem in a nutshell. Standards, open standards are what really promote innovation while preventing corporations from doing the “lock-in” tactics that they love so much.
        The DICOM standard in medical imaging was a huge leap forward for radiology and cardiology, the industry I worked in. Oddly one of the roadblocks to standards is the huge diversity of and sometimes competitiveness between specialties in medicine itself.
        Also, the problem frequently isn’t the lack of standards, but rather that there are too many diverse and sometime overlapping standards.

    • Jack

      Anon-MD, in a perfectly efficient world of true competition without barriers, YES, I would agree with you.
      Realistically that environment doesn’t exist. MA bell brought us the TELEPHONE. You don’t think that’s innovation?
      We have ENOUGH EMRs out there already but NO STANDARD. That makes EMR inefficient to the end users….that’s the providers and patients. I can’t tell you how many times my patients ask me, “why can’t you get my records electronically from my other doctor who also uses an EMR?”
      Even worse same EMR system in different doctor offices can’t “talk” to each other without spending $$ to setup interface.

      Right now EMR works for the insurance companies and government but is only serviceable to the end users.

  • Anon-MD

    I’d agree w/ everyone that standardization would bring some efficiency, but at HUGE cost. Innovation for one. You can argue that Ma Bell innovated, but what you cannot know is what would have come about if there were some actual competition. For all we know, cell phones, answering machines, and voice mail may have been invented 20 yrs prior (in fact technology for answering machines was around for long before they were “released” – there was some “official” reason that little goody wasn’t let out of the bag … there’s standardization for you

    But I digress. The real reason we cannot standardize EMRs right now is that no one developing them really knows why they are being developed. As noted by many above, they do NOT improve health care, do NOT lower costs, and do NOT improve efficiency in the work place. What they do is permit greater supervision of medical documentation and decision making by third parties. It is totally ironic that doctor’s are being asked for something that benefits everyone else but patients.

    We don’t have systems that really do medicine meaningfully. Standardizing right now would mean picking the winner of a crap contest. But we’d all have the same crap

    As I noted above, if it were really time to adopt EMRs, doctors would be knocking down doors to get them. Systems that utilized them would be so cost effective, they’d dwarf their competition with their savings. Patients would line up to go to these places.

    But when patients come to the doctor, the last thing on their mind is – Gee, is this doc connected by EMR? EMR is NOT necessary for a doctor to do what they do

    But lets assume that most doctors are luddites and fail to appreciate the benefits everyone ~knows~ will accrue once we are all on EMRs … how about this … make all EMR costs pass through charges to patients bills, just like the cell phones various bogus fees. You see the doctor and your itemized bill reads:
    99214 – $80
    EMR technology fee – $10

    And let them bear the cost … they are the true beneficiaries of them? Right??

  • PAULMD

    “Don’t make dog food that the dog won’t eat”…excellent.

    The policy wonks are banking on their own idioms….
    “If the dog is hungry enough, you won’t believe the @#$% he’ll eat”.”

  • http://www.concentrica.com Arthur Williams, MD

    Excellent perspective – and from the number of comments you certainly struck a nerve. We have an EMR at one of my groups – an acute care hospital- and no EMR at my other group – a rehab.

    Difficult to argue conclusively if the EMR actually improves patient care. Though very easy to see how lack of communication between EMRs, and between locations, hinders patient care.

  • http://www.patientkeeper.com Peter Henderson, PatientKeeper

    One major reason many physicians don’t want to adopt EHRs is that most information technology forces doctors to change how they work. To encourage adoption, software should support physicians’ current workflow. Physicians love technology when it makes their lives easier. Take mobile technology, for instance: Physicians have been adopting smartphones and tabs/pads at a very fast rate. Providing software that physicians will “meaningfully use” increases the likelihood of attaining the various stages of meaningful use.

    • http://joecascio.net JoeCascio

      Couldn’t agree more! There’s an old saying amongst salesmen, “It’s easier to sell pain-killers than vitamins.” If the industry concentrated on relieving working doctors’ pains instead of telling them what’s good for them, things would go a LOT smoother. This is why doctors *are* adopting mobile technology on their own. It solves a problem they actually have and they can exercise their own freedom of choice. EHR could work like this, too!!

  • http://joecascio.net JoeCascio

    From a patient’s perspective it sure would be nice if doctors that I see could easily all be in the loop about what’s going with my health and treatments. And if I’m away from home, it would be nice to know that a doctor or hospital wherever I am could access my history quickly and in sufficient detail to make use of it in any diagnosis or treatment I might need. Not to mention the fact that I wouldn’t have to fill out the same damned history forms every time I see a new doctor or go to a new health facility. That is a ridiculous waste of everyone’s time, and so error-prone.

  • John Ryan

    Health care reform? Reduce costs, improve quality & efficiency? Let’s spend billions to buy everyone an EHR. Does anyone read the multipage nonsense that these programs produce? I challenge you to figure out what the specialist, home care nurse or physical therapist is saying between the canned, Medicare E&M-compliant prose.


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