Physician barriers to EMR acceptance

Recently, I had my first visit with my new primary care doctor.

I picked him based on recommendations (plus he’s one of the few that accepts my insurance), and also because he seemed to be an eager adopter of electronic medical records (EMR). On his website, there was a portal for making appointments on-line, asking questions of the doctor and staff by e-mail and once a registered patient, I could also use a secure system to access my medical records. With EMRs being portrayed as key drivers of quality and savings in health reform, I felt encouraged by my new doctor’s embrace of the technology.

But when he greeted me in the examining room, I was surprised to see the medical assistant hand my doctor a pad of paper with my height, weight and blood pressure written on it. As we talked and he examined me, he wrote notes down on the same pad—even though there was a computer in the room. When I asked how he felt about his EMR system, he said it was a great advance for his practice—but unfortunately it had crashed  that morning and the “tech guy” said it might take a while to get it back on track. “By next week or so we should have you in our system,” he sheepishly explained.

The federal government is committing some $27 billion over the next 10 years to support the adoption and use of electronic health records by doctors and hospitals. On July 13, they released “meaningful use” criteria for hospitals and doctors to meet in order to qualify for financial incentives—as much as $44,000 (through Medicare) and $63,750 (through Medicaid) per clinician and millions for hospitals, depending on their size. These criteria—which are described in detail here are meant to promote the use of EMRs for improving patient care and quality, not just to aid in billing. Maggie Mahar recently wrote this post about how electronic records can lead to truly “patient-centered” care.

The incentives are meant to spur more practitioners and hospitals to go the way of my new doctor. But although he saw the promise of technology early, in reality, many American hospitals and physicians have been quite slow in embracing the idea of electronic medical records—with large innovative medical centers like the Geisinger system and younger practitioners being among those quickest to adopt the technology.

In a study published in January 2009 that compared physician use of electronic medical records in seven countries, the Commonwealth Fund found that only 28% of US doctors used EMRs, vs. 89% in the UK and a whopping 98% in the Netherlands.

Another finding from this study: “In the United Kingdom, 88 percent of primary care physicians can easily generate lists of medications that patients take, including prescriptions from other doctors, compared with only 37 percent of doctors in the U.S. The ability to generate medication lists promotes coordination of care among doctors and can help prevent medication errors.”

The Center for Disease Control’s National Center for Health Statistics found that in 2009 an estimated 43.9% of doctors reported using full or partial EMRs in their office-based practices. Yet this increased use of the technology is deceptive; just 20% of  the physicians were using “basic systems,” and only 6.3% were employing “fully functional” systems in 2009. A basic system can perform the following functions: provide patient demographic information, patient problem lists, clinical notes, orders for prescriptions, and allow doctors to view laboratory and imaging results on-line. Systems defined as fully functional include all that and more: they can store a patient’s medical history, execute electronic prescribing and test ordering, provide warnings of drug interactions and reminders for guideline-based interventions, among other features.
The rest of the doctors (about 18%) were only using individual elements of the EMR, like electronic prescribing or computerized ordering.

With the push on to get all physicians and hospitals using EMRs by 2015 (or face financial penalties in the form of lowered Medicare reimbursement) it’s important to understand what has kept doctors from fully embracing the technology. It’s not just the financial investment needed to set up EMR systems, says Bruce Carlson, publisher of Kalorama Information, a market research firm in New York that focuses on health information technology. Carlson tells American Medical News (published by the AMA) that “barriers to adoption for physician practices, including a disruption to work flow and a preliminary loss of productivity, are so strong that ‘the stimulus alone is not going to push the issue.’”

On the blogs and in conversations with doctors, I’ve found this same resistance—especially from older practitioners. In a post from Internet Evolution, Mary Shacklett, president of Transworld Data relates some reactions to EMRs that she’s heard from doctors:

“‘I have been practicing medicine nearly thirty years,’ said one New York City physician. ‘Using EMR is time-consuming, and it gets in the way of my relationships with my patients.’ A Midwest general practitioner echoed the sentiment: ‘I am in a situation where the clinic where I work has mandated using EMR, and it takes me six to eight hours a week to learn how to use it and to input information. Instead, I could be using this time to see more patients.’”

Some of the resistance to and difficulty working with EMRs is, frankly, age-related. Shacklett cites a recent CDC study that found that only 7.6 percent of physicians older than 65 used some form of EMR, compared with 47 percent of physicians younger than 35. But, she notes, “the slow movement to EMR has more story lines to it than age.”

Colin Harrington, an associate professor of psychiatry at Brown University’s Alpert Medical School, falls in the middle of these age ranges and also has mixed feelings about the EMR. As a neuropsychiatrist, he sees patients in the hospital as well as in an office or clinic setting. The first application of health IT at Harrington’s hospital was the electronic conversion of lab data and it was a positive experience: “Being able to immediately pull up a patient’s MRI image is unbelievably powerful,” he says, “and being able to pull up lab data proper is out of this world great.” But Harrington does have complaints about the EMR—mainly with how the technology effects his interactions with patients.

“In an outpatient setting, I either don’t type when I’m talking to a patient because it’s rude and I can’t watch patients articulate and observe their movements. For a dinosaur like me, even if I were to type when talking with patients, it would be inefficient.” Instead, Harrington takes notes by hand and then inputs them into the computer later in the day. “The result is that I can see fewer patients and I don’t get paid for the extra time.”

Douglas Perednia, an internist and dermatologist, agrees with this assessment in his recent blog post for KevinMD.com. Perednia writes about a colleague who hired a “scribe” to input written notes into her practice’s EMR system. Although she’s paying the scribe $10-$15/hour for this service, it could be worth the expense, according to Perednia. “It’s well known that, in the vast majority of cases, EMRs make doctors far less efficient when seeing patients.”

“It’s relatively easy to write with pen and paper while listening and explaining. It’s far harder to keep two hands on a keyboard, a third hand on the mouse, one eye on the screen and another eye on the patient and his family. And the fact that most EMRs and user interfaces are designed by computer geeks with no knowledge of clinical care or workflow certainly doesn’t help matters. As soon as EMRs are deployed, physician productivity typically goes down by about 50%. It rarely gets back to where it was prior to installation.”

A study in the Canadian Family Physician also finds that family physicians feel that they don’t have the time (or rather would have to spend too much uncompensated time) to really learn how to implement health IT systems in their practices; for a fair number, their computer skills were lacking. “For each hour of seeing patients, physicians said they needed 20 to 30 minutes of extra time to process paperwork (eg, complete billing, write consultation letters, review laboratory results).” This helps explain why many of them report dissatisfaction with electronic medical records.

Perednia also mentions another barrier to EMR acceptance—some systems can be unreliable or ill-suited for a particular practice. The colleague who hired a scribe is on her second EMR system: “The first one – purchased for tens of thousands of dollars – was a total disaster and had to be scrapped entirely.” Poor tech support (something I experienced firsthand at my recent doctor visit) is another reason doctors cite for being slow to adopt these systems.

For many doctors—as well as smaller hospitals—choosing an EMR can be overwhelming. The Health and Human Services “meaningful use” criteria provide a basic framework of functions for EMRs that are designed to improve quality of care and safety, among other benefits. But there are more than 300 companies selling EMR software, and many of them are promoting their products as qualified for “ARRA” funding—i.e. they meet the meaningful use requirements to receive incentive payments through the American Recovery and Reinvestment Act of 2009. The truth is that EMR systems must also meet the specific needs of a particular clinical practice, otherwise they will be balky and hard to implement. For example, pediatricians need EMRs that keep track of vaccination schedules and can generate school and camp forms; internists who see a lot of diabetic patients need EMRs that notify staff when test results are unusual or blood pressure should be taken, among other features.

With the government taking a “hands-off” approach to regulating these systems—or even providing standards that will allow interoperability between individual doctors, government payers and hospitals—it can be hard for practitioners to make an informed choice about a system.

As it stands now, there is not even a monitoring system in place for recording adverse events caused by EMR glitches. The reason, according to The Huffington Post Investigative Fund, an independent, nonprofit journalism venture affiliated with the Huffington Post, is a “clash of priorities” between the FDA (the agency charged with making sure medical devices are safe and effective) and the Office of National Coordinator for Health Information, “whose central task is to promote the technology’s swift adoption.”

According to the Huffington investigation, “The clash of priorities became public in late February when FDA official Jeffrey Shuren tied 6 deaths and more than 200 injuries to health information technology and said these were likely the ‘tip of the iceberg.’ The data review, based on mostly voluntary reports to the FDA, suggested ‘significant clinical implications and public safety issues surrounding health information technology,’ according to an agency report.
“Shuren laid out three possible options for regulations, none of which have happened. They range from mandatory reporting of ‘adverse events’ to a full blown regulatory structure that would require all digital records system to be approved by the agency prior to marketing.”

The authors conclude; “That no process exists to report and track errors, pinpoint their causes and prevent them from recurring is largely the result of two decades of resistance by the technology industry, a review of government records and interviews by the Huffington Post Investigative Fund shows. The industry argues that even with flaws, digital systems are an improvement over current paper records.”

That may be so. But the improvements may not be immediate. Researchers at Arizona State University’s W.P. Carey School of Business set out to measure the benefits of health IT in a group of more than 300 community hospitals in California that adopted some system of electronic medical records.They were inspired by a 2005 RAND Corporation study that found that America’s health care system could save more than $81 billion annually and improve the quality of care if electronic medical records were widely adopted.  Instead, the researchers, whose work is described in The Fiscal Times “found that the use of IT in a group of California hospitals actually has resulted in higher costs, higher levels of nurse staffing and higher patient complications.”

The problem, note the authors, is that of execution. “Aside from the large, well-funded hospitals, most institutions don’t have adequate IT staffs to implement and operate such systems efficiently.” Some of these systems might be only partially implemented—with some medical records still in paper form. Finally, computerized records are only as good as the processes they are computerizing—if the hospital’s own methods for keeping track of in-hospital patient data are sub-par, then you end up “computerizing inefficient processes,” according to the authors.

The Huffington investigation revealed two major glitches with EMRs that occurred in the Trinity Health System, a large chain that operates 46 hospitals, most in Michigan, Iowa and Ohio. In late June, the computer system (sold by the Cerner Corp.) posted some doctors’ orders to the wrong medical charts in a few cases; then two weeks later, Trinity had to shut down its $400 million system for four hours at 10 hospitals because electronic pharmacy orders weren’t being delivered to nurses for dispensing to patients, according to the article. Neither of these system problems led to patient harm, but the authors point out that they do highlight fallibility in EMR—despite their great promise in improving quality and reducing health care costs.

Still, the W.P. Carey researchers did find that the California hospitals with EMRs in place had reduced mortality rates—presumably because the systems helped cut down on medication errors. And they remain optimistic about the long-term benefits of computerized patient records—with improved patient safety and better quality of care being realized sooner than cost savings. The problems being experienced now are “bumps” in the road as hospitals wrestle with new technology; “nobody questions IT’s value in enhancing productivity.”

Next year marks the start of the five-year push to get doctors and hospitals to adopt EMRs. The release of the “meaningful use” criteria is the first phase of this process. More government action—in terms of creating standards to drive interoperability between doctors, hospitals, ambulatory care centers and other parts of our vast health care system—will be necessary to help achieve the goals of health reform. And so will better oversight from the FDA or whichever agency takes responsibility for monitoring adverse events and other problems with these systems. Right now we are experiencing the growing pains of an emerging technology—a technology that can feel onerous, balky and time-consuming to many practitioners. But as Colin Harrington told me of his hospital’s EMR system, “I imagine this is going to be 90% good and 10% bad in the long-run. It is still an evolving process.”

Naomi Freundlich is a senior research associate of The Century Foundation who blogs at Health Beat, where this post originally appeared.

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  • Primary Care Internist

    I get it. I get your near-universal opinion among non-doctors about how EMRs will magically improve communication and reduce error / streamline patient care.

    Now here is my personal experience – i use an EMR in my office. The nursing home i work at also uses an EMR. Columbia-Presbyterian hospital uses an EMR to document patient encounters and to record admission and discharge medication lists. Visiting nurses use their own EMR system. And pharmacies (assuming a given patient only uses one) has their own electronic record of rxs filled.

    So when i see a patient in my office who’s been discharged from hospital to nursing home for rehab then back to home, i have lots of disjointed, often contradictory info from systems that don’t talk to each other. And i am lucky if any of these printouts have reliable contact info to confirm or investigate what has been recorded in their EMR. In fact, I would say that MOST (maybe 70%) of these records have some error in documentation.

    So besides cost, I am just not convinced that adopting EMR will accomplish any of the stated goals. That is, unless someone (e.g. medicare) picks a universal platform that everyone must use, that generates ONE COMPLETE RECORD for a given patient, that is stand-alone and gives provider entities access to that same common record.

    • Cody

      Agreed. How many remote controls do you have in your house? One for the DVD/Blue Ray, one for the Bose, one for the upstairs TV, one for the bedroom tv, one for the Ipod dock, two for the Direct TV consoles… Every nursing home, hospital, pcp office, specialty clinic have different remotes that work only for the piece they belong to but don’t communicate with the other pieces of the puzzle. Mandatory EHR is a stupid idea and the punative regulations are going to decimate primary care in my small town. The four docs here are going to leave and go work for a big company in the city.

  • http://nostrums.blogspot.com Doc D

    Not all the research published so far has shown a reduction in medical error with improved documentation, checklists, reporting, and…yes…EMR’s. It’s going to take many years before standardization across computer systems becomes seamless. Only then will we be able to study what impact they’ve had…if any. I’m optimistic, but not sanguinely so.

    In the meantime, fielding many incompatible products of unproven reliability could allow–or cause–error and harm.

  • http://www.PhysicalTherapyDiagnosis.com Tim Richardson

    The user interface can be an iPhone and the doctor can “text” the information to and from the EMR/CDS.

    This may prompt (or be the result of) new social norms that allow texting in classrooms, at dinnertime and during face-to-face conversations.

    The mouse is a 45-year old technology, the keyboard is a 150-year old technology. We can probably still use them but they shouldn’t be the default interface.

    I’ve got some PT clients who use voice recognition software. I’m a physical therapist in private practice and I still primarily use a keyboard, mainly because hardware upgrades aren’t in the budget this year.

    I built a Clinical Decision Support software module to “add on” to the EMR I bought 3 years ago. Physical therapists aren’t eligible for HITECH incentive payments in 2011 but, hopefully, we will be by 2015. My new CDS system already qualifies me for meaningful use with 19 evidence based decision rules.

    Now, I just hope I can get the iPhone for Christmas.

    Tim Richardson, PT

    • Primary Care Internist

      You just demonstrate the typical thinking among EMR vendors / techies and ancillary providers. Anyone NOT actually involved in trying to compile lots of information about a patient is just so enamored with stuff like input devices and “coolness” factor that the actual usability and practicality of an EMR takes a back seat.

      Again, if an EMR can’t give the primary MD an updated accurate medication list, what good is it?

      Some requirements, in order of importance are as follows:

      1- updated accurate medication list tagged to diagnosis list; of course, allergies with specific reaction
      2- most recently and most frequently seen specialists and their recommendations and testing (e.g. colonoscopy) results
      3- pharmacy used and their tel#, and when/ what meds last filled
      4- hospital discharge summary with clear contact info for treating inpatient physician
      5- family contact info
      6- advanced directives
      7- insurance info and outstanding bill, if any
      8- “coolness” factor stuff like inputting with ipad etc.

  • http://doctorstevenpark.com Steven Park, MD

    I’m VERY computer savvy, but after researching dozens of EMRs over that past few years for my ENT practice, I recently took the plunge and went completely paperless. Unfortunately, the real world is still stuck with paper, and it’s taking my staff about 20 to 30% longer performing their routine administrative/billing tasks. My charting takes 2 to 5 minutes longer per patient than the paper templates that I had before, and even coding takes about one minute longer. I’m hearing similar gripes from colleagues using various other popular EMRs. I started charting in-between patients, but found it too slow. I continue to do this when I can. However, it’s much faster jotting quick notes and charting at the end of the day. Now, I leave the office about 30 to 45 minutes later. Obviously, I’m not happy about this.

    I agree with Primary Care Internist that we need a unified EMR. In the name of competition, the disparate and incompatible EMR systems will breed more need for technical support, chaos, and physician dissatisfaction.

    I’m hoping that Apple will get into the game and design a program that has a great user interface, efficient input options, and makes you want to use it, like their other programs.

    • pcp

      Another anecdotal report: I wrote my first computer program as a sixth grader in a special program at the prestigious local university, but I’ve yet to find an EMR that improves patient care and maintains optimal physician and staff efficiency.

    • pcp

      I would also add that the title “Physician barriers to EMR acceptance” is misleading. The problem is with the product, not the intended users.

  • Dr. J

    The problem with EMR’s has little to do with physicians and everything to do with EMR programs. EMRs are like early palm pilots, they are cool and they can be fun but they are time consuming and never do exactly what you want them to or think they should. At their current level of development and function they simply don’t do what doctors and patients want them to do, they are very expensive, and they are cumbersome to use.
    Implementing an EMR should be about the same amount of work as ‘implementing’ microsoft excel, or quickbooks or any other major program designed to be used by the actual people who will use it, that is it should be simple. EMRs should be intuitive to end users and able to do the tasks the users need them to do.
    Have you implemented an iphone?? How hard was that, your whole life is on there, your address book, your phone, your camera, your email, and a whole bunch of customization that was easy to do and specific to your (the end users) needs. Compare that to an old palm pilot and how you had to fight for days to even be able to install a basic program. The reality is that when a major company produces a fantastic EMR that is stable, upgradable and useful every doctor will jump on board. Basically we are all waiting for the iphone of EMRs to finally appear.

  • jsmith

    This long post completely misses the point. To wit: Are there good studies that prove that current EHRs improve patient care, lower costs, or both? I defy the poster or anyone else to show us those studies. Those studies do not exist. EHR is at best an experimental intervention, and it is quite possible that time will show that EHR proponents have suffered from mass delusion, thinking that because this technology should by reason be effective that it must be effective, if only we could just tweak it a bit. What we are seeing here is faith-based thinking.
    Indeed, since EHRs have no compelling scientific evidence to back them up, I would submit that not adopting an EHR is just as medically reasonable as not prescribing high colonics as a treatment for cleansing the body of toxins.
    Doctors should continue to resist irrational technophilia.
    Personal note: my practice has used an EHR for over 3 years. Lives saved: zero. Money lost and time wasted: lots.

    • jsmith

      “I imagine this is going to be 90% good and 10% bad in the long-run. It is still an evolving process.”
      That’s simply nutty rhetoric, that’s crazy happy talk. That’s the kind of talk that gave us the tech bubble and the housing bubble. I say show us the data or get out of town.

    • http://www.PhysicalTherapyDiagnosi.com Tim Richardson

      Actually, there are several studies that demonstrate and advantage to EMR use in hospitals, outpatient clinics and emergency rooms.

      Only, the studies don’t call them EMR – an EMR is just a database and an electronic user interface (screen, keypad, iPhone, whatever…)

      They are ususally called Clinical Decision Support:

      Johnston ME, Langton KB, Haynes RB, Mathieu A. Effects of computer-based clinical decision support systems on clinician performance and patient outcome: A critical appraisal of research. McMaster University, Hamilton, Ontario, Canada. Ann Intern Med. 1994 Sep 15;121(6):469.

      Amit X. Garg; Neill K. J. Adhikari; Heather McDonald; et al. Effects of Computerized Clinical Decision Support Systems on Practitioner Performance and Patient Outcomes: A Systematic Review. JAMA. 2005;293(10):1223-1238.

      Hunt DL et al. Effects of Computer-based Clinical Decision Support Systems on Physician Performance and Patient Outcomes: A Systematic Review. JAMA 1998;280(15);1339-1346.

      Samore M et al. Clinical Decision Support and Appropriateness of Antimicrobial Prescribing: A Randomized Trial. JAMA 2005:294(18);pp.2305-2314.

      Kawamoto K. Improving Clinical Practice Using Clinical Decision Support Systems: A Systematic Review of Trials to Identify Features Critical to Success. BMJ, doi:10.1136/bmj.38398.500764.8F (published 14 March 2005).

      While success varies by setting the EMR/CDS seems to prompt about a 50-70% increase in adherance to validated process measures.

      The challenge, going forward, as I see it is to:

      1) improve the link between the process (eg: giving an aspirin tablet) and the outcome (decreased rate of MI).

      2) improve the use interface.

      I agree with many of the physician posters to this blog – reducing the amount of administrative burden from government and payer compliance measures would de-clutter the computer screen.

      Tim

      • jsmith

        No no no. Clinical decision support is way different from most of the EHRs out there, Tim. My EHR provides no support.

        • http://www.PhysicalTherapyDiagnosi.com Tim Richardson

          Agreed. My EMR is A2C Clinic Controller and it has few explicit decision support features. I built an electronic CDS to attach to it.

          A CDS is defined as at least 2 discrete pieces of patient data linked to a knowledge base.

          Only 4% of docs in the USA use an electronic CDS system attached to an EMR. About 20-30% of hospital-based doctors use an EMR.

          Most EHRs provide some limited CDS functionality, eg: reminders, prompts, recommendations, etc.

          Most of this functionality is geared towards “revenue enhancement” – if we believe the vendor marketing.

          Bear in mind that paper-based CDSs existed long before EMRs became de rigueur. Weed’s paper-based POMR and SOAP notes could be considered the first, universally accepted CDS in medicine.

          POMR never caught on but SOAP is recognized in the entire English-speaking medical world.

          I didn’t build a CDS because I “love” technology – I built it because using an electronic CDS is the only way an EMR will ever improve processes, lower costs and improve patient outcomes in medicine.

          Tim

          • jsmith

            CDSs integrated with EHRs could possibly change the calculus so that EHRs are worth it, but I’m not holding my breath. Maybe for many practices paper would work just as well, and be faster and cheaper.
            In any case, expensive CDS-EHRs would need to pass a series of tests to be considered a medical advance.(Of course, if they are cheaper and easier than what you’re doing now, go for it!) First, they have to be shown to improve clinically relevant endpoints–morbidity and mortality. Surrogate endpoints like whether the HgbA1c has been checked are simply not adequate. Second, even if clinically relevant endpoints are improved with CDS system, it would have to be shown to be cost-effective. In other words, it have to be in the cost-effectiveness ballpark of what medicine currently thinks of as reasonable interventions, if it is to be instituted widely in the medical system. Again, individual practices can and should be able to switch over if they think it in their or the patients’ best interests. What I am arguing against is mandates. Third, these systems have to be shown to be effective in a variety of practice types, not just cherry-picked integrated systems or practices run by techies. We must always remember to avoid unwarranted extrapolation.
            I will admit that these are high hurdles for EHRs for CDSs. But advocates of this technology are asking us to spend a tremendous amount of time and trouble, essentially asking us to turn our practices upside-down. They should have to offer us the kind of evidence we demand for other types of medical interventions.

  • http://www.innovativepdf.com ted rudolph

    You guys should checkout the book “The Myths of Innovation”. In that book they list seven factors affecting the adoption of a new innovation:

    1.Culture
    2.Dominant design
    3.Inheritance and tradition
    4.Politics: who benefits
    5.Economics
    6.Goodness is subjective
    7.Short-term vs. long-term thinking

    I think problems with EHR adoption is usually found in one, or more, or these seven items.
    http://answers.oreilly.com/topic/2046-factors-that-affect-the-adoption-of-an-innovative-idea/

  • Ed

    I am concerned that a “pro-health” stance is seen as a way to “brand” a political movement with voters to get votes or take votes from another political “brand.” This then gets all mixed up with the desires of the donors to the political party.

    If HIT vendors are big political contributors, then HIT must be a good thing to tout in the “branding” of a political party. If one party seems to have the edge on another on HIT, then the party with less “investment” in HIT will find ways to deride HIT.

  • Ed

    I see in the comments here a reality check on HIT. Pretty reliable data is accumulated about my credit that can be accessed from almost anyone who needs to know. I have the rights and processes under law to control this adequately and even correct the record if required.

    So my “credit health information” seems pretty well dealt with so why not health information? There simply must be a more simple explanation that all of the discussions to date and I think it has to do with motivation.

    From what I can see, there simply is no motivation of healthcare providers and payors to share data, let me control my data, or accumulate data in a regulated area. Furthermore, there is a motivation not to share.

    Since it is likely that my health would be better served by having my data accessible by those that need to treat me and it seems likely that the MDs want a full record (see comments above), then it must be true that the folks who see to now control my data have something to gain by not sharing it. That would be large businesses mainly, and I have little trust that my best interests are their top priotity.

    Fix the motivations and you will then fix the problem.

  • ninguem

    http://www.extormity.com/

    They have the new death panel module. The patients should roll in now.

  • PICUDoc

    My response below is written as someone who is a full time beside clinician and also works with my hospital with EHR implementation.

    I think consider where there rest of the world is with computers there’s no reason that we in the medical field should be scribbling on paper. I mean we can shop, bank, travel, reserve restaurants and everything else using the internet and do so in a manner that is more efficient than doing the above tasks on paper or face to face.

    Unfortunately I think the key problem here is that we the MDs are not the “customers” for these EHRs. The customers are folks like JCAHO, PQRI, our billing folks who require us to have certain data captured in our records which end up bogging down our workflow. The reality is that running through an orderset should be not more complicated than an Amazon shopping spree (unfortunately it’s not)

    Another factor is the lack of a standard way for these systems to talk to each other. While we build inferaces between systems and we use common codes (like HL-7 and LOINC) the interfacing is not as good as Quicken is at integrating the data from the multiple financial institutions that I participate in to give me a clear picture of my financial health.

    I think these systems have a long way to mature before we’ll all be jumping for joy over them. However, I think the key to making these systems user friendly and working towards that goal is to have “real world” physicians involved in the making and implementing of these products who will put usability at the forefront. Unfortunately some of the “computer doctors” employed by the EHR companies are folks who haven’t practiced in years and forget what its like to be at the bedside trying to work through admission number 10 while using the EHR.

    • rswatkins

      ” I think the key problem here is that we the MDs are not the “customers” for these EHRs.”

      Eactly. It would be very easy to desgin a great EMR if it was used only to improve patient care. But current EMRs are designed for the benefit of government agencies and insurers, not for docs or patients. We have been lied to (most egregiously by our own professional societies) about non-existent benefits that will come from using EMRs: reduced overhead, greater efficiency, improved patient care. None of them are proving to be true.

      • http://www.PhysicalTherapyDiagnosi.com Tim Richardson

        EMR marketing seems to be primarily for “revenue enhancement” – not improved clinical processes or outcomes.

        Nevertheless, studies do exist that show an improving trend in clinical processes with computerization.

        See my post above for the references.

        Tim

    • jsmith

      Good analysis. First, we’re docs, not typists. Keyboarding slows most of us down and irritates the hell out of us into the bargain. Dictating is faster and generally results in higher quality, more detailed notes. Second, getting information out of the EHRs often wastes a tremendous amount of time. Templates are a problem because they carry much irrelevant information, and the formats of the notes are often hard to read and not consistent with how we have been trained to process information. Third, EHRs don’t talk to each other, so the purported benefits of information sharing do not really exist.
      EHRs might be useful someday at reducing costs or improving quality of care, although I have my doubts about this. (Certainly, getting an adequate primary care workforce would do much more for the nation’s health, but that’s a different post.) Time will tell. Right now they are mostly time and money pits.

  • ljpmt

    I would never select a primary care physician based on whether or not he or she uses an EMR. The deciding factor for me (after checking out such basics as credentials, education and experience) is my personal interaction with the physician. If an EMR helps a physician with my care, then that’s great. If it doesn’t, then I have more respect for the physician who chooses not to use one, rather than have it serve as an impediment to my care. Am I an older patient? Yes. I am also one who has worked both in advertising and the software industry. As a result of that exposure, I have developed an immunity to the mind-numbing myths generated by both industries.

  • JP

    In high school and college, I had IT related side jobs (SAS programming, webpage design, network analysis). I was on the superuser teams to implement several EMR systems throughout my training at the several hospitals and clinics. Despite this, I am seriously considering using paper charts when I open my new clinic in a few months.

    Don’t get me wrong, I think EMR is the future. But in this age of ipads and wii in every household, EMRs are woefully inadequate in meeting the needs of physicians and patients. After countless demos lasting hours and hours, not one EMR is able to meet my 3 most frequently used documentation needs.

    Phrases come out in garbled grammatically incorrect bits. The exam is one big paragraph. Screens are visually crammed with hundreds of buttons. My descriptions are limited to the vocabulary provided by a few checkboxes. Dropdown menus are never ending lists. Input time is cumbersome.

    EMR’s have a long way to go before becoming efficient and elegant systems for even just documentation. The technology is there. I suspect that the EMR companies just don’t have the motivation to improve their systems as they know eventually docs will be forced to buy their clunky software.

  • http://www.maatratechnoloy.com Rohit Tanneru

    I posted these comments on a different site, but they are applicable here, as well.

    It seems that healthcare providers need to do a better job of accessing and evaluating which, if any, EMR is best suited for them. I see so many complaints about how long it takes to retrieve patient information and all the convoluted steps in the software that need be performed before retrieving the desired data. Not to mention all the extra time required to enter data in the EMR. If the medical staff, especially the ones that will interact with the EMR most frequently, vetted the EMR before making a decision, you would see EMR adoption rates stay stagnant because they would find that most EMRs are poorly designed and hinder practice. For the ones that adopt them, they would be far more satisfied because they would use a system that was best suited for them. It seems that if EMR systems were tested in typical healthcare work flow scenario, the pros and cons of using it would automatically manifest. In other words, test drive the EMR for a few weeks to a month, and the medical staff will quickly find out the drawbacks and impacts of using a particular EMR. This way the true impact of using the EMR (in terms of efficiency, operational use, patient quality care, doctor patient communication, financial, changes to workflow and behavior will be revealed BEFORE a major investment and change to the practice is made. I can summarize it in4 simple words: TRY BEFORE YOU BUY. Also, keep in mind that all EMRs are not the same, some are good, and some are horrible.
    Maybe the root cause of all the frustration with EMRs and their hindrance is because medical staff don’t know how to go about evaluating and accessing the EMR (if any) for their practice. There are many lessons learned and best practices we can learn from the early adopters of EMR. How about we come up with a white paper which details how to evaluate an EMR? Instead of paying 100s of thousands of dollars to a consultant, let’s use the collective wisdom of the healthcare community do it ourselves (I’m not a healthcare provider, but very much interested in it). I know they are out there, but we need a comprehensive one, which aggregates the best advice, practices and methods into a single concise document.

    Anyone up for the challenge? Where all the healthcare leaders?

    Best regard,
    Rohit Tanneeru, MBA, MS
    CEO/founder
    rohit@maatratechnology.com
    http://www.maatratechnology.com

  • ninguem

    So, it’s the doctor’s fault?

    How about building a better EMR?

    Or is that too much to ask.

  • horseshrink

    Am hoping ONC’s move to standardize health information exchange via metatagging will introduce a much needed dynamic.
    http://m.healthcareitnews.com/news/white-house-calls-health-data-exchange-standards

    The easier it is for physicians to switch EHR products, the more vendor competition will drive product quality up and prices down.

    Currently docs are stuck in proprietary lockup.

    They buy an EHR product and it’s cage … a database idiosyncratic to that product. Migrating that data to a new EHR product can prove prohibitively expensive. Thus, market forces are stymied.

  • Chris

    As a patient and a physician, I can see some real drawbacks to EMR. A sloppy intake nurse who cuts and pastes the medication list for the last admission instead of entering the new one can create a cascade of errors. A pre-printed protocol, without looking at the patient status also can create chaos post discharge. I strongly suspect an awful lot of progress notes are cut and paste affairs, and it is nearly impossible to correct and error once it makes it to the chart. One of my patients is profoundly religious and has had a few sips of wine, period , in her life. One consultant wrote that she uses drugs and alcohol, and it has proliferated into all subsequent admissions, and thus to insurance companies. This occurred with paper charts too, but was easier , I think to correct.
    We are trying out EMR’s-I don’t think the privacy issues are clarified, nor an easy way to “thumb through” the chart. And I have no idea about how we are going to catch a “misfile” if it is “mis scanned”

    • pcp

      Why does an EMR need a cut-and-paste function at all?

      • ljpmt

        Ostensibly, to eliminate the need for repetitive data entry or re-dictation of information found elsewhere in a patient’s EHR that can simply be cut (or copied) and pasted into a “new” report to save time. As clearly illustrated above, however, the problem with this “time-saving” technique is that if the initial information is entered incorrectly and remains unchecked, it has the potential to be copied multiple times by multiple users into multiple reports in a patient’s chart.

        • pcp

          “Ostensibly, to eliminate the need for repetitive data entry or re-dictation of information found elsewhere in a patient’s EHR”

          And why does data already in the chart need to be re-entered?

          Actually, I know the answer: coding for dollars.

          • ljpmt

            Coding for dollars — brings to mind the phrase “data corruption” on a whole new level…

      • http://www.emrandhipaa.com EMR and HIPAA

        Here’s one doctor’s perspective on cut and paste and how it can actually make him a better doctor: http://www.emrandhipaa.com/emr-and-hipaa/2010/11/22/is-cut-and-paste-in-ehr-software-really-such-a-bad-thing/

        It’s like most tools. Used the wrong way and they can be harmful, but used the right way they can have tremendous benefits.

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